Community and Public Health

Nursing
Promoting the Public’s Health

1
 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

2
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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

6
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

7
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.

8
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

9
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

10
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

11
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

12
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

13
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

14
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

15
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

16
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

17
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

18
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

19
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

20
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

21
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

22
Elizabeth Wright, MSN, RN
Assistant Professor of Nursing
Indiana Wesleyan University
Marion, Indiana
Chapter 32

23
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

24
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

25
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

26
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

27
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

28
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

29
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

30
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.

31
 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.

32
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.

33
 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.

34
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

35
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

36
 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.

37
 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.,

38
 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.

39
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

40
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

41
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.

42
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.

43
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.

44
Contact your sales representative or check out LWW.com/Nursing for
more details and ordering information.

45
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.

46
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

47
 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.

48
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.

49
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

50
 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

51
 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

52
 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

53
 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

54
 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

55
56
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

57
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

58
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

59
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

60
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

61
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

62
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

63
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

64
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

65
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

66
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

67
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

68
69
 UNIT 1
Foundations of
Community/Public Health
Nursing

70
71
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.

72
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

73
 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,

74
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

75
 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.

76
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.

77
 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

78
 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

79
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:

80
 “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.

81
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

88
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

90
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).

92
 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

95
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

96
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.

98
 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

113
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).

119
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.

121
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

123
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.

127
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.

128
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.

129
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.

130
 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.

131
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).

132
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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133
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141
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.

142
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.

143
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.

144
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

156
 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

160
 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

162
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.

163
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).

166
 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

169
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.

171
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.

172
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

173
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

174
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.

175
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

176
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

177
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

178
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.

179
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.

180
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

181
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.

182
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.

183
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

184
 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.

185
 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.

186
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.

187
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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188
REFERENCES
American Association of Colleges of Nursing (AACN). (2008). The
essentials of baccalaureate education for professional nursing practice.
Washington, DC: Author.
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194
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

199
 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).

200
 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

202
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,

203
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,

205
 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

206
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?

209
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

210
211
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

212
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).

213
 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/

214
 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

215
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).

216
 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).

217
 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

218
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

219
 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

220
 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.

221
 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

222
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

223
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
)

224
 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).

225
 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

226
 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

227
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).

228
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)

229
 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).

230
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

231
232
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

233
 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

234
 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

235
 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

236
 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

237
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.

238
TABLE 3-11 History of Public Health Nursing and the 10
Essential Public Health Services

Source: CDC. (2020).

239
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.

thePoint: Everything You Need to Make the

Grade!
Visit http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, study aids for
all learning styles, and more!

240
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248
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

250
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.

251
8. Use a decision-making process with and for community/public health
clients that incorporates values and ethical principles.

252
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.

253
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/)

254
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:

255
 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%.

269
 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

282
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

286
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

290
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

291
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

316
 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

317
 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

318
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

319
 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

320
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

321
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.

322
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

323
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.

324
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.

325
 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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326
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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

351
 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:

352
 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

353
 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/

357
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, &

368
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

369
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

374
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

375
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,

377
 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;

378
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?

391
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

397
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).

398
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

400
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.

401
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

402
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.

thePoint: Everything You Need to Make the

Grade!
Visits http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, study aids for
all learning styles, and more!

405
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 UNIT 2
Community/Public Health
Essentials

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415
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.

417
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.

418
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.

419
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).

420
 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).

422
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

423
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.

424
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).

425
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).

426
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)

427
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

428
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.).

429
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.

430
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).

431
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)

432
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).

433
 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

434
 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.

435
 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

436
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).

437
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

438
 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.

439
 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.

440
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.

441
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)

442
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).

443
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)

444
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).

445
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.

446
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),

447
 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

449
 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

450
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.

456
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

460
 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:

461
 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

462
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

463
 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

464
 (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

465
 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).

466
 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).

467
 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

468
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.

469
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.

470
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).

471
 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

472
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

473
 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):

474
 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,

475
 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).

476
 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

477
 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).

478
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

479
 (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

480
 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).

481
 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

482
 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

488
(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

489
 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).

490
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)

493
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)

494
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).

495
 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).

496
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/)

497
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%

498
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).

499
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,

500
 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?

501
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).

502
 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.

503
 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).

504
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

505
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

506
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).

507
 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

508
 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,

509
 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.)

510
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

511
 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/.

512
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.

513
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).

514
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).

515
 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.

516
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

517
 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

518
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).

519
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

520
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.

521
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.

522
 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!

523
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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.

561
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

562
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

563
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.

564
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)

565
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

566
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.

567
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.

568
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.

569
 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).

570
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

571
 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).

572
 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

573
 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).

574
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)

575
 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)

576
 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.

577
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.

578
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

579
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).

580
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

581
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:

582
 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.

583
 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).

584
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).

585
 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.

586
 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

587
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

588
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).

589
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

590
 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.

591
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.

605
 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

607
 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

608
 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?

609
 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.

611
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

614
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

615
 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.

616
 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

617
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.

618
Reprinted from CDC. (2012b). Lesson 3: Measures of risk.
Retrieved from https://www.cdc.gov/csels/dsepd/ss1978/lesson3/section2.html

619
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).

620
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.

621
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).

622
 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.

623
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.

624
TABLE 7-4 Steps in Epidemiologic Research

625
 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

626
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.

627
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)

628
 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.

629
Retrieved from https://www.cdc.gov/vitalsigns/foodsafety-
2015/index.html)

630
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.

631
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

632
 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).

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!

633
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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

646
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

649
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).

650
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.

662
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

663
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.

664
 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).

665
 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

667
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

669
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)

670
 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

678
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)

682
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).

684
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

685
 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

686
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

687
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).

688
 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).

689
 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).

694
 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

695
 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.

697
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.

698
 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.

699
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-

700
 children.html?
CDC_AA_refVal=https%3A%2F%2Fptop.only.wip.la%3A443%2Fhttps%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).

701
 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.

702
 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

703
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);

704
 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:

705
 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

706
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

707
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

708
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:

709
 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.

710
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.)

711
 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:

712
 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).

713
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

714
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.

715
 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

716
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.

717
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).

718
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.

719
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?

720
See Chapter 7 for more on epidemiology.

721
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.

722
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)

723
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).

724
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).

725
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.

726
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.

727
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).

728
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).

729
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.

730
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.

731
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?

thePoint: Everything You Need to Make the

Grade!
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review questions, journal articles, supplemental materials, study aids for
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732
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748
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

749
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

751
Promotion, 2019). Our national framework for health is therefore in line with
global goals and the WHO definition of health.

752
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.

753
 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)

754
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

755
publication of the 2010 Standard 16: Environmental Health, all nurses
must incorporate environmental health principles into nursing practice.

756
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

757
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

758
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.

759
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).

760
FIGURE 9-1 Ecological model for public health.

761
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

762
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.

763
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;

764
 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

765
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).

767
 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

768
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

770
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).

772
 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).

773
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

774
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).

775
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

776
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).

777
 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).

778
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

779
 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.

780
 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”

781
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

782
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

783
 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

784
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

791
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

792
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

793
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

794
 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.

795
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

796
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

797
 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.

798
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).

799
 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

800
 (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).

801
 Water can become contaminated from a number of sources, including
point and nonpoint sources.

Point sources are those that can be traced to one source, such as a
wastewater facility release into municipal water or discharge from an
industrial site.
Nonpoint sources are runoff from agricultural areas, gasoline stations,
and other contaminants carried by rain and waterways. Some common
water contaminants are microbial (frequently Cryptosporidium and
Giardia).

To rid public water systems of microorganisms, disinfection processes

are used. Disinfectants that are chlorine based can produce by-products that
can also be hazardous to health. Additionally, other inorganic (such as
nitrogen derivatives, arsenic, lead, fluoride, cadmium, and mercury) and
organic chemicals (commonly organophosphates, phthalates), as well as
radionuclides, are frequent water contaminants (EPA, 2018b, 2018e, 2018g).
More recently, there is a global concern about pharmaceutical waste in
water. During 1999 to 2000, the U.S. Geological Survey (USGS, 2018b)
found chemicals such as medications for humans and animals, natural and
synthetic hormones, metabolites, pesticides, insecticides, plasticizers, and
fire retardants in 80% of the streams sampled (Health Care Without Harm,
2020a).
Not only are pharmaceuticals used by humans, excreted in their urine,
and discarded into locations where they can reach water supplies but also
animals are fed with hormones and antibiotics in animal feeding operations
that can leach into water supplies (Diaz-Sanchez, D'Souza, Biswas, &
Hanning, 2015).
C/PHNs must be aware of sources of water contamination that puts
vulnerable population groups such as the growing fetus, infants and children,
older adults, and those with compromised immunity at great risk (Marcoux &
Vogenberg, 2015). Organizations such as Health Care Without Harm seek to
address the pharmaceutical waste issue through measures that address
production, use, discharge, and disposal, treatment in wastewater facilities,
and collection of unused medications (Health Care Without Harm, 2020a).
The Right to Know legislation and use of Safety Data Sheets provide
some assurance and can be helpful in teaching our clients how to better
protect themselves as well. C/PHNs can direct community members to
consult the EPA Web site to learn about their right to know. To locate local
information, nurses and community members can visit the EPA Web site at
www.epa.gov. One link connects to “your own community” and leads to
MyEnvironment, where consumers can learn more about the risks for one's
own community, how to address specific pollution, and ensure safe drinking

802
water. Nurses can teach their community partners how to access a consumer
confidence report. Every public water system is required to provide
information to consumers that identify any detected contaminants or factors
that affect the water quality for those customers that they serve. This
responsibility to provide the public with information about public water
systems is mandated through the SDWA enacted in 1974 that established
standards for safe drinking water. Individuals can access information from
their own water supplier or can visit the EPA Web site (EPA, 2020j). In
September of 2019, the Trump administration announced plans to repeal the
2015 rules related to the 1972 Clean Water Act and to roll back protections
on wetlands and tributaries (Eliperin & Dennis, 2019).
Finally, a risk to community water supplies occurs in the communities
where unconventional natural gas or oil extraction, also known as fracking,
occurs. This is a process to extract natural gas or oil from deep underground
for public use. Fracking has the potential to contaminate air and water from
chemical sources such as methane, benzene, and other hydrocarbons, and it
poses health risks to community members as well as the workers involved in
extraction operations.
Fracking is occurring throughout the United States. In fact, 21 states
permit fracking, including Arkansas, California, Colorado, Pennsylvania,
Texas, and Wyoming. Methane, benzene, and other chemicals have been
found in the groundwater in communities where fracking takes place. Health
concerns, such as respiratory and nervous system problems, along with blood
disorders, cancers, and birth defects, have been noted (McDermott-Levy,
Katkins & Sattler, 2013; Wilke & Freeman, 2017).
It is important to remember that process of fracking and health risk is not
only related to exposures from the well sites but the entire process from well
preparation to delivering the fuel to the marketplace, sometimes across state
lines where gas or oil extraction is not permitted. An example of this is
discussed in Box 9-12.

BOX 9-12 STORIES FROM THE

FIELD
Fracking Laurel is a small community in rural
northeastern Pennsylvania where the local
citizens have become concerned about their
drinking water as a result of fracking activities.
In your work in the local community hospital,

803
you have noted more pediatric hospital
admissions for asthma exacerbations, and a
recent study pointed out that children exposed
to Pennsylvania's newly drilled gas wells were
1.25 (OR 95% CI: 1.07, 1.47) times more likely
to be hospitalized for an asthma-related
diagnosis compared with children who did not
live near gas wells (Willis, Jusko, Halterman, &
Hill, 2018).
Community members also reported feeling powerless as they noted
health problems and were concerned about the quality of their air and
water; yet, the elected officials and government agencies were not
responding to their concerns (McDermott-Levy & Garcia, 2016).
Meanwhile, nurses and other health professionals in New York state, to
the north of Laurel, were attending town halls and meeting with state
and federal policy makers to prevent Pennsylvania's natural gas from
coming through their communities via the new proposed pipeline. The
New York health professionals cited air quality, water quality, and safety
concerns related to the required infrastructure to transport the gas
through their region and on to New England.
In 2012, the ANA passed a resolution, “Nurses' Role in
Recognizing, Educating, and Advocating for Healthy Energy Choices,”
that states nurses must be knowledgeable about the health risks involved
with fossil fuel energy, such as fracking (McDermott-Levy et al., 2013).
Because the local community shows great trust in nurses and seeks
advice from nurses in hospitals, schools, and community settings, it is
important for all nurses to understand and provide education for
community members about this health concern.

1. How might you learn more about hydraulic fracturing and the
associated health risks?
2. Describe the role of the nurse working in communities where
hydraulic fracturing occurs.
3. Describe how an interdisciplinary approach might be used to
address the health issues of Laurel, PA, and in the state of New
York.
4. How might you identify issues related to environmental justice in
this scenario?
Source: McDermott-Levy et al. (2013); McDermott-Levy & Garcia (2016); Willis et al. (2018).

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Food
Food quality, quantity, and safety are essential to human health. Food quality
refers to the relative nutritional value, cost, and variety of food available. The
CDC estimates that each year more than 3,000 people die from foodborne
illness and 1 in 6 Americans becomes ill from food consumption (CDC,
2020).
C/PHNs frequently work closely with environmental sanitarians in state
and local health departments who routinely monitor food establishments for
their safety to prevent exposure to microbial agents that cause foodborne
illness (CDC, 2014).
Environmental issues that affect food quality extend beyond the
microbial exposures and include the availability of adequate nutritious food,
chemical exposures through food additives and from agrichemicals and
antibiotics, contaminated food from diseased animals, and improper food
handling. Pesticides are ubiquitous in the environment and are transmitted to
humans through foods (EPA, 2020). Fresh fruits and vegetables must be
thoroughly washed to remove pesticide residue. In addition, antibiotics fed to
animals in animal feeding operations are transmitted through this food (EPA,
2017b).
After production, many foods are processed for market. Food additives
such as dyes and flavors provide the color and often improve flavor of foods.
Leavening and thickening agents improve consistency, while preservatives
keep food from spoiling on the shelf. Many of these additives can be harmful
to health with examples being linked to cancer and endocrine disruption.
Recently, there is a concern about genetically modified foods being
marketed. These concerns not only address the safety of the food for human
consumption but also raise questions about the ecological impact and
sustainability.
Microbial outbreaks are common from a variety of bacteria (Shigella,
Salmonella, Campylobacter, Escherichia coli) and parasites
(Cryptosporidium parvum, Amoeba; CDC, 2020). In 2018, for example,
there were two national recalls of romaine lettuce as the result of E. coli
O157:H7 contamination. FDC, state and local authorities, and CDC joined to
investigate food contamination outbreaks, isolate the cause, and inform
health professionals and the public (CDC, 2020).
Although the public often hears about these outbreaks through the media,
they may not be as aware of the risks from chemical contaminants. A great
resource for families and community members is the Partnership for Food
Safety Education (2018) that promotes safe food handling and education for
both children and adults.

805
 The U.S. Food and Drug Administration (FDA) is charged with the
responsibility to ensure the safety of food produced, shipped, imported, and
sold in the United States. This includes the monitoring of microbial toxins
and chemicals such as lead and cadmium, pesticides, food additives, and
packaging (EPA, 2020; Johnson, 2016; Maffini, Neltner, & Vogel, 2017).
Although the FDA operates to ensure that the genetically modified foods
meet the same safety standards as other foods, the technology used to modify
or engineer new food varieties from plant and animal breeding techniques is
expanding rapidly (FDA, 2020).
Fish and other seafood are an important part of food safety. Nurses
should be aware and instruct communities to monitor fish advisories (EPA,
2019a). The advisories warn consumers of contaminants (mercury, PCBs,
chlordane, dioxins, and DDT). These contaminants persist in the
environment, particularly in river and lake sediments where fish consume
them from bottom-feeding organisms (Fig. 9-6).

FIGURE 9-6 Fish contain valuable nutrients, but contaminated

waterways can make fish a health risk.

Bioaccumulation refers to the process where toxins accumulate in

greater concentration in an organism than the rate of elimination. Toxins can
accumulate from direct exposure or from eating contaminated food products.
Through biomagnification, the toxins present at lower levels of the food
chain are in greater concentration in those species further up the chain.
Therefore, humans who eat contaminated fish are exposed to toxins at all
levels across the food chain. Public health nurse and Georgetown University
faculty member, Dr. Laura Anderko (2015), has been involved with fish
advisories for many years. In collaboration with the EPA, she prepared the
educational set of four modules on this topic: Fish Facts for Health

806
Professionals: Methylmercury Exposure, Fish Consumption, and Health
Risks/Benefits. This is available through the Web site (www.fishfacts.org).

Vulnerable Groups
C/PHNs must also be aware of the increased vulnerability of certain groups.
For example, pregnant women are likely to transmit their exposure to
chemicals, pesticides, and toxins to the unborn fetus, children are more
susceptible to hazards from food because of their immature gastrointestinal
systems and increased food intake per size compared to adults, and those
with altered immunity due to cancer, diabetes, and other health conditions are
more likely to be affected by food exposures.
Nurses can be a resource to ensure that community members learn about
the specific local risks and identify ways to decrease their risk. The EPA
produces a booklet entitled Citizen's Guide to Pesticides and Pesticide Safety
that is available from their Web site (EPA, 2005). The booklet is written to
help nonprofessionals understand pesticides. Although it is not directly
focused upon food, it helps community members understand the hazards
present in pesticides and strategies to reduce their use and to ensure safety
when using pesticides.
The Pesticide Action Network (2018) uses data from the USDA Pesticide
Program to identify commonly applied pesticides for many foods.
Consumers can consult their Web site to be informed of foods that pose the
most serious threats to health, particularly for the most vulnerable groups.
In addition, the effect of climate change on weather extremes (droughts,
foods, and storms), changes in rainfall and water supply for soil, rising
atmospheric greenhouse gases, and the ecology of microbial growth will
have negative impacts upon the food supply. Extreme weather events
increase the likelihood of chemical contaminants and pesticide exposures
from runoff that occurs with flooding.
Agriculture and fisheries industries are sensitive to specific climate
conditions related to changes in temperature and levels of CO2 in the
atmosphere (EPA, 2019b; Smith & Fazil, 2019). Additionally, our changing
climate has led to loss of nutritional content (Zhu et al., 2018) and impact on
water resources and crop production (Blanc, Caron, Fant, & Monier, 2017).
Globally, these changes can also affect human health. Scientists report
the risks for waterborne and foodborne pathogens in drinking water, seafood,
and fresh produce from climate variability and the potential for ecological
changes that can affect watershed and drainage (EPA, 2019a).

Toxic Waste

807
Individuals, families, schools, governmental agencies, health care facilities,
and industries all create waste that must be managed to minimize
environmental impact and to protect human health. The EPA reports that in
2017, Americans generated about 267 million tons of municipal solid waste.
This comes to 4.51 lb of waste per person, per day (EPA, 2020c).
In an effort to minimize waste and environmental impact, local, state,
and federal agencies have begun supporting sustainable practices that
highlight the environmental value of reducing and reusing products. The EPA
offers a waste management hierarchy that highlights (this image would be
good to include) the value of reducing and reusing materials as a priority and
recycling is the second level, when the items are not able to be reused (EPA,
2020c).
In particular, our use of plastics and its ecological impact on sea life
highlights the importance of reducing and reusing products. The waste
management hierarchy offers an upstream approach of reducing waste at the
source of waste generation. For health care facilities, this can mean
environmentally preferred purchasing of products that are less toxic, contain
recycled materials, more energy efficient, and are safer and healthier for
patients, health care workers, and the environment (Health Care Without
Harm, 2020a).
Although efforts are made to reduce health risk, hazardous wastes
continue to be produced. These wastes include solvent wastes, dioxins, and
wastes from electroplating and other metal finishing operations, wastes from
oil refineries, organic chemicals, pesticides, explosives, lead processing
materials, and wood preservatives. We are exposed to these chemicals if they
are aerosolized into the ambient air, leach into ground or wells, and reach the
soil where children play, or crops are produced. What is particularly
dangerous for human exposure is the fact that most community members are
unaware of the hazards in their communities.
Communities may be burdened with many brownfield sites, as well as
those listed on the National Priorities List of hazardous sites as Superfund
sites (EPA, 2018j). Popular media such as books, films, newspapers,
television, and social media may be the first place that nurses become aware
of communities affected by toxic waste. The Flint water crisis was played out
in the news and chronicled in Dr. Mona Hanna-Attisha's book, What the Eyes
Don't See. Nurses should be knowledgeable about the toxic hazards in their
own communities and those where the patients and families they care for
reside. Through the EPA Superfund Web site (EPA, 2018j), nurses can assist
community members in learning about Superfund sites that impact their
communities. Further, on the EPA Brownfields Web site, nurses and
community members can learn about Brownfields Near You (EPA, 2019g). It
is important for the nurse to be alert for reports of toxic exposure risk,

808
evaluate the science and toxicological risk, and advocate for
community/public health.

Radiation
Humans are exposed to radiation in a variety of forms. Risks and forms of
radiation are generally categorized as ionizing and nonionizing radiation.
Ionization refers to the process where the atomic particle (ion) breaks away
from the nucleus of the atom. Ionizing radiation occurs in natural forms as
radon gas and cosmic radiation from the atmosphere. Nonionizing radiation
refers to radiation from sources such as infrared, microwave, and radio wave
radiation (EPA, 2020i).
Radon is an odorless, ionizing, radioactive gas. Radon can seep into the
foundation of homes from the ground and expose residents to the radiation
effects. Radon exposure is a leading cause of lung cancer.
Nurses must be aware of areas with high radon risk and should be sure
that community members are educated about the risks of radon. Community
members can access the EPA's A Citizen's Guide to Radon: The Guide to
Protecting Yourself and Your Family from Radon from their Web site (EPA,
2020i). EPA map of radon zones is available at y

809
Policy Development
Community/public health nurses participate in the other core functions of
public health for environmental health nursing. Policy development is the
core function that addresses the need for legislation to protect human health.
In addition, policy development also provides opportunities for nurses to
engage with communities in addressing policies specific to their needs
(CDC, 2018c).
To advocate for change, C/PHN must be informed about the community
hazards, existing legislation, and governmental and nongovernmental groups
that can be partners in the efforts to protect health (Leffers & Butterfield,
2018).
Nurses can begin their environmental advocacy by writing letters to their
legislators in support of health-protective laws such as sustainable energy
choices, improved air quality, or ecological agricultural practices. Important
nursing actions related to environmental policy are to advocate for health-
protective policies and to inform community members about the health risks
related to the specific issue (Moyer, 2016).
Additionally, letters to local newspapers and periodicals can remind
community members of safe practices in the home and personal
environment. Nurses can also present testimony at public forums or hearings
(Waddell, Audette, DeLong, & Brostoff, 2016). As knowledgeable and
trusted members of the community, C/PHN help to educate and empower
community members; nurses in many other settings are also realizing the
benefits of population-based advocacy (Christopher, Duhl, Rosati, &
Sheehan, 2015); (Waddell et al., 2016).
C/PHN serve on local and national committees and boards to advocate
for change. Examples of agencies where nurses play an advocacy role are the
Children's Environmental Health Network, Just Green Partnership, local and
country environmental groups, state nurses association environmental affairs
committees, and Health Care Without Harm, to name just a few. Nurses
engaged in environmental health research can share the findings of
successful environmental health nursing interventions to promote policy
change (Snell, 2015).
For nurses to function effectively as advocates for safer environments, it
is essential to be aware of important legislation for environmental health.
Nurses can also use the EnviRN Web site to follow current advocacy efforts
in nursing practice (ANHE, 2019). For more on policy development and
advocacy, see Chapter 13. See for a list of important legislation
related to environmental protection.

810
Assurance
The regulatory function for policy ensures that appropriate services are
provided. This public health function demands that C/PHNs must incorporate
environmental health principles into practice (ANA, 2015b; Leffers &
Butterfield, 2018).
For example, a nurse can educate families to reduce their risks from
environmental hazards in the home, an OHN will ensure that safety
regulations are followed in the work settings, or a school nurse can ensure
that indoor air quality is monitored for the school setting. Assurance
guarantees that policy and regulatory functions are followed through the
provision of public health essential services. The following examples
illustrate how community nurses fulfill the assurance function.

Home
People spend 90% of their time in their homes. To assure that nurses are
prepared to address environmental risks to health in home settings,
competencies for nursing education include home assessment strategies
(Leffers et al., 2017). Nurses working with families and in communities
participate in research programs and collaborative projects that impact home
environments.
To address some of those health issues, particularly for children, the U.S.
Department of Housing and Urban Development (USHUD, 2018) created the
Healthy Home Intuitive (HHI) to protect children and their families from
health and safety hazards in their homes (Ashley, 2015). The program targets
multiple childhood diseases and injuries in the home by using a
comprehensive approach. Some of the environmental health concerns
addressed include lead, carbon monoxide, pesticides, radon, mold, home
safety, and asthma.
In New York, the Erie County Health Department took an upstream
approach and addressed lead exposure, carbon monoxide, falls, and burn
risks for low-income families before they moved into their homes (USHUD,
2018). In Ohio, C/PHN collaborated with other professionals (program
manager, health educator, sanitarians, community outreach worker) through a
Healthy Homes Program Grant to perform housing control assessments,
education, and interventions in housing units. The interventions included
home visits and education, and they were found to reduce asthma symptoms,
school days missed, workdays missed, and the number of emergency room
visits for asthma events. Results continued 6 months postintervention (Sweet,
Polivka, Chaudry, & Bouton, 2014).

811
Severe Weather Events
A second area for nurses to assure that essential services are provided to
community members is in response to severe weather events (Fig. 9-7).
Although studies indicate that nurses are involved in disaster response,
results indicate that nurses are not always prepared for their role in
emergency response situations (Usher et al., 2015; Yan, Turale, Stone, &
Petrini, 2015).

FIGURE 9-7 Severe weather, like tornadoes, can have a serious

impact on the environment and population health.

The United States is experiencing more frequent and severe weather

events. In 2018, extreme weather events caused damage and destruction
across the United States. Colorado, Maryland, Michigan, North Carolina,
South Carolina, and Wisconsin all experienced 1,000-year rainfall events
with severe flooding. A 1,000-year event means that there is a 0.1% chance
of such rainfall occurring in any given year (The Weather Chanel, 2018).
In addition, California experienced devastating wildfires (Box 9-13),
Alaska had a 7.0-magnitude earthquake, and EF3 tornadoes were reported in
Montana, South Dakota, and Virginia. Loss of power and homes, and
disruption of services from flooding, fires, earthquakes, tornados, and
hurricanes, put many people at risk from natural disasters. Category 5
hurricanes ravaged the Bahamas and Puerto Rico (Korten, 2019).

BOX 9-13 PERSPECTIVES

812
A Nurse's Viewpoint on a California Wildfire In
November 2018, California experienced the worst
wildfire in its history to date. Eighty-eight people
lost their lives and 12,000 homes were destroyed.
The town of Paradise, California, was engulfed in
flames, and nurse manager, Allyn Pierce, was
among the last to evacuate patients from the
town's hospital. As they traveled through the
evacuation route with heavy traffic and smoke
fires burned on both sides of the road, Mr. Pierce
knew that his family had already been evacuated
to safety days earlier. After a harrowing
evacuation, he returned to the hospital to assist
first responders, physicians, and other nurses help
smoke inhalation victims and those with more
serious injuries. Afterwards, Mr. Pierce reported
that although he was frightened for his own safety,
he did what nurses are trained to do, remain calm,
work within the team, and address the situation.
He also reported that following the wildfires, he
has had unsettling moments where he sees fires in
his sleep.
In addition to the loss of life and property, the air quality in the surrounding
area had reached the “dangerously unhealthy” range for 10 consecutive
days requiring San Francisco bay area (roughly 170 miles away) to close
schools and issue warnings to limit outdoor activity.
Source: Santiago (2018).

Whereas Chapter 17 discusses disasters and the role for public health,
this chapter covers some specific issues related to environmental risks that
occur after severe weather events or disasters that are important for C/PHNs.
These include power outages, safe water and food supply, wastewater, mold,
toxic exposures, and poor air quality (EPA, 2012, 2020g).

813
 For example, when there is a power outage, many families depend upon
generators to supply electricity. These can be a source of carbon monoxide
poisoning if not effectively functioning or not well ventilated. During cold
weather, families may use wood or kerosene for heat that can pose danger of
fire, explosion, and asphyxiation from carbon monoxide, but kerosene
heaters can also emit other pollutants including carbon dioxide, nitrogen
dioxide, and sulfur dioxide.
In particular, pregnant women, asthmatics, individuals with
cardiovascular disease, older adults, and young children are at particular risk
from these toxic emissions. Nurses must inform community members of
safety in the home when using alternate sources of heat or power (Wisconsin
Department of Health Services, n.d.).
If a home is without power, there is a risk for food storage and safety. If
the home has a well and water pump, there may not be access to potable
water during the power outage. Community members should be informed of
issues related to safe storage of food and the need to dispose of improperly
refrigerated foods.
Homes that have septic systems may find that they have overflowed if
there is any flooding from a severe storm. It is important to understand when
it is safe to return to well or septic system use after ground-level flooding.
Floods also pose a problem to residents who have water enter their
homes. Standing water can cause mold and mildew, possibly harm home
furnaces, pose a risk of fire, and release toxins into the water and air. Small
children and older adults are at more risk of environmental exposures during
and after a natural disaster, and the C/PHN must address not only emergency
planning but also safe remediation strategies to avoid toxic exposures among
community members (EPA, 2020g).

814
GLOBAL ENVIRONMENTAL
HEALTH
Nurses must engage in strategies to protect human health in their
communities through the core functions of public health: assessment, policy
development, and assurance. To effectively do this, nurses must think
globally in order to be effective locally. This means adopting an ecological
perspective related to impacts on human health.
By broadening our perspectives, consideration of foods imported from
countries around the world, toys made in other countries and used in the
United States, and the manufacture of products in locations where the
regulations for safety are not as stringent (or in some cases more stringent) as
in the United States is helpful for nurses in addressing environmental health
knowledge and advocacy. See Chapter 7 for an example.
Nurses who endorse “green nursing” by promoting more ecological and
environmentally safe practices in their workplace are making an impact upon
global environmental health. The UN SDGs call on us to think more broadly
as global citizens of the multiple factors that influence thriving communities
and thus enhance human health. See Chapter 16.
Climate change reinforces that we are one ecosystem. What is placed in
the environment, in the form of greenhouse gases affects the entire planet
and the human family. Although it is now illegal in most countries to dump
waste into the ocean or to ship waste to less developed countries that have
less stringent laws to protect their citizens from toxins, large quantities of
toxic industrial waste, medical waste, toxic ash from incinerators, as well as
the growing issue of e-waste from computers and other electronic products,
have found their way to ocean waters and poorer countries. In order to fully
promote the health of populations, nurses must take personal action to reduce
their use of products (particularly those with toxic chemicals), reuse as much
as possible, and recycle (in safe processes) to decrease their personal
environmental footprint (ANA, 2015a; EPA, 2020c). Nurses must also
incorporate the environmental health knowledge and skills mandated by the
ANA Scope and Standards of Nursing Practice into their nursing practice
(ANA, 2015b). See Chapter 16 for more on global health issues.

815
SUMMARY
Environmental health is a discipline encompassing all of the elements of
the environment that influence the health and wellbeing of its
inhabitants.
C/PHNs include environmental health in their practice by:
Accessing environmental information from reliable resources
Relying on environmental frameworks such as HIA and the
precautionary principle to determine and address risk
Utilizing an upstream approach to reduce environmental risk
Monitoring for causal links between people and their environments
Including an ecologic perspective by linking the human–
environment relationship and how the health of one affects the
health of the other
Addressing specific needs of groups that are vulnerable to
environmental risk
Understanding that what is done today may affect the health of
future generations
Both public and private sectors are involved in regulating, monitoring,
and preventing environmental health problems.
Utilizing the core functions for public health, the C/PHN recognizes the
key role of assessment, assurance, and policy development to influence
change in the health of individuals, families, communities, and the
environment.
The C/PHN should be a leader of the team of health professionals who
promote and protect the reciprocal relationship between the
environment and the public's health.

816
ACTIVE LEARNING EXERCISES
1. How important is engaging in climate mitigation and adaptation? This
effort has met with resistance from a variety of people. There are
several organizations that have examined messaging climate and
health risk.
a. Examine the Yale Climate Opinion Map at
http://climatecommunication.yale.edu/visualizations-data/ycom-
us-2018/?est=personal&type=value&geo=county&id=42029.
b. Select your state and county or a state and county of interest.
c. Choice five topics in the select topic response for the selected state
and county. Look at the county level response to the topic you
selected. Were you surprised by the response? Why or why not?
How can you address this as a C/PHN?
2. Review EcoAmerica's 15 Steps to Create Effective Climate
Communications found at https://ecoamerica.org/wp-
content/uploads/2017/03/5_ea_15_steps.pdf
a. Given what you learned about the county you examined in
question 1, how would you communicate climate risk with the
selected county?
b. Would you change the message between your selected group and
your family? Why is there or is there not a difference in your
communication?
3. Have you heard alerts on TV or radio or seen Internet reports about
unhealthy air quality? Do you know what toxic substances are in your
community's air? How do these may impact you and sensitive groups
such as children and older adults?
a. You can find out by examining the EPA's MyEnvironment and
AirNow Web sites (http://www.airnow.gov/). Other helpful sites
may be found through the CDC, the EPA, and local air resources
board or agencies. Go on a computer scavenger hunt and see what
you can find.
b. Look around your city or neighborhood. What are the most
common environmental hazards? Visit the EPA
“MyEnvironment” site. Look at the AQI and air facilities on the
map on this site. Be sure to read about radon too. How might
these impact the air you breathe?
c. Find the AirNow Web site and enter your zip code. For your city
or area, which three companies have the highest amounts of
emissions? Are there any VOCs, metals, or polycyclic aromatic
hydrocarbons listed for the top company?

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 d. If you were an OHN, what safety measures would you want in
place to respond to accidental exposures to these chemicals?
What could you do for emergency first aid until assistance
arrives?
e. If you were a school nurse, what would be your concerns for the
children's exposures to air pollution?
f. If you were a home care nurse, what would be your concerns for
the elderly patients you care for?
4. To explore personal care and cleaning products in the hospital setting,
on the ToxTown site (https://toxtown.nlm.nih.gov), next to Sources of
Exposure, click on “Explore,” scroll down to Health Care Services,
and then click on the “Hospitals” link.
a. Select one possible chemical exposure in the hospital setting. Read
the information about exposure risk including the ASTDR Web
site source offered at the bottom of the web page.
b. Select a personal care product that you use (shampoo, conditioner,
moisturizer, deodorant, etc.). Visit the EWG Web site Skin Deep
database https://www.ewg.org/skindeep/ of commonly used
products. Search for the item you selected and identify the risks
posed to your personal health and that of your patients.
c. Visit the DHHS Web site for the Household Products Database
(https://householdproducts.nlm.nih.gov), and examine other a
common product that you use at home (cleanser, pet care
products, pesticide). Review the information for health risks.
d. Finally, consider a population group (neonates, adolescents, older
adults) in the community that might be at risk when using any of
the products you reviewed, and consider how you might educate
that group about their exposures.
5. As a nursing student, it is important to know about common
community hazards in order to educate community members. Visit
the EPA's MyEnvironment Web site, and enter you home zip code or
that of the community where you work. The link for this site is
http://www3.epa.gov/enviro/myenviro/.
There you will find headings for MyMaps, MyAir, MyWater,
MyEnergy, MyHealth, MyClimate, MyLand,
MyEnvironmentReports, and MyCommunity.
a. Look through these headings to identify the hazards in your
community. What is the air quality? Are there particular
industries, power plants, or high areas for auto emissions that
affect health? What about water quality? Are there significant
toxic waste sites? What types of exposures are there in the
community?
b. Can you identify possible risks from climate change and severe
weather events? What might be ways to assure emergency

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 preparedness for those most at risk?
c. Using the framework for this chapter, the core public health
functions, select a strategy that is most appropriate for your
community for each area: assessment, policy development, and
assurance.
6. Conduct a walking tour of a community. Consider housing stock,
industry, the built environment, and open space.
a. What do you observe that could be an environmental risk for this
community?
b. Do you observe specific vulnerable populations in the
community?
c. Use the resources at the EPA Web site, including MyEnvironment,
and develop a list of five recommendations to reduce
environmental health risk in the community you observed.
Identify why these are an environmental health risk for this
community.
d. Describe which of the 10 essential public health services applies
here.

thePoint: Everything You Need to Make the

Grade!
Visit http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, study aids for
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819
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 UNIT 3
Community/Public Health
Nursing Toolbox

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CHAPTER 10
Communication, Collaboration, and Technology
“Think like a wise man but communicate in the language of the people.”

—William Butler Yeats (1865–1939)

KEY TERMS
Active listening
Asset-based community development (ABCD) Big data
Brainstorming
Community-based participatory research (CBPR) Critical pathway
Electronic health records (EHRs) Emotional intelligence (EI) Feedback loop
Geographic information system (GIS) Group process
Health literacy
Health technology
Integrative strategies
Interpersonal skills
Mobile health (mHealth)
Nominal group technique
Telehealth

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Describe five barriers to effective communication in community/public
health nursing and how to deal with them.
2. Summarize the key issues related to health literacy.
3. Explain the stages of group development.
4. Discuss the value of contracting to both clients and community/public
health nurses.
5. Design a contract useful in community/public health nursing.
6. Debate the pros and the cons of using electronic health records.
7. Describe the unique features of big data and areas of public health where
it is most helpful.
8. Explain the main trends in mobile health and give a public health–
related example of each.
9. Identify a current example of the combination of data and geographic
information system applications in public health.

838
INTRODUCTION
Although you have learned how to effectively communicate with your
patients in acute care settings, communication with community/public health
nursing (C/PHN) clients entails additional skills and techniques.
Communication, collaboration, and contracting are primary tools for
community health nurses. They form the basis for effective relationships that
contribute both to the prevention of illness and to the protection and
promotion of population health. Health literacy is a concept that is important
because of its relationship to health promotion and disease prevention and
management. For the nurse accustomed to communicating one-on-one with
clients, communicating with community groups requires new skills, because
the effective application of group process skills facilitates collaboration with
both task and support groups. Unlike ordinary social relationships,
collaborative relationships

Are based on a team approach, with shared responsibilities and mutual

participation in establishing and achieving goals
Involve working creatively across sectors and disciplines
Lead to improved health outcomes
Foster organizational commitment

Health technology serves as a powerful equalizer for improving health

education and access to care among vulnerable and minority populations by
reaching people where they are and in whatever environment they live. This
chapter examines these tools and discusses their integration into C/PHN
practice.

839
COMMUNICATION IN
COMMUNITY/PUBLIC HEALTH
NURSING
Effective communication is vital to all areas of nursing but is considered to
be a fundamental core competency needed in C/PHN practice. The Quad
Council Community/Public Health Nursing Competencies (Quad Council
Coalition Competency Review Task Force, 2018) include communication
skills as one of the eight competency domains (see the appendix). Nurses
working in community/public health must be skilled in effective
communication to be able to maintain relationships with individual clients,
families, the community, members of the health care team, and community
partners (Joyce et al., 2018). The lack of effective communication can lead to
misunderstanding, poor performance, interpersonal conflict, ineffective
program development, and medical mistakes, all resulting in poorer health
outcomes. Whereas ineffective communication is one of the major causes of
preventable adverse events in acute care settings (Robertson & Long, 2018),
effective communication skills empower community/public health nurses to
(Hansson et al., 2017)

Provide quality health care and health education that improves patient
outcomes
Advocate effectively for clients, families, and populations
Enhance professional collaboration and organizational commitment
Initiate public health policy
Implement programs designed to meet the needs of clients despite
societal, organizational, and individual obstacles

Successful nurses must use both sound clinical skills and good
communication skills (Arnold & Boggs, 2016). Necessary communication
skills include soliciting input from others and listening to others in a
nonjudgmental way.
Communication provides a two-way flow of information that nourishes
nurse–client and nurse–professional relationships. For communication to take
place, client and professional messages are sent and received. As participants
in the communication process, community/public health nurses play both
roles: sender and receiver. The nurse must be able to elicit ideas as well as
contribute to the planning process by speaking and acting in ways that
promote information sharing.

840
The Communication Process
Communication in its simplest form is the sending and receiving of a
message, a process by which one assigns and conveys meaning to create
shared understanding. This process incorporates the conventional aspects of
communication: sender, receiver, message, channel (e.g., verbal, nonverbal,
social networking), encoding, decoding, and feedback (e.g., checking the
message meaning, revising for clarity) (El-Shafy et al., 2017). Effective
communication is seen only when the message sent is received and
interpreted by the receiver as intended (Borkowski, 2016 and Slade et al.,
2018). This process forms a communication loop, which is shown in Figure
10-1.

FIGURE 10-1 The communication process.

841
Strategies to Overcome Communication Barriers
Community/public health nurses should be aware of the barriers that block
effective communication (Box 10-1).

BOX 10-1 Barriers to Effective

Communication in Community/Public
Health Nursing
Selective Perception Individuals interpret a
message through their own perceptions, which
are influenced by their own experience,
interests, values, motivations, and expectations.
This perceptual screen leads to possible
distortion or misinterpretation of the meaning
from the sender's original intent. Nurses can
overcome this barrier by using the feedback
loop to ask clients to voice their understanding
of the message they just received from the
nurse. This enhances clarification and
correction of misunderstandings, which is an
essential step in the communication process.
Filtering
Filtering is described as manipulation of information by the sender in
order to make it seem more favorable to the receiver (Cain, Surbone,
Elk, & Kagawa-Singer, 2018).
Clients sometimes use filtering during the assessment process,
giving only partial or distorted information because they think this is
what health professionals want to hear. Filtering can also affect
community/public health nurses. Cole (1990), in a classic work, notes
that we have “filters” through which we view others—often influenced
by culture, ethnicity, and socioeconomic class or even gender—and
these can lead to miscommunication. Cole's premise is that people from
different backgrounds actually view the world differently, thus

842
confounding communication and leading to prejudice and stereotyping.
Community/public health nurses should consider their communication
style and those of the people with whom they come in contact (Cain et
al., 2018).

Emotional Influence How a person feels at the

time a message is sent or received influences the
meaning. Emotions can interfere with rational
and objective reasoning, thus blocking
communication. Nurses need to be aware of
their own emotions and the emotional status of
clients or health professionals with whom they
are communicating. For example, it is
important for community/public health nurses
to remain calm and unruffled when dealing
with families in crisis. Family communication
may be angry, blaming, and confrontational
because of a child's serious health crisis, for
instance. A calm, firm, reassuring presence can
go far in diffusing the situation and promoting
clearer and more constructive communication.
You may say, “I sense that you are feeling upset
about Joey's diagnosis. Are there any questions
I can answer for you? How can I be of help to
you?”
Language Barriers People interpret the
meaning of words differently, depending on
many variables, such as age, education, cultural
background, and primary spoken language. For
example, an adolescent might understand the
term “lit” to mean that something is good or
exciting, whereas an 80-year-old person might

843
 understand the word refers to lighting. In the
community, nurses work with a wide range of
clients and professionals whose disparate ages,
education levels, and cultural backgrounds lead
to different communication patterns.
Language of Nursing The context of health care
provides nurses with a unique vocabulary that
may not be understood by clients, family, and
community members. The use of scientific
terminology or jargon by some health
professionals can be confusing to clients.
Communication techniques would be different
when educating a new mother on proper
breastfeeding techniques than when discussing
community health needs with the director of a
public health department (Cain et al., 2018).
Source: Cain et al. (2018); Cole (1990).

Overcoming barriers to effective communication requires the

development of sound communication skills, including sending, receiving,
and interpersonal skills.

Establish Trust and Rapport

Nurses are considered to be knowledgeable professionals who have standing
within the community. Those working for public health agencies have power
and authority as representatives of a government agency. Clients may feel
apprehensive about C/PHNs entering their homes. Therefore, it is essential
for the nurse to demonstrate respect for the client, especially for those clients
who lack self-respect. Having an appreciation for the dignity and worth of all
individuals, being nonjudgmental, and demonstrating empathy (acceptance
and acknowledgement of the client's situation and feelings) are prerequisites
for successful communication with clients in the community setting
(Townsend & Morgan, 2018). To establish trust and rapport with clients,
nurses must

844
 Develop a relationship with the client, not just around the public health
issues of interest to the nurse but concerning the client's life and
challenges
Over time, by being consistently trustworthy, reliable, sincere, and
truthful with clients

To promote trust, nurses can

Commit to develop knowledge and experience of the client and their

situation
Clarify expectations, anticipated behaviors, and boundaries of the
nurse–client relationship
Be aware of attitudes and behaviors that do not promote trust (Springer
& Skolarus, 2019)

Many factors that are often shaped by clients' cultural background and
upbringing influence trust and rapport. For many, the societal norm is to
agree with someone in a position of authority, such as a community/public
health nurse, even if they do not fully understand what that person is
communicating. This can lead to mistrust and poor client outcomes.
Establishing a trusting relationship can empower clients to accomplish
important lifestyle changes (Box 10-2). However, it is important to keep in
mind that although nurses have a good deal of knowledge and education, to
be effective they must appreciate the knowledge gained by clients through
life experiences and the environments in which they live (Strandas &
Bondas, 2018). An “analogy about shoes” is helpful in understanding this; it
involves a shoemaker and a shoe customer in a classic story by Clement and
Roberts (1983, p. 192): The shoemaker is an expert in making shoes, but the
shoe wearer can tell if the shoe made by the shoemaker is uncomfortable and
can give the shoemaker important information (e.g., exactly where it
pinches). If both appreciate the knowledge that each one possesses and can
work together, a comfortable shoe can be the outcome.
Showing respect is a fundamental behavior that conveys the attitude that
clients and others have knowledge, importance, dignity, and worth (Sabatino,
Rocco, Stievano, & Alvaro, 2015). C/PHNs can work with clients in many
ways to change their lives for the better, but just like acute care nurses need
to “know the patient” in the hospital setting in order to pick up subtle cues
that may indicate serious problems, we must begin with what is important to
the client rather than our own agenda (Johansson & Martensson, 2019, p.
120). A new nurse making a home visit to a mother who has missed several
immunization clinic appointments for her infant may think that the mother
needs only information on why immunizations are important for her baby.
However, the mother may be dealing with an abusive husband who has drug
and alcohol problems. If the nurse begins the visit with a reminder about the

845
missed appointments and the potential consequences involved, it may end
abruptly. It is best to begin by asking about the client's concerns so the nurse
can gain a deeper understanding of the client's experiences, fears, and
perspectives while communicating a demeanor of understanding and the
intention to help (Gholamzadeh, Khastavaneh, Khademian, & Ghadakpour,
2018).

BOX 10-2 Evidence-Based Practice

Community/public Health Nurse–Client
Communication Evidence-based research has
verified the importance of establishing rapport
and trust, understanding clients, and the
complex communication skills used by nurses
with their clients. For trust to occur, the nurse
must be accessible and available, be competent,
and have a good bedside manner, and the
client's past experiences with the health care
system must be positive (Ozaras & Abaan,
2018). A trusting relationship is developed over
time and is dynamic and changing; it is a
reciprocal relationship, and the nurse earns
continued trust by meeting patient expectations.
Characteristics of the nurse that facilitate trust
include being honest, sensitive, authentic,
respectful, caring, accepting of the patient,
encouraging, and committed to giving good
care. Barriers include the use of professional
jargon, not listening for understanding, being
neglectful, being incompetent, and having
power struggles. The trust relationship is
negotiated over time and becomes more stable
as the patient feels respected and accepted and

846
 values the ethical and moral practice of the
nurse.
Talk with your instructor and community/public health nurses about
these findings. Do they concur? How can you use this information to
promote more effective trusting relationships with your clients? What
experiences can you draw upon that may promote an understanding of
how trust affects the relationship of the client and community health
nurse?
Source: Ozaras and Abaan (2018).

Actively Listen
An essential skill is active listening, also referred to as reflective listening
(Hardavella, Aamli-Gaagnat, Saad, Rousalova, & Sreter, 2017). Active
listening is the skill of assuming responsibility for and striving to understand
the feelings and thoughts in a sender's message, thus giving importance to the
person speaking (Karp, 2015). Skills that promote active listening (see Fig.
10-2) include the following:

FIGURE 10-2 Six key skills for active listening. (Source: Center
for Creative Leadership. (2019). Active listening: Improve your
ability to listen and lead. Greensboro, NC: Author.)

Being attentive and mindful: Being focused and engaged in

conversation with your client gives insight into the client's frame of
mind, reactions, and body language (Raphael-Grimm, 2015).
Conveying a nonjudgmental attitude: Keeping an open mind, having
interest in what your client is saying, and not arguing help build client
self-confidence.
Using reflection: Mirroring the client's message by occasionally
paraphrasing key points demonstrates empathy and shows the client you
can view the world through the client's eyes.
Asking for clarification: By asking probing questions to clear up
ambiguity or to expand on the client's ideas, you check your
interpretation of their message, closing the loop and preventing
communication breakdowns.

847
 Summarizing: By restating key themes of your conversation, you
ensure that you understand the true nature of the message and help the
client reflect and focus on issues raised (Schumacher & Madson, 2015).
Sharing: Explain your ideas, feelings, or messages only after client
indicates readiness and you have first fully understood the other
person's views (Center for Creative Leadership, 2019; Harmon, 2016;
Schumacher & Madson, 2015).

Active listening with nonjudgmental empathy (see Fig. 10-3) helps to

communicate acceptance and increase trust (Heslip, 2015). It also allows for
an accurate understanding of another person's viewpoint and helps to bring
issues and concerns into the open, where they can be more easily resolved
(Canpolat, Kuzu, Yildirim, & Canpolat, 2015). However, our own personal
beliefs and values may confuse the message. A critical response to the
client's message by the nurse can cut off communication and cause the client
to disengage; therefore, a nonjudgmental approach better supports a
therapeutic relationship (Karp, 2015). Students interested in learning more
about active listening skills can listen to a podcast developed by the Centers
for Creative Leadership (2019), which may be found at
https://www.ccl.org/multimedia/podcast/the-big-6-an-active-listening-skill-
set/.

FIGURE 10-3 An example of active listening.

Communicate Clearly
The CDC hosts a site that provides valuable resources to augment clear
communication, including a clear communication index use guide, index
widget, example material, and everyday words for public health
communication found at https://www.cdc.gov/ccindex/. The basic rules for

848
effective verbal or written communication can be summarized in this
manner:
1. Use everyday words.
2. Use as few words as possible.
3. Use active voice.
4. Ask for feedback to make certain that the message is understood (CDC,
2019d).

849
Promoting Effective Communication and Change:
Motivational Interviewing and OARS
Many techniques promote effective communication. One of the most
successful is using motivational interviewing (MI) to join with clients to help
them change behaviors. MI was first developed as a method of counseling to
break through ambivalence and motivate clients to change problem behaviors
such as excessive drinking (Miller & Rollnick, 2013). It involves having a
conversation that establishes a “collaborative partnership” with the client
about change and is focused on client feelings of ambivalence regarding the
need for change. The nurse elicits client motivations and ideas about change
(Schumacher & Madson, 2015, p. 2). This technique can be used in
conjunction with the Transtheoretical or Stages of Change Model to
determine the client's stage from his or her statements (see Chapter 11).
Listen carefully to what the client is saying about the issue (e.g., smoking,
hypertension, dietary changes), and determine if the client is amenable to
making changes (see Box 11-3). Clients in the last three stages are most
amenable to change, and MI can then be most helpful (Haque & D'Souza,
2019; Schumacher & Madson, 2015).
OARS is an acronym encompassing the skills needed in MI:
Open-ended questions: Rather than closed-ended questions that often result
in only Yes or No answers, these questions open up conversation and help
clients talk about thoughts and feelings, as well as behaviors and motivations
for change. An example follows:
Nurse: “What are your concerns for your baby (Rose)?”
Affirmations of client strengths: These are genuine and congruent statements
about clients' positive behaviors, skills, and accomplishments. An example
follows:
Nurse: “You were very caring in comforting Rose while she was getting her
shots.”
Reflective listening: Similar to active listening, discussed earlier. It helps
discern what the client is saying and if the nurse is hearing and understanding
the client's meaning. Reflective comments demonstrate empathy and
understanding and can move conversations to deeper levels. An example
follows:
Nurse: “So it sounds like you would like some information on how to sign up
for WIC.”
Summaries: Statements used to move the conversation into different areas or
to review final highlights of a conversation; can also be helpful in adding
information about resources or future planning. Two examples follow:
Nurse: “Let me see if I understand what you said so far….”

850
Nurse: “We talked about x, y, z; let me know if I understood you correctly or
missed anything.”
Through MI conversations, client statements may reflect indecision or
motivation to change. If motivated to change, clients may discuss their
desire, ability, or reasons for change along with importance and urgency. The
nurse can help them mobilize these feelings by asking open-ended questions
about their commitment to change, how they could begin to plan for change,
and other steps they need to take to move toward their goal (Dobber et al.,
2019; Palmer, 2018; Schumacher & Madson, 2015). See for a list
of Web sites that offer more information on MI and OARS, including
suggestions for open-ended questions and shared decision making.
Research demonstrates the effectiveness of MI and OARS delivered by
counselors (including lay counselors), physicians, nurses, and nurse
practitioners working with a variety of clients:

Heart failure patients with depression (Navidian, Mobaraki, & Shakiba,

2017)
Patients with inflammatory arthritis (Palmer, 2018)
Coronary artery disease patients (promoting a healthy lifestyle; Dobber
et al., 2019)
Individuals with HIV (Dillard, Zuniga, & Holstad, 2017)
Intimate violence partner treatment clients (Soleymani, Britt, &
Wallace-Bell, 2018)
Appalachian women (supporting breastfeeding; Addicks & McNeil,
2019)

Emotional Intelligence
The concept of emotional intelligence (EI) is central to nursing practice. EI
is the ability to recognize and understand one's own emotions and those of
others as well as to manage one's own emotions so as to be able to adjust
appropriately to a wide range of situations (Goleman, 1995; Park & Oh,
2019; Raghubir, 2018).
Studies have shown that nurses who possess a high level of EI have
increased job performance and job satisfaction, both of which lead to
improved health outcomes (Park & Oh, 2019; Raghubir, 2018).
Recently, EI has further been defined as an eclectic mix of traits or
attributes. The five most widely recognized attributes are self-awareness,
self-management, social skills, motivation, and empathy (Raghubir, 2018;
Goleman, 1995). People who demonstrate high levels of EI

Consider other people's feelings

Examine their own feelings and how they react to stressful situations

851
 Practice empathy for others and relate to them in conversation
Operate on trust, by communicating honestly and building trust through
verbal and nonverbal cues
Recognize, identify, and resolve ambiguity or misunderstandings
Take responsibility for their own actions
Consider how their actions affect others (Ackerman, 2019)

Table 10-1 details online sites that offer free testing to assess your level
of EI.

TABLE 10-1 Online Sites Offering Free Emotional Intelligence

Testing

A person can increase EI attributes through training and practice.

Practice focuses on making a conscious effort to display the positive
behaviors indicated above. MindTools has a number of online resources at
https://www.mindtools.com/search?search_term=Emotional+Intelligence.
Formal training is also available through a variety of programs found online.
In a helping relationship, it is important for the community/public health
nurse to demonstrate effective communication. Box 10-3 lists key
components that assist in promoting a helping relationship.

BOX 10-3 Characteristics of a Helping

Relationship In a helping relationship, it
is important to promote

852
 Openness, genuineness, trustworthiness, and self-awareness
(ability to reflect on one's strengths and weaknesses)
Sensitivity, acceptance, and concern for the client
Respect for the client as an individual, which includes
Encouraging client to take an active role in health care and to
be included in all decisions and choices
Considering ethnic and cultural backgrounds
Considering family background, beliefs, and values
Knowledge, self-confidence, creativity, compassion, and empathy
Ability to problem solve and to confront or direct when necessary
(Ozaras & Abaan, 2018)
Source: Ozaras and Abaan (2018).

Cultivating Cultural Awareness

Effective communication is also strongly influenced by previous experiences
and the culture of both the nurse and the client. For example, adolescents
who are having difficulty with authority may hear the nurse's suggestion to
“learn more about sexually transmitted diseases” as an authoritarian
command or an effort to exert control. Differences in culture, ethnicity, and
linguistics pose even greater challenges in establishing a helping relationship
(Box 10-4).

BOX 10-4 PERSPECTIVES

Mr. Sanchez Needs an Interpreter I am a student

in community/public health nursing now, but I
work as an extern at our small, local county
hospital helping in the emergency department
(ED). A man came in one Saturday a month or so
ago with a bad cut to his right hand from a
manual push lawnmower. The ED doc asked him
if he had received a tetanus shot recently, and he
quickly nodded “yes.” He spoke little English, and

853
none of us spoke Spanish. The interpreter was not
available. We cleaned his wound, closed it with
stitches, bandaged it, and told him to keep it clean.
He was given a prescription for an antibiotic
medication, but a tetanus shot was not
administered.
A short time later, Mr. Sanchez was back in the hospital because his wound
had gotten infected; he used a needle to drain some pus from his hand and
developed tetanus. He ended up in the ICU on a ventilator. Mr. Sanchez
spent 30 agonizing days in the ICU because of miscommunication about the
tetanus booster. We should have used an interpreter, and I truly understand
the importance of a translator now. I have some Spanish-speaking clients in
my community/public health nursing rotation. I do my best to speak with
them, and they are usually very welcoming and patient, but when I need to
be sure that something is fully understood, I request that an interpreter
accompany me on my home visits. I always remember Mr. Sanchez and
what can happen when you don't use an interpreter, and communication is
not clearly understood.

1. What first comes to mind when you think of this scenario?

2. Can you imagine an incident like this occurring in your facility?
3. What barriers exist in using an interpreter? How can communication
and understanding be validated in a situation where language is a
barrier?

Amy, age 24

Community/public health nurses often find themselves communicating

cross-culturally and sometimes through an interpreter. This requires patience
and constant effort to ensure accurate and inoffensive messages. For
example, silence in Native American cultures may indicate patience and
thoughtfulness, but someone not familiar with these cultures may interpret it
as weakness or indifference. Culture is dynamic, and community/public
health nurses cannot make assumptions about a client's cultural background,
but it has been shown that knowledge of someone's cultural background can
aid in providing quality care within the cultural context of the client
(Crawford, Candlin, & Roger, 2015; Henderson, Horne, Hills, & Kendall,
2018). See Chapter 5.

854
Health Literacy and Health Outcomes
Health literacy is essential to client autonomy and good client outcomes.
Any client in need of health services or information needs health literacy
skills to:

Access services and information.

Communicate individual needs and preferences.
Internalize the meaning of health information and services available.
Grasp the context, options, and resulting consequences in health
settings.
Make choices that are aligned with their preferences and needs (CDC,
2019c).

Health literacy is critical to health promotion, and disease prevention

encompasses cultural, scientific, media, and technological literacy (Feinberg,
Tighe, Greenberg, & Mavreles, 2018). Vulnerable groups such as older
adults, recent immigrants, migrants, ethnic minorities, and clients with low
levels of education and dominant language proficiency are most affected by
low health literacy (Johnson, 2015).
Presenting information in a manner that matches the clients' health
literacy level can help address health disparities and empower clients to
effectively manage their health by

Understanding and complying with self-care instructions, including

complex daily medical regimens
Planning and attaining necessary lifestyle adjustments to improve their
health
Making positive, informed health-related decisions
Knowing when and how to access necessary health care
Addressing health issues in their community and society by sharing
health-promoting activities with others (Feinberg et al., 2018)

Health information is disseminated in person, in print, and online, so

health literacy is relevant to all of these processes (Rowlands, Berry,
Protheroe, & Rudd, 2015). Clear communication is important to outcomes;
one example is the link between the level of health literacy among rural heart
failure patients and morbidity and mortality rates (CDC, 2019d; Moser et al.,
2015; Nouri & Rudd, 2015). In addition, adequate health literacy among the
nursing population is imperative in addressing the problem. A study by
Erunal, Ozkaya, Mert, and Kucukguclu (2019) revealed that approximately
50% of nursing students failed to demonstrate adequate health literacy skill
levels. Hence, it is vital that nursing students (and nurses) improve health

855
literacy skills to communicate effectively with clients and fellow health care
personnel (Erunal et al., 2019).

Low health literacy skills are associated with poorer health status,
increased health care costs, and use of emergency care, because patients
with low health literacy levels are less knowledgeable about their health
conditions and are less likely to seek preventative care, especially in
older adults (≥65 years of age; Fabbri et al., 2018; Mantwill & Schulz,
2015).
Children with caregivers who have low literacy skills have poor health
outcomes, because the caregivers are less knowledgeable about their
child's condition and less likely to engage in behaviors to help improve
it (Kakarmath, Denis, Encinas-Martin, Borgonovi, & Subramanian,
2018).

The federal government has set standards to encourage health

professionals to consider clients' health literacy when communicating with
them. Table 10-2 details the most relevant acts, guidelines, and standards
addressing our nation's health literacy goal.

TABLE 10-2 Acts, Guidelines, and Standards on Health

Literacy

The U.S. Department of Health and Human Services (USDHHS)

developed the National Action Plan to Improve Health Literacy based on the
vision and principles that “(1) everyone has the right to health information
that helps them make informed decisions and (2) health services are
delivered in ways that are understandable and beneficial to health, longevity,
and quality of life” (USDHHS, 2010, p. 16). Online health literacy
suggestions are found in Box 10-5.

BOX 10-5 Health Literacy Online:

Helpful Suggestions for Digital Access
People often search the web for answers

856
 to a specific question or problem or to
gain knowledge of a particular subject.
They want to
Have a better understanding of the health problem or behavior
Learn about actions they can take to change the behavior or deal
with the problem
Find information that is concise, focused, engaging, and actionable
Checklists, conversation tools, or interactive features improve
engagement

Individuals with limited health literacy may get easily distracted;

they decide within the first few words or sentences if they can
understand the content and want to keep reading.

Start with the most important information to pique their interest.

Briefly describe the health behavior or problem to hold their
interest.
Describe the benefits of changing a behavior or addressing a
problem to motivate them.
List specific steps or actions to take. Break the information into
small steps, and use bulleted points.
Use plain language, including short, simple sentences and
paragraphs, no jargon (only common language used by clients),
and active voice. (An example is “You need to have a yearly
mammogram.”)
Use simple sans serif (e.g., Verdana, Arial, Calibri) fonts in 12-or
14-point sizes.
Identify links with color or underlining so users can easily click on
them.
Use images or graphics to reinforce your message and to ensure
your meaning is clear.
Check the accuracy of your content.
Source: DeSalvo (2016).

To be sure that these goals are being met, the improvement of health
literacy and health communication for our population continues to be a
priority in the Healthy People 2030 goals (Box 10-6).

BOX 10-6 HEALTHY PEOPLE 2030

857
Selected Objectives Related to Health Literacy or
Health Communication

Reprinted from U.S. Department of Health and Human Services (USDHHS). (2020a). Browse 2030
objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives
Health communication includes health literacy, but it also incorporates
health messages and campaigns targeted to populations. Population health
promotion is best achieved by health communication that uses multiple
communication channels to reach stakeholders, including television, radio,
newspapers, Web sites, social media, smartphones/applications, text
messaging, educational pamphlets, and nutrition and medication labels. To
manage disease and promote health, we must make sure our patients can
understand the health information they see, hear, and read from multiple
sources (Feinberg et al., 2018). More information on these topics can be
found in Chapter 11.

858
COMMUNICATING WITH GROUPS
An important aspect of communication in C/PHN involves working with
groups of people. C/PHNs are regularly involved in committees, task forces,
support groups, and other work-related groups (Fig. 10-4). Group
communication patterns can be complex, and interaction requires skill on the
nurse's part to elicit feedback from all members to generate a common
understanding among the group's members. C/PHNs need to understand how
to organize groups and how groups function and develop over time as well as
techniques for facilitating group support and decision making.

FIGURE 10-4 An example of a functioning group.

859
Group Development
In 1977, Tuckman and Jenson identified five stages of group development: 1.
Forming

Members: feel awkward and hesitant and depend on the group leader to
help them develop mutual trust and give them structure and guidance
(Carter & Mossholder, 2015)
Group leader: helps members become oriented to each other and to the
work
“Ice-breaker” activities at the first group meeting
Setting of ground rules (e.g., confidentiality)
Defining scope of work and timeline for completion (Box 10-7)

BOX 10-7 Task, Maintenance, and

Nonfunctional Roles in Groups Task
Role Behaviors
Behaviors required in selecting and carrying out group tasks include the
following:

Initiates Activity: Proposes solutions; suggests new ideas and new

approaches to the problem
Seeks Information: Asks for clarification and requests additional
information
Seeks Opinions: Looks for input from members; seeks
clarification of values, suggestions, or ideas
Gives Information: Offers facts or observations; relates one's own
experiences to the group problem
Gives Opinions: States an opinion or belief related to concerning a
suggestion; generally based on value rather than its factual basis
Elaborates: Envisions how a proposal might work if adopted;
gives examples and clarifies meaning
Coordinates: Shows relationships among various ideas or
suggestions; draws together activities of various subgroups or
members
Summarizes: Restates a summary of suggestions after the group
has discussed them

Maintenance Role Behaviors

860
Behaviors required in maintaining group relationships and activities
include the following:

Encourages: Praises others and their ideas accepts contributions of

others; maintains a warm and friendly manner
Gatekeeps: Ensures that all have a chance to be heard; suggests
limited talking time for everyone
Sets Standards: Suggests standards for the group to use in
choosing its content or procedures or in evaluating its decisions
Follows: Goes along with decisions of the group, thoughtfully
accepting ideas of others, and serving as audience during group
discussion
Expresses Group Feelings: Summarizing what group feeling is
sensed to be and describing reactions of the group to ideas or
solutions

Both Task and Maintenance Role Behaviors

The following behaviors are true of both task roles and maintenance
roles:

Evaluates: Compares group decisions or accomplishments with

group standards and goals
Diagnoses: Determines sources of difficulties, appropriate steps to
take next, and analyzes the main block to progress
Tests for Consensus: Asks for group opinions in order to find out
whether the group is nearing consensus on a decision
Mediates: Harmonizes differences in points of view and suggests
compromise solutions
Relieves Tension: Balances negative feelings by putting a tense
situation in a wider context

Nonfunctional Roles
Roles that harm the group and its work include the following:

Being Aggressive: Strives for status by criticizing or blaming

others, showing hostility toward the group or some individual, and
deflating egos or status of others
Blocking: Interferes with the progress of the group by arguing too
much on a point and rejecting ideas without consideration
Self-confessing: Uses the group as a sounding board to express
personal, non–group-oriented feelings or points of view
Competing: Vies with others to produce the best idea; talks the
most

861
 Seeking Sympathy: Tries to induce other group members to be
sympathetic to one's problems or disparaging one's own ideas to
gain support
Special Pleading: Persistently lobbies in support of one's own
opinion, concern, or philosophy
Horsing Around: Clowns, jokes and disrupts the work of the
group
Seeking Recognition: Calls attention to one's self by loud or
excessive talking, extreme ideas, and unusual behavior
Withdrawal: Acts indifferent or passive, using excessive
formality, daydreaming, doodling, and whispering to others

Source: Boyd (2018); Schneider Corey et al. (2018).

2. Storming

Group begins to work together

Conflict and competition over different agendas, ideas, and
approaches
Group leader: guides group in problem-solving and setting goals,
models maintenance roles (e.g., encouraging all to participate), and
summarizes group feelings

3. Norming

Group shows signs of cohesiveness, trust, openness, shared sense of

“belonging”
Work begins to progress
Creativity and shared ideas and opinions
Group leader: continues to role model good maintenance behaviors

4. Performing

May not occur with all groups

Members: can work as a total group, in subgroups, or independently
Most productive stage, as group members are motivated and able to
handle the decision-making process in a competent and autonomous
manner
High level of team satisfaction

5. Adjourning

Emphasis is on wrapping up the project

Withdrawal from both task and relationship or maintenance activities

862
 Members: often feel happy to have accomplished goal but sad about
the loss or disbanding of the group (Betts & Healy, 2015)

Group Functions in Decision Making

Groups are often called on to make important decisions. It is widely accepted
that decisions made by groups are stronger than those made by individuals
(Bang & Frith, 2017). However, group decision making can go astray when
group members

Lack independent knowledge, which results in “groupthink”

Bring background and experiences that are too similar, resulting in
similar biases to the problem being addressed
Adapt to each other's knowledge too quickly, resulting in “herd
mentality”
Fall into the trap of social compliance out of a desire to fit into the
group
Believe that others have better knowledge and ignore their own
instincts, following the others instead (Bang & Frith, 2017)

One way to avoid these pitfalls is to ensure strong diversity among group
members. This is best achieved by recruiting members with diverse identities
(age, gender, ethnicity), cognitive styles, and even goals. Although this
sometimes invites conflict, working through the conflict is often how groups
reach the best decisions. Harnessing the group diversity draws on vastly
different experiences and expertise allows for a wider range of potential
solutions and minimizes individual biases (Bang & Frith, 2017).

Techniques for Enhancing Group Decision Making

As a member of many decision-making groups in the community, the
community/public health nurse can facilitate the process through certain
techniques such as brainstorming, multivoting, and nominal group technique.

Brainstorming
Brainstorming is an idea-generating process that encourages group
members to freely offer suggestions. Group members are asked to present
creative ideas without criticism or discussion. This technique is helpful for
generating creative possibilities and is most useful in the early stages of
decision making. Research has shown that brainstorming is considered to be
the most widely used method of generating creative ideas (Oztop,
Katsikopoulos, & Gummerum, 2018).

Multivoting

863
Multivoting is a decision-making tool that enables members to prioritize a
long list of ideas with minimal discussion and difficulty. Multivoting often
follows brainstorming to narrow the list to a few items worthy of immediate
attention. All of the ideas are listed on a flip chart and members are allowed
to vote on one third of the total number of items (Minnesota Department of
Health, 2016).

Nominal Group Technique

Nominal group technique is a group decision-making method in which
group members are asked to not speak to each other but instead are asked to
write down their ideas, along with the advantages and disadvantages of the
issue being addressed. After everyone has completed the task, the members'
ideas are presented to the group, and discussion takes place so that the
information can be categorized and prioritized (Gorman & McDowell, 2018).
Advances in technology have resulted in the availability of a number of
online tools and apps that can help facilitate group decision making, whether
the groups are sitting together in a room or working virtually. A Web site that
provides links to 14 free online applications that support various forms of
group decision making can be found at https://tallyfy.com/brainstorming-
tools/.

864
Other Group Communication Settings
Not all C/PHN work with groups involves group process and group decision
making. Often, nurses are called on to incorporate group-teaching methods to
change behaviors (see Chapter 11 for more on health teaching). Group
teaching can be an effective tool for many health care challenges, such as for
diabetes teaching and education (Aeyoung, De Gagne, Sunah, & Young-Oak,
2015; Kewming, D'Amore, & Mitchell, 2016).
Community/public health nurses are also called on to share best practices
and research findings. Public speaking is an important community/public
health nurse skill. This involves developing public speaking and presentation
skills that engage and draw in audiences, ultimately influencing
improvements in health outcomes for individuals and populations (Sherman,
2016).

865
CONTRACTING IN
COMMUNITY/PUBLIC HEALTH
NURSING
Contracting means negotiating a working agreement between two or more
parties in which they come to a shared understanding and mutually consent
to the purposes and terms of the transaction. Contracts are common and
include legal and nonbinding agreements. Legal contracts, such as signing a
contract for a loan, are legally binding, and the terms are clearly provided.
Contracts in C/PHN can be either verbal or written, and clients can make
them with themselves, family members, or health care practitioners. Such
contracts commit clients to a set of behaviors, with the goal to improve
adherence to a health promotion program or plan.
Box 10-8 shows a contract used by C/PHNs when counseling clients who
desire to stop smoking. Contracts in a collaborative relationship or a nurse–
client alliance are flexible and changing and are based on mutual
understanding and trust, making this a valuable tool for community/public
health nurses (Ackley, Ladwig, Makic, Martinez-Kratz, & Zanotti, 2020).
The same format is followed with clients who are receiving home health care
services called a critical pathway. It consists of the written plans for client
care with a timetable. This is a more formal type of contracting that is
typically a fiscally driven and agency-required tool designed to document
standards and quality of care while reducing costs (see Chapter 30 for
additional information).

BOX 10-8 Client Service Plan With

Contract Madera County Public Health
Department
Public Health Nursing: Client
Individual Service Plan

866
Source: Gulanik and Myers (2017).

867
Value of Contracting
C/PHN has used the concept of contracting for many years, developing
partnerships with clients to address issues such as weight loss, exercise, and
substance abuse. Without always labeling it contracting, these techniques are
used with clients who want to lose weight, for instance. In this case, the
contract involves mutual agreement on certain exercise and eating patterns
for clients and teaching and support responsibilities for the nurse. Contracts
set time limits (e.g., 6 months) within which to achieve the intended goal
(e.g., weight loss). Nurses can help take a complex behavior and break it into
manageable steps, such as by contracting to walk at a moderate pace for 30
minutes three times a week, which may seem more feasible than beginning
by jogging 2 miles a day. Success in meeting the contract may encourage
future efforts to increase exercise activities. Nurses and clients are, in effect,
contracting even though they may see it simply as setting goals with clients
(Ackley et al., 2020).
Community/public health nurses may use contracting when
implementing health promotion programs. Contracting may be appropriate
when planning to stop or reduce substance use, change eating habits, or
increase physical activity. Contracting can also be done with groups or
agencies (e.g., schools, businesses). For instance, a school district may want
to contract with a public health agency to provide C/PHNs and health
educators to address pregnancy prevention, and the nurse may informally
contract with the students about sharing aggregate information gleaned in the
small-group teaching exercises with their parents to encourage adolescent–
parent communication.
Common benefits of contracting in C/PHN include that it

Involves clients in promoting their own health

Motivates clients to perform necessary tasks
Focuses on clients' unique needs, regardless of aggregate size
Increases the possibility of achieving the health goals identified by
collaborating team members
Enhances all team members' problem-solving skills
Fosters client participation in the decision-making process
Promotes clients' autonomy and self-esteem as they learn self-care
Makes nursing service more efficient and cost-effective (Duiveman &
Bonner, 2012)

868
Characteristics of Contracting
The concept of contracting, as used in the collaborative relationship,
incorporates four distinctive characteristics: partnership and mutuality,
commitment, format, and negotiation. Box 10-9 displays the concept and
process of contracting.

BOX 10-9 Concept and Process of

Contracting Contracting is based on
four distinctive features, shown here as
spokes of a wheel, that form the basis of
a nurse–client collaboration. This
relationship is a dynamic process that
moves through phases, represented here
as the outer rim of the wheel, and is
focused on meeting client needs and
aiding in the achievement of their goals.

869
Partnership and Mutuality
All aspects of contracting involve shared participation and agreement
between team members; they become partners in the relationship (Westefeld,
2019). In a mutual partnership, the nurse and partner come to an agreement
on what the partner needs and what the nurse can provide. Together, they
develop goals, outline methods to meet those goals, explore resources to help
achieve them, define the time limits for the contract, and outline their
separate responsibilities (Fig. 10-5). The contract involves reciprocal
negotiation and shared evaluation.

FIGURE 10-5 Contracting is an important aspect of client care.

Commitment
Second, every contract implies a commitment. The involved parties make a
decision that binds them to fulfilling the purpose of the contract (Westefeld,
2019). In community/public health collaboration, there is a pledge of trust
and dedication to see the contract through to completion. All parties feel
responsible for keeping promises; all want to achieve the intended outcomes.
When the nurse and the partners identify their tasks, they commit to success.

Format
Format, the third distinctive feature of contracting, involves outlining the
specific terms of the relationship. Clients and professionals gain a clear idea
of the purpose of the relationship, their respective responsibilities, and the
specific limits to their work. Expectations are clarified for all parties
involved. The format of contracting provides the framework for collaboration
to clearly articulate the logistics, avoid the difficulty of terminating long-

870
term relationships, and shift health care responsibilities from the
professionals to the client.

Negotiation
Finally, contracting always involves negotiation (Westefeld, 2019). The nurse
and other team members propose certain responsibilities and then ask
whether the clients agree. A period of give-and-take then occurs in which
ideas are discussed and conclusions and consensus are reached without
coercion. Team members may find over time that terms or goals on which
they had agreed need modification. Negotiation is dynamic and allows for
changes that facilitate the ultimate achievement of goals and encourages
ongoing communication among all team members. Although C/PHNs are
experts in nursing care, our clients know more about their life own
circumstances and how health and illness impact them. Think of the
shoemaker and shoe wearer, described earlier.

Principles of Contracting
Contracting applies the basic principles of adult education: self-direction,
mutual negotiation, and mutual evaluation. Contracting may be formal or
informal, written or verbal, simple or detailed, and signed or unsigned by
client and nurse. It should be adapted to the particular client's abilities and
may vary greatly from situation to situation. The nurse should date initial
interventions as well as follow-up and reassessment visits. Like all nursing
tools, contracting enhances a client's health only if it is adapted to each
particular client.

871
The Nursing Process and Contracting
Contracting follows a sequence of steps that are aligned with the nursing
process. As a working agreement, it depends on knowing what clients want,
agreeing on goals, identifying methods to achieve these goals, knowing the
resources that collaborating members bring to the relationship, using
appropriate outside resources, setting limits, deciding on responsibilities, and
providing for periodic reviews. The tasks are incorporated into the
contracting process and can be described in eight phases that follow the
nursing process.

Assessment
1. Explore needs: Assess the clients' health and needs, with the
involvement of the clients and other relevant persons.

Nursing Diagnosis/Goal Setting

1. Establish goals: Discuss goals and objectives with contracting
members and come to an agreement.

Plan/Intervention
1. Explore resources: Define what each member has to offer (clarifying
the C/PHN role, client's role) and can expect from the others; identify
appropriate resources and agencies.
2. Develop a plan: Identify methods, activities, and a timeline for
achieving the stated goals.
3. Divide responsibilities: Negotiate the activities for which each
member will be responsible.
4. Agree on time frame: Set limits for the contract in terms of length of
time or number of meetings.

Evaluation
1. Evaluation: Conduct formative and summative assessments of
progress toward goals at agreed-on intervals.
2. Renegotiation or termination: Agree to modify, renegotiate, or
terminate the contract.

As community/public health nurses use this process to negotiate a

contract, they must adapt it to each situation. Nevertheless, the basic

872
elements remain important considerations for successful contracting.

873
Levels of Contracting
Community/public health nurses use contracts at levels ranging from formal
to informal, based on the situation. To fund a community health program for
preventing child abuse, for example, a formal contract in the form of a
written grant proposal may be needed. To conduct a wide-scale needs
assessment of a homeless population, the services of an epidemiologist and
statistician may require a formal contract to clarify roles and expectations as
well as fees. Formal contracting involves all parties negotiating a written
contract by mutual agreement, signing the agreement, and sometimes having
it witnessed or notarized.
Informal contracting involves some form of verbal agreement about
relatively clear-cut purposes and tasks. A client group may agree to prioritize
their list of needs, the nurse may agree to conduct health teaching sessions,
the social worker may agree to obtain informational materials, and so on.
Sometimes, nurses use contracting informally without realizing it. They
conclude a session with clients by agreeing with them about the purpose and
time of the next meeting. Clients often find it helpful if the nurse gives them
a written list or reminder of tasks or goals.
The level of contracting also may change during the development of
communication and collaboration. Clients often need education about their
options. Initially, they may have difficulty in identifying needs and making
choices. The professional team can work to promote clients' self-confidence
and help them assume increasing responsibility for their own health.

874
COLLABORATION AND
PARTNERSHIPS IN
COMMUNITY/PUBLIC HEALTH
NURSING
Effective interdisciplinary and interprofessional collaboration is essential in
the health care system to achieve quality health care and assure successful
outcomes (Morgan, Pullon, & McKinlay, 2015). Collaboration is a
purposeful interaction among nurses, clients, other professionals, and
community members to develop strategies for improving the health of
individuals, families, and communities (Hudson & Croker, 2017; Mitchell et
al., 2013).
Although collaboration is a complex, dynamic process, it has two basic
components: (1) a goal and (2) two or more parties assisting one another to
achieve that goal. The overriding purpose of collaboration in
community/public health practice is to benefit the health of the public.
According to a study done by Valaitis et al. (2018), two intrapersonal
factors influence collaborative efforts: a person's skills, knowledge, and
personal qualities and a person's attitudes, beliefs, and values (see Chapter
4). Interpersonal factors that promote collaboration in community/public
health settings are the ability to
1. Develop trusting and inclusive relationships
2. Identify shared values, beliefs, and attitudes
3. Ensure role clarity
4. Communicate effectively
5. Influence effective decision-making processes (Valaitis et al., 2018)
Two examples of community collaboration are the asset-based
community development (ABCD) approach and community-based
participatory research (CBPR).
The ABCD approach is a methodology that starts with identifying
community assets and strengths, including local persons, community
associations and networks, natural resources, and institutions, as a means of
working with residents to create sustainable communities. Rather than a
needs-focused approach, ABCD starts with identifying the types of skills and
resources already available in the community and then involves consulting
with the community members on improvements they would like to make
(Nel, 2015; 2018). If you are interested in learning more about how to apply

875
the ABCD methodology, you can access a free, easy-to-complete training at
http://www.uniteforsight.org/community-development/abcd/. You will learn
more about community assessment in Chapter 15.
Similarly, CBPR involves community members in the entire research
process, from identifying a topic of importance to the community to
implementing the research and disseminating the results (Springer &
Skolarus, 2019). See more on CBPR in Chapter 4. Involving stakeholders in
planning and implementing programs and research increases their buy-in and
the likelihood of success as well as the quality of research findings.
Key principles for establishing partnerships and collaboration with
communities and interprofessional team members include the following:

Think “outside the box” when looking for partners or collaborators.

View plans as guides toward a goal, staying flexible.
Incorporate partners as part of the planning process; continuously
expand participants, being prepared to replan.
Maintain different levels of collaboration.
Use consensus-building techniques that are creative and visual.
Establish a shared vision; then share the plans and leadership (Nel,
2015; Suarez-Balcazar, Mirza, & Garcia-Ramirez, 2018 ).

To meet the needs of clients, C/PHN practice draws on the expertise and
assistance of numerous individuals. The list of team members can include
many different interdisciplinary health care professionals, as well as the
population being reached. All partners should be encouraged and allowed to
use their skills and knowledge to optimize outcomes (Springer & Skolarus,
2019; Suarez-Balcazar et al., 2018).
Depending on the need to be addressed, C/PHNs may work with many
people on a single project or on multiple endeavors. Remember to involve
the most important team players, members from the client population, which
facilitates addressing potential barriers. Refer to the CoursePoint+ case study
on community health improvement partnerships for an in-depth look at this
process.

876
Culture and Collaborative Services
Culture is a set of shared understandings related to knowledge, attitudes, and
behaviors that give meaning to an experience. In C/PHN, clients and
providers are often separated by their own distinct cultures. Therefore,
clients' cultural background, experience in collaboration and partnership
building, perspectives, and expressions of need provide important
information for the planning and delivery of services. By being aware of
one's own culture and the difference between one's culture and the client's, a
nurse can participate in cultural exchanges with clients that promote stronger
alliances (Dyches, Haynes-Ferere, & Haynes, 2019). See Chapter 5 for more
on culture in C/PHN.

877
Characteristics of Collaborative Partnerships in
Community/Public Health Nursing
To explore the meaning of collaboration in the context of C/PHN, this
section examines five characteristics that distinguish collaboration from other
types of interaction: shared goals, mutual participation, maximized resources,
clear responsibilities, and set boundaries.

Shared Goals
First, collaboration in C/PHN is goal directed. The nurse, clients, and others
involved in the collaborative effort or partnership recognize specific reasons
for entering into the relationship (Kraaijenbrink, 2019). For example, a
lumber company with 150 employees seeks to develop a wellness program.
The interdisciplinary health team will work together to develop specific
physical and mental health goals. The team enters into the collaborative
relationship with broad needs or purposes to be met and specific objectives to
accomplish.

Mutual Participation
Second, in C/PHN, collaboration involves mutual participation; all team
members contribute and are mutually benefited (Ma, Park, & Shang, 2018).
Collaboration involves a reciprocal exchange, in which individual team
players discuss their intended involvement and contribution, and all members
of a team should feel equally valued—no hierarchies should exist (Davis &
Travers Gustafson, 2015). In interdisciplinary teams, physicians, nurses, lay
community health workers, clients, outside agency personnel, and others
must be able to effectively share ideas and frustrations on an equal,
reciprocal basis.

Maximized Use of Resources

A third characteristic of collaboration is that it maximizes the use of
community assets (Majee, Goodman, Vetter-Smith, & Canfield, 2016). That
is, the collaborative partnership is designed to draw on the expertise of those
who are most knowledgeable and in the best positions to influence a
favorable outcome. In this age of dwindling resources, it is now common for
public health agencies to seek additional funding assistance from other
agencies to support new community/public health programs or to provide
educational information or interventions. Being able to demonstrate fiscal
responsibility and evidence-based outcomes will assist nurses in sustaining

878
health promotion efforts on a long-term basis through collaborative
partnerships.

Clear Responsibilities
Fourth, the collaborating team members work in partnership and assume
clearly defined responsibilities. Each member in the partnership plays a
specific role with related tasks. Effective collaboration clearly designates
what each member will do to accomplish the identified goals. Each member
of the team develops an understanding of individual responsibilities based on
realistic and honest expectations. This understanding comes through
effective communication. The collaborating partners explore necessary
resources, assess their capabilities, and determine their willingness to assume
tasks.

Boundaries
Fifth, collaboration in community/public health practice has set boundaries,
with a beginning and an end, that fall within the goals of the partnership. An
important part of defining collaboration is determining the conditions under
which it occurs and when it will be terminated. The temporal boundaries
sometimes are determined by progress toward the goal, sometimes by the
number of team member contacts, and often by setting a time limit
(Browning, Torain, & Patterson, 2016). Once the purpose for the
collaboration has been accomplished, the group as a formal entity can be
terminated.
In some settings, the partnership may desire to continue to work on other,
mutually agreed-on activities. Some partnerships are ongoing. For example, a
university department of nursing might use a neighborhood community
center for clinical experiences for their students. When people collaborate
and work together in partnership, many possibilities exist.

879
Levels of Prevention
In Box 10-10, the levels of prevention are used to provide a framework for
the collaborative process in C/PHN. One objective in Healthy People 2030 is
the Environmental Health objective EH-04: Reduce blood lead levels in
children aged 1 to 5 years (USDHHS, 2020). To achieve this objective,
community/public health nurses need to be able to collaborate effectively
with community partners in the design and implementation of health
programs that address this very significant issue.

BOX 10-10 Levels of Prevention Pyramid

Children's Health and the Environment
SITUATION: High lead blood levels were
identified in a community GOAL: Using the
three levels of prevention:
Develop programs and policies to prevent childhood lead poisoning.
Screen children for elevated blood levels.
Ensure that lead-poisoned infants and children receive appropriate
medical care and environmental follow-up.

880
 *The goal of Tertiary Prevention is to reduce morbidity from lead
exposure. The goal of Secondary Prevention is to minimize absorption of
lead and eliminate chronic exposure. The goal of Primary Prevention is to
remove lead from the environment to eliminate exposure.
Source: CDC (2019a).

The importance of effective collaboration to address lead contamination

(Fig. 10-6) was highlighted when the United States witnessed the tragic
contamination of publicly supplied drinking water in Flint, Michigan. The
contamination occurred in 2014 when the community's water source was
switched to the Flint River as a cost-saving measure (Zahran, McElmury, &
Sadler, 2017). Signs and symptoms of lead poisoning are primarily
neurologic, especially in children, and include seizures, stupor, delirium,
behavioral changes, and headaches (Craft-Blacksheare, 2017). For more on
this, see Chapters 7 and 9.

FIGURE 10-6 Emergency water distribution following the

discovery of lead contamination of water supplied in Flint,
Michigan in 2014.

Nurses played a major role in the public health response to the

contamination in Flint, including assessing clients for lead exposure and
offering health education aimed at primary, secondary, and tertiary
prevention. Nurses also offered emotional support, particularly to those most
vulnerable and marginalized (Craft-Blacksheare, 2017). This modern-day
example of a major public health response involved nurses working in
collaboration with the U.S. Public Health Service; the Centers for Disease
Control and Prevention; the U.S. Surgeon General; county and state health
departments; the Environmental Protection Agency; federally qualified

881
health centers; the Red Cross; free medical clinics; local, state, and national
political leaders; and a wide array of other community agencies.
Effective public health responses are possible only when
interdisciplinary, cross-sectoral bodies collaborate efficiently and effectively.
The Public Health Leadership Forum (2018) and the Health Care
Transformation Task Force developed a framework aimed to support and
improve collaboration between health care and public health bodies. Five
primary elements of collaboration include establishing a governance
structure, creating a financing plan, utilizing cross-sector prevention models,
developing a data-sharing strategy, and ensuring that performance is
measured and evaluated.

882
Fostering Client Participation
This chapter has stressed that communication and collaboration are based on
mutual participation. The extent of clients' participation varies, however,
depending on their readiness and ability to participate (Biswas, Faulkner, Oh,
& Alter, 2017). The client's level of wellness at the time of the initial nurse–
client encounter directly influences participation. In this case, the nurse may
have to take a stronger initial leadership role; however, the nurse should not
abandon the goals of collaboration. Gradually, as the client's wellness level
improves or the client's family becomes more involved, the nurse can
encourage more active participation. Clients with developmental disabilities
or cognitive impairment may not have the capacity for true collaboration at
any point in the process.
Engaging clients in a collaborative process may be difficult at times.
Clients with low literacy, with low income, or from different cultural
backgrounds may need extensive encouragement to actively participate in a
collaborative relationship. Sometimes, a client's previous experience with
health personnel limits participation in collaboration. For example, clients
who were not previously encouraged to participate in decision making by
health care providers or team members may take a passive role and not feel
that they can truly collaborate. Unless the nurse persists in efforts to
empower clients, the relationship can fall short of therapeutic goals
(Dawson-Rose et al., 2016).
The nurse's own view of collaboration also influences the degree of
client participation. Nurses who see their position as more informed and the
client's position as one of complete ignorance and need may find that a
paternalistic relationship develops. All clients have resources on which to
build, and the community/public health nurse should help clients to discover
these resources and empower clients to use them to enhance collaboration
and attain health goals.

883
Barriers to Effective Collaboration
Communication barriers and miscommunication can inhibit effective
collaboration. This is sometimes caused by misconceptions on the part of
team members regarding the professional knowledge and motives of other
team members. Stereotypes and the perception of unequal power and
authority can sabotage the effectiveness of communication and collaboration.
Organizational or structural factors, such as ineffective coordination and lack
of agency support, are also cited as barriers to effective collaboration
(Hanson et al., 2018).
Conflict is inevitable when dealing with groups of diverse individuals,
but how potential anger, resentment, and mistrust are handled is the key to
getting beyond conflict (Gerardi, 2015). Agreeing on how conflict will be
handled prior to any incidents sets a positive stage for resolution. One
strategy is to agree to handle conflict by using the carefronting model,
which is described as a method of addressing and resolving conflict by
confronting others in a caring, responsible, yet self-asserting manner
(Sherman, 2016). Using “I” messages ensures that all parties in the conflict
matter and that you care enough to negotiate differences so that common
goals can be met. Key principles in the carefronting model are presented in
Table 10-3.

TABLE 10-3 Key Principles for Carefronting: Facing Client

Aggression

Source: Lamont & Brunero (2018); Sherman (2016).

884
HEALTH TECHNOLOGY
Health technology/informatics incorporates processes, procedures, theories,
and concepts from information and computer science, health sciences, and
social sciences. Nurses use the tools of information technology to support
delivery of care and improve the health status of all. Health data,
information, wisdom, and knowledge can be collected, stored, processed, and
communicated. Nurses and other health professionals, administrators, policy
and decision makers, consumers, and clients or patients can use information
technology, hardware, and software (Veazie et al., 2018).

885
Electronic Health Records
Electronic health records (EHRs) are, at their simplest, digital
(computerized) versions of patients' paper charts. The contemporary EHR is
a complex piece of software with multiple functions and capabilities that
enables a health care provider to record patient progress in free text, place
prescription orders, receive decision-support alerts and reminders, order
laboratory tests, receive and review results electronically, message patients or
fellow providers, and perform a variety of other documentation and clinical
tasks. It may contain lab and x-ray results and medications and medical
history, along with administrative and billing information (Office of the
National Coordinator for Health Information Technology [ONC], 2019).
The use of EHRs in community/public health has followed a slower
progression than in hospitals. Reporting (e.g., communicable disease,
immunizations) has moved from paper to unidirectional electronic reporting
in many areas. In public health, EHRs have been shown to improve
efficiency, productivity, quality of care, cost reduction, and data
management, although drawbacks include missing data, complex technology,
and the learning curve (Kruse, Stein, Thomas, & Kaur, 2018; Pyron &
Carter-Templeton, 2019). Agencies may find EHRs helpful in areas such as
epidemiology, largescale planning, budgets, and grant writing. For example,
an agency may search for specific characteristics and target vulnerable
populations to best determine more effective planning and targeted
interventions (e.g., clients with specific chronic diseases, current smokers).
Individuals may also gain access to their own health information, and this is
especially helpful in the case of immunization records (Birkhead, Klompas,
& Shah, 2015; Kruse et al., 2018).

886
Big Data
We live in a digitized world. Massive amounts of data are captured daily as
we browse the Internet, swipe our credit cards, visit a clinic for a flu vaccine,
or use social media sites. Other sources include biological or genomic data,
geospatial analyses (statistical analysis of geographic mapping) data sets,
readings from personal monitoring devices people wear (e.g., GPS, FitBit),
payer and EHRs, or “effluent data” constantly flowing from computer
searches, online records, cell phone accounts, or social media (Mooney &
Pejaver, 2017, p. 96).

Big data represent “largescale data collections…” from a wide variety

of sources and includes the unique methods of data processing,
analyses, and storage (e.g., cloud servers, distributed data warehouses)
needed to accommodate massive data sets (Zhu, Han, Su, Zhang, &
Duan, 2019, p. 229).
The four V's of big data include
Volume: Denotes the massive amount of data (2.5 quintillion bytes
of data every day)
Velocity: Refers to the speed of data generation, collection,
analysis, and transmission
Variety: Means the different types of data (often unstructured) that
are collected that require sophisticated technology to overcome
data inconsistencies
Veracity: Refers to assuring accuracy and trustworthiness of
massive data sets that may be used for secondary analysis, have
missing items, or need statistical cleaning to assure validity
(Massachusetts Medical Society, 2018; Zhu et al., 2019)

Nurses in all settings add to big data through sharable and comparable
documentation in the EHR. The use of big data makes it easier to drill down
(or view more detailed information), drill up (or see data in an aggregate
view), as well as combine different data variables than when using more
traditional forms of data collection and analysis (Garcia, 2015).
A goal of EHR documentation is capturing health and nursing care data
in structured ways that help build a foundation for accurate, reliable,
clinically meaningful measurement across systems and settings of care
(ONC, 2019). Big data are the core of that documentation, but the lack of
standardized data and a common data structure are barriers to nursing
research that highlights the outcomes of nursing care linked to assigned
patients. The consistent and reliable use of data elements will allow
information to be collected once and reused for multiple purposes

887
(Sensmeier, 2015). If EHR systems are not integrated (e.g., if they do not
work together and talk to each other), the task is much more challenging.

The National Patient-Centered Clinical Research Network (PCORnet) is

a central source of data from EHRs and provider billing that is currently
used for health care research. Providers can be linked to patients, and
nursing researchers are “working on a structure to make the location of
care and nurse characteristics visible to researchers” (Garcia, Harper, &
Welton, 2019, p. 100).
The Nursing Value Data Model (NVDM) is a framework to guide big
data use in nursing research, and the National Database of Nursing
Quality Indicators (NDNQI) provides a means of consistent coding for
various populations receiving nursing care (Garcia et al., 2019).
Because nursing is a process-oriented profession, to effectively
demonstrate nursing interventions and patient outcomes, data specific to
nursing must be collected (Hersh, 2019).

Precision medicine (Fig. 10-7), using genomic and other big data, can
provide more individualized care and treatments, along with more personally
tailored medication regimens. It is also useful in disease prediction and
differential diagnosis (Prosperi, Min, Bian, & Modave, 2018). In the future,
even vaccines may be tailored for “homogeneous subpopulations” rather than
a single vaccine given to everyone (Dolley, 2018, p. 4). Big data are used in
precision public health to promote population health through epidemiology,
disease surveillance, risk prediction, research, and preventive care. Big data
have also been used to identify treatment and intervention in public health
research on childhood obesity and asthma, HIV, misuse of opioid
medications, use of smokeless tobacco and with HIV and the Zika virus
(Dolley, 2018) (Fig. 10-7).

888
FIGURE 10-7 Precision public health infographic. (Reprinted
from Prosperi, M., Min, J. S., Bian, J., Bian, J., & Mopdave, F.
(2018). Big data hurdles in precision medicine and precision public
health. BMC Medical Informatics and Decision Making, 18(1),
139. doi: 10.1186/s12911-018-0719-2. Reprinted under the
Creative Commons License
http://creativecommons.org/licenses/by/4.0)

889
Mobile Health (mHealth)
The rapid expansion of mobile technology provides an opportunity for nurses
and other clinicians to improve health and health care through forms of
interactive mobile health (mHealth), referred to as mHealth services.
mHealth includes the use of wireless technologies, such as smartphones,
tablets, and notebooks for improving health. mHealth offers great
opportunities for improving global health, safety, and preparedness. The
potential of mobile technology's impact on sharing health information and
collecting disease/health data is tremendous due to its portability,
affordability, and availability; it also has the potential to save billions of
dollars in health care costs (Naqvi & Shah, 2018). The potential of mHealth
will be further established as patients' experiences with technology and
clinical/psychosocial outcomes are evaluated (Marcolino et al., 2018).
Three current mHealth trends have been identified by USDHHS (2014).
The trends include mHealth technology that is interactive, integrated, and
multimedia.

Interactive strategies enable “two-way flow of information that engages

patients more actively” in their health management.
Integrative strategies use multiple “self-management applications to
share health information between patients and providers through text
messages, centralized web-based” tracking and management programs,
and mobile monitoring (such as glucose monitoring).
Multimedia use “games and quizzes” to communicate preventive
messages and motivate behavior change (USDHHS, 2014, p. 5).

mHealth is extending health care to underserved and hard to reach areas.

Technology puts health care providers in a position to change how health
care is delivered, the quality of the patient experience, and the cost of health
care. Advantages include management of chronic disease, empowering the
elderly and expectant mothers, reminding people to take medication, serving
underserved areas, and improving health outcomes and medical system
efficiency. However, big differentials in the number of mobile devices exist
among nations. In 2020, China and India (1.65 billion and 1.2 billion,
respectively), followed by the United States (422 million), had the highest
number of mobile devices, whereas several island nations (e.g., Falkland
Islands, Marshall Islands, Cook Islands) had the lowest number—between
5000 and 14,000 (Central Intelligence Agency, 2020). A report cited
common uses for mHealth globally that included call centers, reminders, and
telemedicine. Mobile medical applications and wearable medical devices
were projected to be growth areas for mHealth (Center for Technology
Innovation at Brookings, 2016).

890
 As an example of mHealth, Flagstaff Medical Center piloted a remote
monitoring program for heart failure patients who had lower incomes and
longer distances to drive to the facility. Researchers used wireless devices to
track blood pressure, weight, and activity level. These data were
electronically transmitted daily to health care providers, who then instructed
patients about medication and diet management. The 50 participants in the
pilot study had fewer hospitalizations and fewer hospital days than did those
not enrolled in the study (comparing baseline 6 months before enrollment
and 6 months after enrollment), with a mean savings of $92,317. Higher
patient and caregiver satisfaction levels were also noted (Center for
Technology Innovation at Brookings, 2016). Continued research is needed to
link mobile technology to health outcomes (Box 10-11).

BOX 10-11 Evidence-Based Practice

Using Mobile Phone Data to Assess Drivers of
Seasonal Outbreaks of Rubella in Kenya
Incidence of rubella is often higher than
reported because it may be characterized as a
mild illness. However, congenital rubella
syndrome, contracted by mothers in early
pregnancy, can have long-lasting repercussions
(e.g., stillbirth, serious birth defects). In 2016,
Kenya began a largescale measles–rubella and
tetanus vaccination campaign (WHO Africa,
2016). Rubella was added to the existing
measles vaccine due to an increased incidence
over the previous few years.
In 2015, Wesolowski and colleagues used mobile phone data to
determine seasonal travel patterns that may influence rubella outbreaks.
Data from 15 million anonymous mobile phone users revealed higher
movement and aggregation rates at three peak times of rubella
incidence. Peak incidences varied by province. Rates of rubella and
other communicable diseases often rise during the school year, when
children are gathered in classrooms. However, in the western area of
Kenya, the risk of rubella transmission was highest during school
breaks. Researchers statistically controlled for rainfall and school terms
and used maps to examine spatial and temporal patterns of risk based on

891
the mobile phone data of population movements. They were able to
identify high-risk areas and variations over the 1-year period of the
study. They found that all regions except Nairobi varied in areas of high
risk for rubella during the year.
The Wesolowski et al. study verified a new tool in the fight against
communicable diseases, as “patterns of population fluxes inferred from
mobile phone data are predictive of disease transmission ….showing ….
that mobile phone data capture epidemiologically relevant patterns of
movement” (Wesolowski et al., 2015, p. 11114).

1. How could public health departments use mobile phone data to

track communicable diseases in your area? Which data would
be most critical?
2. In what other instances would knowledge of population mobile
phone use in your area be helpful (e.g., disaster notification,
health promotion, immunization reminders)? Are these being
utilized in your area?
3. Find other research about digital technology in public health.
Are the findings significant, valid, and helpful to your
population?
Source: Wesolowski et al. (2015); WHO Africa (2016).

892
Mobile Phones
Approximately 96% of Americans own a cell phone, and 81% of those are
smartphones (Pew Research Center, 2019). And 67% of cell owners find
themselves checking their phone for messages, alerts, or calls—even when
they don't notice their phone ringing or vibrating. Konok, Gigler, Bereczky,
and Miklósi (2016) reported that people are extremely attached to their
mobile phones; most were kept within arm's reach. Mobile phone use is
highest among individuals who use a cell phone as their primary method of
communication.
Text messaging and the use of applications and other mHealth
interventions can reduce geographic and economic barriers to health
information and services. These interventions have the potential to reduce
health disparities and leverage a profound effect on health (USDHHS,
2020b). A recent study found Black and Hispanic participants used mobile
digital devices to access patient portals more often than White participants,
who relied more on computers (Chang, Blondon, Courtney, Lyles, Jordan, &
Ralston, 2018). Another study found that “racial/ethnic minorities and
patients living in poorer neighborhoods” most often checked personal health
records exclusively by means of a mobile device (Graetz et al., 2018, para.
1). Optimizing Web sites for mobile devices could be helpful in reaching
diverse populations and would enable a wide audience to test and review
apps in development. Mobile phone technologies offer promising
opportunities for nurses working in the community setting (Brayboy, McCoy,
Thamotharan, Zhu, Gil, & Houck, 2018).
Connected health offers the patient the opportunity to feel constantly
connected to the health delivery system and offers the system a just-in-time
messaging opportunity that can be motivating, educational, and caring
(Health Information and Management Systems Society, 2019). A
disadvantage is that mobile or cellular phones are less reliable than landlines,
with users sometimes citing spotty service, dropped calls, and text messages
delayed or lost in cyberspace.
Text messages are the initial, simplest, and most common type of mobile
data service and are becoming a vital tool for the delivery of health
information and engaging users to improve their health (CDC, 2019e;
Kazemi et al., 2017). Text messaging is a way of connecting quickly with a
large population (Benetoli, Chen, & Aslani, 2018). The use of text messaging
has been advocated in HIV testing as a means of improving health quality
and preventing complications (Brown, Tan, Guerra, Naidoo, & Nardone,
2018). Marcolino et al. (2018) conducted a systematic review of text
messaging and the implications in health care and noted that this is growing
in use and popularity. Given the widespread use of mobile phone text

893
message reminders among different patient groups, it may have the potential
to improve adherence to medication and attendance at clinical appointments
globally.
Text messaging is simple, low cost, and ubiquitous. It continues to
increase as a form of communication. Text messaging is considered more
private and less intrusive than a phone call. Pictures, video, and text
reminders can also be sent. Text messaging allows for automatic contact with
groups of clients without the sender having to send an individual message to
each intended recipient (Griffiths et al., 2017). Response may be real time or
at the leisure of the recipient. Text messages are less expensive than phone
calls and less prone to spam than e-mail. Texts may be stored and revisited,
and all languages are supported. The benefits of text messages and social
media are numerous (Eckert et al., 2018). However, health literacy and
cultural appropriateness for diverse populations must be considered when
using text messages (USDHHS, 2014).
Reminder and educational text messages have the ability to be
disseminated widely and broadly, reaching mass number of recipients
quickly and inexpensively (Arya et al., 2018). Tailored, user-friendly
interventions delivered by mobile phone may be a better fit with many
individuals' lifestyles than traditional treatment and an attractive option for
both clinicians and patients or clients. Mobile phones have a broad range of
uses, diverse functions, and the ability to intercede in “real time.” Text
messaging can overcome barriers of time and access to reach even high-risk
populations (Arya et al., 2018).
Much research in public health has found that it is possible to use text
messages to help deliver health-related information and to aid people in
disease management (e.g., diabetes) and make better health decisions such as
smoking less and exercising more. Text message interventions promote
healthy lifestyle behaviors, have become widely integrated into routine daily
life, and are simple, low cost, and nonlabor intensive. Use of text messaging
to deliver information about more sensitive topics, such as sexual health and
reducing risky behaviors, seems promising. Opt-in features, which allow
choice for the recipient, can also be used (Arya et al., 2018). These are
helpful for immunization reminders, encouraging healthy behaviors, and
more. Text messages may be used for simple reminders to have blood
pressure checked, to notify individuals about an upcoming appointment, or to
pick up prescriptions (Benetoli et al., 2018). Box 10-12 provides selected
examples of how text messaging has been used to implement interventions as
well as supporting research.

894
BOX 10-12 Selected Examples of Text
Messaging Interventions and Research
PHNs providing case management to low-income women with
chronic conditions results in improved mental health and functional
status.
A series of automated text messages to predominantly low-income,
Hispanic parents about influenza and the importance of flu shots
results in a small but meaningful increase in child vaccinations.
Sexual health clinics communicate most test results via text
message, leading to quicker diagnoses and treatment and improved
clinic capacity for processing new cases.
Weekly text messaging service for teens and young adults
improves access to sexual health information/services and
engenders positive changes in behavior and knowledge.
Low-income, African American, rural HIV patients receive regular
text message reminders that encourage them to regularly access
HIV/AIDS primary care, leading to improved retention in care and
quality of life.
Daily, automated text messages combined with nurse follow-up
improved diabetic patient self-management behaviors and led to
better glycemic control, fewer doctor visits, and higher patient
satisfaction.
A statewide text messaging service targeting minority youth and
young adults in Illinois provides accurate information on
HIV/AIDS and how to access free HIV testing and related services.
A Medicaid managed care organization uses cell phone text
messaging to remind members with type 2 diabetes to get blood
glucose testing, resulting in a significant increase in members
being tested on a regular basis.
Regular reminders via text message increase adherence to
medication regimens and reduce risk of organ rejection in pediatric
liver transplant patients.
SexInfo provided free basic information and referrals for in-person
health consultations to at-risk youth in San Francisco via an opt-in
text messaging service.
Weekly text messaging service for teens and young adults
improves access to sexual health information and services and
produces positive changes in behavior and knowledge.
Source: Agency for Health Care Quality & Research (AHRQ) (2018).

895
 Loescher, Rains, Kramer, Akers, and Mossa (2016) conducted a
systematic review of research studies on adult physical activity and a text
messaging intervention. They concluded that text messaging as a method to
promote health activities shows improvement in healthy behaviors and health
outcomes.
Text messaging is used globally to communicate and to motivate
individuals to engage in healthy or healthier behaviors, deliver public health
messages, and alert populations about available resources or disasters. In
some cases, other digital solutions may be more effective. A systematic
review of research studies using texting, video-observed therapy (VOT), or
medication monitors in tuberculosis care found that text messaging did not
significantly affect completion of treatment, whereas VOT rates of treatment
completion were comparable to the much more expensive directly observed
treatment (DOT) option. Groups using medication monitors demonstrated
statistically significant reductions in missed doses over those using standard
care measures (Ngwatu et al., 2018).
Nurses and other clinicians may use texting to assist patients and
caregivers with management of chronic conditions and disease prevention.
Text messaging provides a venue to deliver information to hard-to-reach
populations and the opportunity to have a positive influence on health
knowledge and behaviors, as evidenced by clinical outcomes in a recent
study among college students (Glowacki et al., 2018; USDHHS, 2014). See
Box 10-13 for best practices in using text messages.

BOX 10-13 Text Messaging Best

Practices
1. Keep messages short. Text messages should be short and concise.
The entire message should be <160 characters, including spaces
and punctuation and any branding or links to additional
information (p. 25).
2. Make messages engaging: Write relevant, timely, clear, and
actionable messages.
3. Make content readable: Content should be at or below an 8th grade
reading level.
4. Use abbreviations sparingly: Only use those that are easily
understood and don't change meaning.
5. Limit foreign language characters: Accented letters do not work
well in texts.
6. Provide access to additional information: Include a way for users to
follow up or respond to the message (e.g., URL, phone number,
mobile Web site).

896
 7. Include opt-out options: Include information on how to opt-out of
the text message program.
8. Evaluate your efforts. Evaluation can be accomplished with surveys
and metrics reviews.

Source: Centers for Disease Control and Prevention (CDC) (2016).

897
Applications
An application, or app for short, may be defined as a software program
developed to help the user perform specific tasks (Greenie, Morgan, Sayani,
& Meghani, 2018). Apps are self-contained programs, used to enhance
existing functionality, in a simple and user-friendly way. Today's modern
smartphones come with powerful web browsers, meaning nearly anything
that can be done on a desktop computer can be done with a smartphone's
browser. The portability of the app that allows the user to remain connected
is very appealing to both nurses and clients. Many new mobile apps are
targeted to assist individuals in their own health and wellness management.
Other mobile apps are targeted to health care providers as tools to improve
and facilitate the delivery of patient care (Greenie et al., 2018).
Application developers have noticed the potential of health care apps.
Health professionals are necessary in app development to peer-review the
reliability, usability, and usefulness of medical apps. Zweig, Shen, & Jug
(2019) conducted a national survey of 4000 adults about digital health
adoption that revealed an upward trend from 2015 to 2017 in the use of
digital tools like online health information, online health provider reviews,
wearables, and telemedicine. The most common reasons for wearable use
were to lose weight and increase physical activity. Those keeping track of
their blood pressure rarely utilized digital tracking. Almost a quarter of
respondents owned a wearable device (Fig. 10-8), but about a quarter of
users discontinued use either due to reaching their goals or due to inability to
reach goals. Data security was important to participants; although 87%
reported willingness to share health data with their providers, they were less
confident in the security of their data in the hands of health insurance
companies, pharmacies, government organizations, and tech companies and
were therefore less willing to share data with these entities. Although older
adults could reap greater benefits from the use of health tools, they were less
likely to use them than young, high-income adults. There is a significant
market for these technologies to promote health (Brayboy et al., 2018).

898
 FIGURE 10-8 Social media and technology have the capacity to
reach and influence the health behaviors of a wide audience.

The Food and Drug Administration (FDA) is responsible for the

protection of public health by assuring the safety, effectiveness, quality, and
security of human and veterinary drugs, vaccines and other biological
products, and medical devices (FDA, 2019). The FDA intends to apply
regulatory oversight to medical mobile apps and identifies apps as medical
devices whose functionality could pose a risk to an individual's safety if the
mobile app did not function as intended (Shuren, Patel, & Gottlieb, 2018).

FastStats and Mobile Apps

The CDC offers a Web site called FastStats, which provides quick access to
statistics on topics of public health importance and is organized
alphabetically. Links are provided to publications that include the statistics
presented, sources of more data, and related web pages (CDC, 2019b). The
site can be accessed at https://www.cdc.gov/nchs/fastats/default.htm.
In addition, CDC offers a free “CDC Mobile App” where you can access
important public health information at any time. The app automatically
updates when your device in online, so you are sure to receive the most up-
to-date health news and information. The app also provides direct links to
social media, text, and email, enabling you to share information with clients
and colleagues. In addition, you can gain access to CDC's Morbidity and
Mortality Weekly Report (MMRW) and their Disease of the Week articles
(CDC, 2018). The following link will take you to CDC's site where you can
download the free CDC Mobile App:
https://www.cdc.gov/mobile/applications/cdcgeneral/promos/cdcmobileapp.h
tml.

899
Twitter
Twitter is a micro-messaging/microblogging technology and an online social
networking service that enables users to send and read short 140-character
messages called “tweets.” Posts are delineated by a hashtag (#) symbol to
organize topics (Benetoli et al., 2018). Microblogging began with the advent
of Twitter in 2006 and is a method of mass communication. “Followers” or
users sign up to follow the microblog (Benetoli et al., 2018). Twitter is real
time and designed for mobility. E-registered users can read and post tweets
by computer or smartphone, and anyone on Twitter (not just followers) can
see tweets on a public account. Twitter provides important insight related to
health and is a useful tool to promote health behaviors (Baumann, 2016;
Grover, Kar, & Davies, 2018).
Grover et al. (2018) found that Twitter was a helpful tool to engage
patients. Nurses/clinicians and health care systems can use Twitter to
communicate timely information, both within the medical community and to
patients as well as the general public. Short messages, or tweets, are
delivered to a group of recipients simultaneously, providing an easy and
quick method to reach large groups in limited time. There are obvious
advantages for sharing time-critical information such as disaster alerts and
drug safety warnings, tracking disease outbreaks, or disseminating health
care information. Twitter applications can deliver information about clinical
trials, for example, or link brief news alerts from the CDC to reliable Web
sites that provide more detailed information (Vijaykumar, Nowak,
Himelboim, & Jin, 2018). Clinicians can tweet from the operating room or a
disaster site allowing live updates (Eckert et al., 2018).
The CDC also encourages the use of Twitter as an effective vehicle to
disseminate health information and engage communities and partners. Box
10-14 offers CDC's best practices for using Twitter to improve health (CDC,
2019e).

BOX 10-14 Twitter Best Practices

1. Clearly Define Your Objectives: Do you want to highlight content,
spark action, or encourage awareness of an issue?
2. Know Your Target Audience(s): Knowing your target audience
informs how you develop and communicate messages that resonate
with your audience.
3. Determine Resource Needs: Who will manage the Twitter profile?
Who will be the point of contact and monitor the posts on a regular
basis?
4. Keep Your Content Short and Simple: Use not more than 120
characters (including URL, punctuation and spaces) to make it easy

900
 for followers to retweet the message without having to edit it.
5. Determine Schedule and Frequency of Twitter Posts: Set a posting
schedule that defines a frequency for posts per week.
6. Conduct Promotion Activities: Promote your Twitter profile to the
extent possible to expand your reach.
7. Determine Approach for Engaging with Twitter Followers: Develop
a strategy for identifying and retweeting or replying to posts from
partners and followers.
8. Evaluate: Regularly monitor your Twitter account to review the
number of followers, updates, retweets and mentions in Twitter;
also consider monitoring the increases in traffic to your Web site.
9. Establish a Records Management System: Set-up a system to keep
track of your Twitter posts, @replies, retweets, and mentions to
comply with Federal guidelines for records management and
archiving.

Source: Centers for Disease Control and Prevention (CDC) (2019e); Christofferson et al. (2015).

901
Blogging and Online Support Communities
Blogs or weblogs are web-based chronological journals (Thomas, Allison, &
Latour, 2018). They are free or low cost and easy to use. Blogs typically
include date-stamped, multiple entries in chronological order and are updated
frequently. Blogs usually focus on a particular subject or topic. One type of
blog, referred to as a simple blog, is a form of online personal diaries. Other
blogs relate to group causes such as political or social concerns, and some
may ask for contributions. Blogs may contain reflections, commentaries,
comments, images, videos, and often hyperlinks to other information of
interest to the blogger or that she/he feels will be of interest to their readers.
The ability for readers to leave comments on a blog post depends on the
settings that the blog administrator uses (Thomas et al., 2018).

The popularity or success of a blog is judged by its ability to draw

individuals together who are interested in a specialized topic. Many
journals, health care systems, nursing and other professional
organizations, health care provider networks, and educational
institutions create blogs to provide the latest information and promote
discussion (Thomas et al., 2018).
Many people create personal blogs when faced with an illness or are a
family member/support for someone facing health challenges.
Participating in the creation of health information through blogging and
social networking contributions influences experiences and supports an
individual's understanding of their role in health care management and
ability to copy with their disease process (Tsai, Crawford, & Strong,
2018).

Traditional forms of contact and support groups are limited to certain

hours of the day, week, or month. Some face-to-face support groups meet
weekly or monthly and may require considerable travel and effort. Telephone
help lines may be available only during office hours. Conversely, online
blogs allow for contact and support that are available at any hour of the day
or night via the Internet. Individuals who have joined an online support
group benefit from venting their feelings and from the support they receive
as well as feeling connected by helping and supporting others (CDC, 2015;
Partridge, Gallagher, Freeman, & Gallagher, 2018). Online supportive
relationships generally provide a safe environment. Others' experiences can
induce feelings of compassion, and one becomes less self-absorbed and may
gain a better perspective (Wagner, 2018). Finding a safe place to share can be
very empowering, and the value of first-person accounts, the appeal and
memorability of stories, and the need to make contact with peers all strongly
suggest that reading and hearing others' accounts of their own experiences of

902
health and illness will remain an important component of health
management/care. For example, PatientsLikeMe
(https://www.patientslikeme.com/) is a great example of a free Internet-based
tool for sharing and learning.

903
Video Games and Virtual Reality Games
As of 2018, 67% of American adults have played video games (Electronic
Entertainment Design and Research, 2019). Public attitudes toward video
games and the people who play them are complex and often mixed. Video
games are typically thought of as entertainment. However, there is a growing
interest in video games as a means to facilitate healthy behaviors. Exercise
programs based on video game activities provide an alternative to motivate
and increase adherence to activity and exercise (Taylor, Kerse, Frakking, &
Maddison, 2018).
Games can serve as a means to engage patients behaviorally in order to
improve their health outcomes. Behaviors, often necessary to maintain and
improve health, are reinforced.

A recent 9-month study examined the use of an augmented reality game,

Pokémon Go (Fig. 10-9), and discovered that it provided opportunities
for increased exercise levels and suggested further research in public
health (Wong, Turner, MacIntyre, & Yee, 2017).
A systematic review of virtual reality rehabilitation found some
evidence of improvement in motor skills and balance for children and
adolescents with cerebral palsy (Ravi, Kuman, & Singhi, 2017).
Researchers developed a game to help individuals with Parkinson's
disease improve coordination, gross and fine dexterity, and strength of
upper limb muscle grip. Results showed significant improvement in the
experimental group (Fernandez-Gonzalez et al., 2019).

FIGURE 10-9 Individuals playing Pokémon Go.

904
 With game play, tension and fears are released in a safe setting, and
aversive or shameful aspects of an illness may be managed. The focus of
attention on an engaging distraction (the game) may explain how individuals
manage aversive symptoms through video game play. An example of
distractive use of a virtual reality game is SnowWorld (see Table 10-4 for
description) that is used to distract patients during burn care.

TABLE 10-4 Selected Health-Related Video Games and

Virtual Reality Games

Source: Cigna (2019); Coravos (2018); Lee (2017).

905
Telehealth
Telehealth is the “use of technology to deliver health care, health
information, or health education at a distance” (Association of State and
Territorial Health Officials, 2017, p. 4). Telehealth Nursing: A Position
Statement from the Telehealth Special Interest Group of the American
Telemedicine Association states: Telehealth is “remote healthcare….via
electronic communications to improve patients' health status” using
“different types of programs and services” (2019, p. 8). Telehealth gives the
community/public health nurse an opportunity to see and speak with clients
located at remote sites as well as provide education and counseling.
Telehealth consists of delivery, management, and coordination of health
services, integrating telecommunication and electronic technologies, to
increase client access to health care and improve outcomes while lowering
costs (Smith, Watts, & Moss, 2018).
Telehealth provides access to care and the ability to export clinical
expertise to individuals who require care, regardless or geographic location
of the patient or the clinician (Donelan et al., 2019). The boundaries of
telehealth are limited only by the technology available, and new applications
are being developed and tested every day. Telehealth can be divided into two
general types of applications: real-time or synchronous communication and
store-and-forward or asynchronous communication.

Real-time communication scenarios include a patient and clinician

consulting with a specialist via a live audio/video link, a clinician and a
patient in an exam room communicating through an interpreter
connected by phone or webcam, or a patient at home communicating
with a C/PHN via a live audio/video link (Fig. 10-10).
Asynchronous telehealth applications do not require members to be
present at the same time but share the same information at the time most
convenient to each one (Siwicki, 2019).

906
 FIGURE 10-10 Telehealth gives the community/public health
nurse an opportunity to see and speak with clients located at
remote sites, as well as provide education and counseling.

Telehealth has been growing rapidly because it offers four fundamental

benefits:

Improved access: Can reach patients in distant locations

Cost efficiencies: Reduces the cost of health care
Improved quality: Similar to traditional in-person care
Patient convenience/satisfaction: Reduces travel time and related
stresses

Telehealth shows great potential for advancing preventative medicine

and the treatment of chronic conditions. The first year of reimbursement for
telehealth services delivered outside of care settings occurred in 2015
(Wicklund, 2015). Between 2016 and 2017, telehealth use grew 53%,
outpacing growth in urgent care clinics (14%) and retail clinics (7%).
Injuries, respiratory infections, and digestive problems were most commonly
seen, along with mental health and joint/soft tissue issues. The growth in
telehealth services demonstrates continued demand for this service (FAIR
Health, 2019).
In a survey of state health departments, ASTHO (Kearly & Oputa, 2019)
found that over 51% used telehealth services to provide patient and
professional health education. Other uses included behavioral health
(42.4%), specialty care (40.2%), chronic disease (23.9%), and infectious
disease (23.9%). Increased access was the greatest achievement (33.8%),
whereas securing funding (22.4%) was the greatest challenge.
There are nursing licensure barriers, as nurses working in telehealth must
be licensed in the state where patients are located at the time services are
provided. Licensure compact regulations provide for multistate nursing

907
licenses through the Enhanced National Licensure Compact (eNLC), which
requires criminal background checks and licenses within states and reporting
between states participating in the compact (Mataxen, 2019). As of January
2020, there were 38 member states of eNLC, either enacted or pending
(Gaines, 2020).
Telehealth can be a lifeline during disasters and pandemics, such as the
Covid-19 pandemic in 2020. In March 2020, because a national emergency
declaration was issued, a waiver was made for the requirement that
physicians or other health care professionals hold licenses in the state in
which they provide services, as long as they have an equivalent license from
another state. In addition, the Medicare telehealth waiver expanded chronic
care management, interprofessional consultations, and digital evaluations
(evisits) and lifted geographical limitations as well as the requirement for a
prior health care relationship to exist between the client and the health care
provider. Other constraints were relaxed for the duration of the public health
emergency, including restrictions on prescribing controlled substances and
HIPAA-related limitations on the use of Facebook or Skype for telehealth
(Center for Connected Health Policy, 2020).

908
Geographic Information Systems
A geographic information system (GIS) is a computer-based information
system designed to capture, store, manipulate, analyze, manage, and present
all types of spatial (relating to space) or geographical data (Fig. 10-11). GIS
allows the user to visualize, question, analyze, and interpret data to
understand relationships, patterns, and trends. Spatial or mappable data are
integrated with conventional data. GIS can be thought of as a two-
dimensional Google earth map. Google earth allows you to zoom in and out
and pan around, and GIS additionally allows users to select a feature on the
map and, in return, will be provided with any information in the database
associated with that feature (University of Mary Washington, 2016). Much of
community/public health is spatially related, so the use of GIS can provide
information about demographic, epidemiological, and logistical issues and
emerging trends. GIS output is location-based information. GIS can provide

FIGURE 10-11 Map of Virginia indicating uninsured, children

accessing CDCs, and five regional CDC locations. (Adapted from
DeGuzman, P., Altrui, P., Doede, A. L., Allen, M., Deagle, C., &
Keim-Malpassa, J. (2017). Using geospatial analysis to determine
access gaps among children with special healthcare needs. Health
Equity, 2(1), 1–4. doi: 10.1089/heq.2017.0050. Copyright ©
Pamela DeGuzman et al. Reprinted under the Creative Commons
License http://creativecommons.org/licenses/by/4.0)

Better understanding of a current situation

Planning/targeting of appropriate interventions
Monitoring and revision of interventions as needed
An opportunity for cooperation with other organizations and
government departments through a culture of data sharing and working
together

Sharing, comparing, and integrating GIS data will eliminate silos and
result in better outcomes providing additional information to identify health
disparities (Mohammadi et al., 2018). There is great potential for GIS to

909
inform C/PHN. Nurses can play an important role in demonstrating how
various data sources come together to enable informed decisions for
populations and individuals (Kolifarhood, Khorasani-Zavareh, Salarilak,
Shoghli, & Khosravi, 2015). Understanding of GIS may be considered an
essential skill for the evolution of nursing practice (Mohammadi et al., 2018).
The tremendous potential of GIS to benefit health care delivery is being
realized. Both public and private organizations are developing innovative
ways to use GIS, from public health departments and public health policy
and research organizations to hospitals, medical centers, and health insurance
organizations. Public health uses of GIS include tracking child
immunizations, evaluating the spread and clustering of diseases, conducting
health policy research, and establishing service areas and districts (ArcUser
Online, n.d.).
An example of how GIS has been used to benefit health care delivery is
the research by DeGuzman et al. (2018). The purpose of their study was to
use GIS and other mapping to identify local and regional access gaps of
children with special health care needs (CSHCN), with the aim of
pinpointing and reducing disparities. This collaborative group of academic
and practice researchers recognized that access to necessary services for
families of CSHCN is less convenient for rural populations due to distance
and travel required. Public health departments often serve as safety net
providers in these areas but sometimes need to refer clients to specialized
programs at child development centers (CDCs). In the state of Virginia, there
were only five CDCs helping children with motor/physical disorders,
speech/developmental delays, attention-deficit hyperactivity disorder, or
autism spectrum disorder. Researchers “layered individual-level data over
county-level socioeconomic data” to bring the sociodemographic
environment into focus (p. 2). A chloropeth map (i.e., color progression from
lighter to darker areas) indicated the number of uninsured CSHCN children
at the county level. As Figures 10-11 depict, darker red and orange areas
have a greater number of uninsured children. You can easily discern larger
cities (groupings of dots) and rural areas (scattered dots) as well as the
distance of the child from the nearest CDC. At a quick glance, it is evident
that many children live in rural areas, and many of them are uninsured. One
of the significant limitations of this chloropeth map is that it cannot include
the unknown number of unserved children who never made contact with a
CDC.

910
Electronic Health Literacy and the Digital Divide
The rapid development of communication technology affects every aspect of
society as information is instantly available. Health communication and
health information technology competencies are identified as vital skills of
an informed consumer and essential for improving population health
outcomes and health care quality. Electronic health literacy was first defined
by Norman and Skinner (2006, para. 1) as the “ability to seek, find,
understand, and appraise health information from electronic sources and
apply the knowledge gained to addressing or solving a health problem.”
Computer literacy and knowledge of the use of current technologies are
part of health literacy. Increasingly, individuals must be able to use
technology and navigate through a vast array of information, tools, and
sources to acquire and critically analyze the information necessary to make
appropriate and informed decisions (Vajan & Baban, 2015). The same is true
for community/public health nurses, as noted in the Quad Council C/PHN
competencies (2018) (see the appendix).
A digital divide exists between those who have easy access to computers,
broadband Internet, and smartphones/tablets and those who do not. Often this
affects those living in rural areas (Perrin, 2019). Recent technological
developments have elevated the importance of assessing how electronic
health tools have empowered patients and improved health, especially among
the most vulnerable populations. There is potential for electronic health
technologies to aid in reducing communication inequalities and disparities in
health. The need exists to educate at-risk and needy groups (e.g., chronically
ill) and design technology in a way that works for them. Addressing these
areas may not diminish the digital divide, but it may ameliorate its
consequences (Griebel et al., 2018).

911
SUMMARY
Communication and collaboration are important tools for
community/public health nurses to promote aggregate health.
Communication involves the transfer and understanding of meaning
between individuals. Motivational interviewing and OARS are means of
joining with clients to effect change or meet needs. There are many
barriers, skills, factors, and core skills essential to effective
communication in community health nursing.
In community/public health, nurses frequently need to promote group
communication and in-group decision making. Decisions made by
groups have many advantages, including sharing of members'
experience and expertise, diversity of opinions, potential for broadening
members' perspectives, and a focus on arriving at consensus solutions.
There are several methods of enhancing group decision making.
Collaboration and partnership building are purposeful interactions
among the nurse, clients, community members, and other professionals
based on mutual participation and joint effort. It is characterized by
shared goals, mutual participation, maximized use of resources, clear
responsibilities, set boundaries, and collaborative relationships.
Contracting is a helpful tool in promoting clients' participation,
independence, and motivation. It is used at all levels of
community/public health nursing to promote partnership in the
collaborative process, to encourage commitment to health goals, and to
ensure a format and a means for negotiation among the collaborating
parties. Contracts may be formal or informal, written or verbal, and
simple or complex.
EHRs are becoming more prevalent in public health and are
commonplace in hospital and outpatient settings. There are both
advantages and disadvantages to using electronic records.
Big data include very large and complex data sets that are analyzed to
uncover trends, associations, and patterns. This is very helpful in public
health agencies in the areas of disease surveillance, population health
management, and immunization trends.
mHealth involves the use of mobile devices (e.g., smartphones, tablets,
notebooks) for communication between clients and community/public
health nurses and can be useful in promoting health. Trends in mHealth
include interactive (two-way communication), integrative
(patient/provider and tracking systems), and multimedia uses
(games/quizzes to promote health).

912
Technology applications are used for computers, tablets, and
smartphones, and more health-related apps are available every year.
C/PHNs must be aware of reliable applications to assist in health
promotion.
Blogging and online support communities have proven to be helpful to
those with chronic diseases or others needing emotional support.
Video games and virtual reality games, such as exercise programs, are
being used for health applications, in addition to their usual
entertainment value.
Telehealth provides health information or health care to many
individuals and groups who may otherwise not be able to access it, and
its popularity is increasing.
Electronic health literacy and the digital divide often prevent full use of
technology among vulnerable and rural populations.

913
ACTIVE LEARNING EXERCISES
1. Pick a classmate and take turns practicing motivational interviewing
(using OARS). Role play working with a client who has a
problematic behavior (e.g., needs to eat healthier, exercise more).
How will you approach them? Describe how you can demonstrate
active listening and effective communication skills. List three
effective communication skills and practice them.
2. Think of a patient you have worked with who may have low health
literacy. Give three examples of how to help them better
communicate with their physician and other health professionals.
Debate with a classmate if health literacy is important, not only for
the patient as an individual but for the community and society as a
whole. Which of the 10 essential public health services (see Box 2-2 )
is being utilized here?
3. Discuss with a community/public health nurse or supervisor
collaboration and the importance of collaborative skills. Ask about
examples of types of collaborative projects or interventions. What
facilitates effective collaboration in the community? What inhibits
effective collaboration, and how can you overcome this? Describe
how collaboration is essential in mobilizing community partnerships
(see number 4 of the 10 essential public health services listed in Box
2-2 ).
4. Search the literature for research examples of the use of big data in
assessing public health problems and designing interventions. Were
the findings significant and applicable to your community? Explain
ways in which these data are more helpful than traditional data. How
is this most useful in public health?
5. Consider the various types of technology available (e.g., mHealth,
mobile health applications, video games, telehealth, GIS). Which
would you find most effective as you design public health
interventions for various age groups and populations (e.g., low-
income, Spanish-speaking Latino women needing nutritional
information; adolescents seeking information on STDs and sexual
health; addressing an outbreak of foodborne illness in a large
metropolitan area; 10-to 14-year-olds with asthma)?

thePoint: Everything You Need to Make the

Grade!

914
 Visit http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, and more!

915
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CHAPTER 11
Health Promotion Through Education
“It is health that is real wealth and not pieces of gold or silver.”

—Mahatma Gandhi

KEY TERMS
Affective domain Anticipatory guidance Change
Cognitive domain Evolutionary change Health literacy Health promotion
Learning theory Planned change Psychomotor domain Revolutionary change
Social determinants of health Social marketing Socioeconomic gradient
Stages of change

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Describe social determinants of health and how each relates to health
inequities and change through education.
2. Explain the three stages of change and planned change strategies.
3. Describe the C/PHN role as an educator in promoting health and
improving quality of life.
4. Identify educational activities for the nurse to use that are appropriate for
each of the three domains of learning.
5. Identify health teaching models for use when planning health education
activities.
6. Develop teaching plans focusing on primary, secondary, and tertiary
levels of prevention for clients of all ages and learning needs.

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INTRODUCTION
Think about one of your favorite teachers from nursing school, high school,
or earlier. How did the teacher get and hold your interest? How can you
apply that in your work with public health nursing clients? Teaching has been
a critical role of the community/public health nurse (C/PHN) since the
origins of the profession, and frequently it is the primary role or function.
C/PHNs develop partnerships with clients to achieve behavior changes that
promote, maintain, or restore health. This partnership focuses on self-care—
the ability to effectively advocate and manage a person's own health. The
rationale for health teaching is to equip people with the knowledge, attitudes,
and practices that will allow them to live the fullest possible life for the
greatest length of time.
This chapter begins by discussing the Healthy People 2030 goals and
objectives, as well as key concepts related to health promotion. It then covers
the nature and stages of change and the process and principles of planned
change. Next, we consider some foundational concepts related to learning
and teaching, including the domains of learning, learning theories, health
teaching models, and teaching at the three levels of prevention. Finally, the
chapter concludes by providing guidance on effective client teaching,
including some principles of learning and teaching, steps in the teaching
process, teaching methods and materials, and teaching clients with special
learning needs.

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HEALTHY PEOPLE 2030 AND KEY
CONCEPTS RELATED TO HEALTH
PROMOTION
To understand the goals of health promotion and the C/PHN's role in meeting
them, we must explore relevant aspects of the Healthy People 2030 initiative
and some key concepts, including the social determinants of health, the
socioeconomic gradient in health, health disparities, access to care, and
quality of care.

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Healthy People 2030
The vision of Healthy People 2030 is for “a society in which all people can
achieve their full potential for health and well-being of all people” (U.S.
Department of Health and Human Services [USDHHS], 2020, para. 6). The
Healthy People 2030 objectives address social determinants of health and
health equity (USDHHS, 2019). Healthy People 2030 objectives for
Educational and Community-Based Programs are listed in Box 11-1
(USDHHS, 2020). These objectives, when viewed in the broader context, can
be used to identify client needs and align educational efforts that will
advance this national initiative.

BOX 11-1 HEALTHY PEOPLE 2030

Objectives for Educational and Community-Based
Programs

Reprinted from U. S. Department of Health and Human Services (USDHHS). (2020). Educational
and community-based programs objectives.
Retrieved from https://health.gov/healthypeople/search?query=ECBP

935
Social Determinants of Health
The World Health Organization has defined the social determinants of
health as “the conditions in which people are born, grow, live, work, and
age” (World Health Organization, 2018, para. 1). Economic stability,
education, health and health care, neighborhood and built environment, and
social and community context are five key domains associated with social
determinants of health (Centers for Disease Control and Prevention [CDC],
2017). The unequal distribution of these factors among certain groups
contributes to health disparities that are persistent and pervasive.
Recognizing and reducing health inequities is a priority of Healthy People
2030.

Understanding social determinants of health requires examination of

numerous factors, beyond individual behavior, that contribute to our
state of health.
Factors that influence an individual's ability to maintain good health
include social, economic, and physical factors such as access to social
and economic opportunities; safe housing; quality education; clean
water, food, and air; safe workplaces; equitable social interactions
(class, race, and gender); and adequate community resources
(USDHHS, 2018).
Addressing these factors in a manner that has a positive impact on
social, economic, and physical conditions and supports positive health
behavior change can improve the health of communities over time.

Social determinants of health influence both morbidity and mortality.

Singh et al. (2017) examined the health inequalities among different
populations in the United States from 1935 to 2016 and found that although
life expectancy increased during this time, gender and racial/ethnicity
disparities were present. Life expectancy was lowest in African American
populations and rural populations. Additionally, infant mortality rates were
greater in Black infants and rural, poor communities (Singh et al., 2017).
In an effort to improve the health of disadvantaged groups, early public
health efforts addressed determinants of health such as sanitation and
poverty, along with living conditions and other environmental issues, as
noted in Chapters 3 and 7. It is now widely acknowledged that to truly have
an impact on the health of the population, there is a need to improve social
conditions (Bharmal, Derose, Felician, & Weden, 2015). Political action and
participatory action research are vital tools in reducing the effects of these
conditions, as are methods of community empowerment (Lee et al., 2018).
See Chapters 4 and 13. See Box 23-5 for the Healthy People 2030 social
determinants of public health.

936
Socioeconomic Gradient in Health
Socioeconomic gradient in health refers to the improvement in health
outcomes as socioeconomic position improves (CDC, 2014). A series of
large-scale, longitudinal studies in England, the now-classic Whitehall
studies, divided British civil servants into socioeconomic groups based upon
their occupational status (e.g., from executives to unskilled workers). What
the investigators discovered was an improvement in mortality and morbidity
rates as the level of occupation and pay increased. Those at the lowest levels
had the poorest health, but as they moved up the salary scale and
occupational level, their health improved. What makes this so interesting is
that all of the workers had basic health insurance coverage and free medical
care—no real problems with access to health care existed. Although less
pronounced, even when the researchers adjusted for diet, exercise, and
smoking, the gradient persisted (Center for Social Epidemiology, 2018).
Researchers have found higher rates of mortality in all causes and
cardiometabolic disorders among those with lower socioeconomic position
(Petrovic et al., 2018).
Globally, socioeconomic gradients in health are noted. For example, the
infant mortality rate is 2 per 1,000 live births in Iceland compared with more
than 120 per 1,000 live births in Mozambique. The life expectancy for men is
54 years in Calton (a neighborhood in Glasgow, Scotland) compared with 81
years in Lenzie (a neighborhood just a few miles away; Marmot, 2015). The
socioeconomic gradient has also been noted in behaviors, such as smoking,
that are highest among those who are from the working class and who have
low income and low educational levels (Petrovic et al., 2018).
As noted above, the social determinants of health involve the conditions
in which we live, work, and exist, which include socioeconomic factors such
as income, education, and social status. Our health is determined to a great
extent by these upstream social determinants, such as “education, labor,
criminal justice, transportation, economics, and social welfare” (Adler et al.,
2016, p. 2). Social determinants of health affect both morbidity and mortality,
and targeted programs such as the Nurse-Family Partnership and the
Supplemental Nutrition Assistance Program (SNAP) address some of health
disparities resulting from these factors (Adler et al., 2016). See Chapter 23
for more on the social determinants of health.

937
Health Disparities
Health disparities are differences among populations in the quantity of
disease, burden of disease, age and rate of mortality due to disease, health
behaviors and outcomes, and other health conditions (Duran & Pérez-Stable,
2019). Put another way, health disparities can be objectively viewed as a
disproportionate burden of morbidity, disability, and mortality found in a
specific portion of the population in contrast to another. Although health
disparities can result from poor choices by an individual despite health
education and counseling efforts, most are thought to be due to social
inequities that can be corrected (CDC, 2018). A long-held belief about health
inequities, adopted by the World Health Organization, is that health
differences that are avoidable and unnecessary are patently unfair and unjust
(World Health Organization, 2020).
The topic of social determinants of health was added to Healthy People
2020 and continues to be a focus of Healthy People 2030 (Office of Disease
Prevention & Health Promotion, 2020). Reported disparities exist in the areas
of quality of health care, access to care, levels and types of care, and care
settings; they exist within subpopulations (e.g., older adults, women,
children, rural residents, those with disabilities) and across clinical
conditions. Thus, to continue the work on eliminating health disparities, one
overarching goal for Healthy People 2030 is to “eliminate health disparities,
achieve health equity, and attain health literacy to improve the health and
well-being of all” (USDHHS, 2020, para. 10).

Poor access to quality care and overt discrimination are examples of

disparities.
Discrimination can occur during service delivery if health care
providers are biased against a specific group or hold stereotypical
beliefs about that group.
Providers may also not be confident about providing care for a racial or
ethnic group with whom they are unfamiliar.
Language barriers can be a problem, as can cultural values and norms
that are unfamiliar to providers. Patients can also react to providers in a
way that promotes disparities; patients may not trust the information
given to them and may not follow it as explained, leading to inadequate
care (Kaiser Family Foundation, 2018).

938
Access to Health Care
The Institute of Medicine's (2003) classic report Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health Care noted a large body
of research highlighting the higher morbidity and mortality rates among all
racial and ethnic minority groups when compared with Whites. This report
drew attention to an issue that continues today and remains relevant.
Differences in health care access were also explained, be it in the form of
inadequate or no health insurance, problems getting health care, the quality
of care, fewer choices in where to go for care, or the lack of a regular health
care provider.

Residential segregation, although illegal, still exists and can play a role
in health disparities.
Historically, vulnerable populations, especially racial and ethnic
minority groups and low-income populations, have found access to
health care difficult. Recent data showed that the Patient Protection and
Affordable Care Act is improving access to health care for Hispanic and
African American young adults (Lipton, Decker, & Sommers, 2017).
However, it is estimated that approximately 55% of all uninsured who
are not older adults are people of color (Kaiser Family Foundation,
2016).
Other geographic factors can affect access to health care services. For
example, the opioid epidemic has impacted low-income, low-
employment areas harder than other geographic areas. Additionally,
there remains a lack of access to drug treatment programs for minority
groups (Santoro & Santoro, 2018).

Health care access is also problematic for other vulnerable groups. For
example, services and resources for the mentally ill and those with substance
use disorders are often fragmented and inadequate, as are those for victims of
abuse and homeless persons. Refugees and immigrants may have difficulty
finding affordable and easily accessible health care, largely because of their
lack of health insurance and the need to find care at free clinics or emergency
rooms (McNeely & Morland, 2016). When vulnerable individuals cannot get
appropriate health care or treatment for illness or disease, for whatever
reason, they are more likely to have health deficits.

939
Quality of Health Care
Quality of care is essential for positive health outcomes. The World Health
Organization states that “health care must be safe, effective, timely, efficient,
equitable, and people centered” (2019, para. 4). To receive quality care,
people must be able to access it. Research confirms that minority groups
have more barriers to access health care when compared with White
populations and use less care (Kaiser Family Foundation, 2016). One factor
contributing to the lower use of care could be the lack of diversity that exists
in the U.S. health care system. Research indicates that racial and ethnic
minority clients feel more comfortable and satisfied with care from a health
care provider who comes from the same racial and/or ethnic group (Fig. 11-
1; Duke & Stanik, 2016). The USDHHS reports that all minority groups,
except Asians, were underrepresented in health diagnosis and treating
occupations. These occupations include nursing, occupational therapy,
physical therapy, dietetics, physicians, pharmacists, dentists, speech language
pathology, respiratory therapy, and optometrists (USDHHS, 2017).

FIGURE 11-1 Racial and ethnic minority clients often prefer

health care providers from the same racial and ethnic background.

Lack of access to quality health care services is common among racial

and ethnic minority groups. Significant disparities in the quality of care were
found in a study examining diabetes quality of care. The study was a cross-
sectional study examining adults diagnosed with type 2 diabetes. Study
findings revealed that when compared with White adults, Hispanic adults had
fewer HbA1c lab tests, eye exams, cholesterol lab tests, foot exams, and flu
vaccinations; Black adults had fewer flu vaccinations; and Asian adults had
fewer HbA1c tests, foot exams, and flu vaccinations (Canedo, Miller,

940
Schlundt, Fadden, & Sanderson, 2018). Other studies have similar findings.
A review of 25 studies examining quality of care in cardiovascular disease
revealed racial disparities. The use of statins for treatment of peripheral
artery disease, prescription for ischemic vascular disease, hyperlipidemia
behavioral counseling, and clinical measures for coronary artery disease and
congestive heart failure were lower for Black and Hispanic populations when
compared with non-Hispanic White populations (Dong, Fakeye, Graham, &
Gaskin, 2017).
Communication can be a factor in poor quality of care. Marginalized
vulnerable populations are at a greater risk for experiencing communication
problems in health care. Vulnerable populations include those who are
uninsured, low-income, low-education, or low health literacy; those with
cultural barriers (social, cultural, or linguistic); and those with environmental
challenges (lack of housing or instability, environmental exposures, limited
physical activity opportunities). Poor health outcomes may result as
effectiveness of health care for vulnerable populations is not often considered
or even well defined (Bhatt & Bathija, 2018).

The C/PHN can play a significant role in addressing social determinants

of health by first being aware and educated about factors that influence
health beyond an individual's choices, looking at root causes of disease.
C/PHNs can educate their client base on the social determinants of
health, facilitate community action that supports positive change, and
advocate for policies that address the root causes of disease and health
inequities (USDHHS, 2018).

The Robert Wood Johnson Foundation conducted seminal research to

determine the most effective messages on social determinants of health that
are meaningful and understandable to Americans (Robert Wood Johnson
Foundation, 2010). The C/PHN educator can use these messages to
communicate concepts about social determinants of health to clients and
communities (see Boxes 11-1 and 11-2). See Chapters 14, 15, and 23 for
additional information.

BOX 11-2 HEALTHY PEOPLE 2030

Key Factors for Social Determinants of Health
(Selected Objectives)Core Objectives

941
Reprinted from U.S. Department of Health and and Human Services (USDHHS). (2020). Browse
objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

One example of an effective intervention using social determinants of

health is the Kaiser Permanente's Healthy Eating Active Living program.
There were a series of several implementation programs that were conducted
over a period of 10 years that touched 60 communities and over 700,000
individuals from five states. These programs included nutrition patient
education programs, physical activity programs, healthy school lunch
programs, programs to reduce food insecurity, and improved physical
education school programs. Over 60% of the 143 obesity-prevention
strategies revealed improvements in behavior change (Heath, 2018).
For health education to be effective, awareness of the underlying
principles of behavior change is vital. The C/PHN should consider what
motivates individuals and groups to adopt new behaviors and what factors
may inhibit or prevent that change. By understanding the principles of
teaching and behavior change, the C/PHN can work toward the ultimate goal
of health promotion for individuals, families, groups, and communities.

942
HEALTH PROMOTION THROUGH
CHANGE
Health promotion has been defined as health behaviors that improve well-
being and lead to a desire to meet one's human potential (Pender, Murdaugh,
& Parsons, 2015). Another term often confused with health promotion is
disease prevention (or health protection), which is “behavior motivated by a
desire to actively avoid illness, detect it early, or maintain functioning within
the constraints of illness” (Pender et al., 2015, p. 17).
These two terms, so often used interchangeably, are clearly both
important aspects of health education efforts, yet they imply a decidedly
different motivation. For the C/PHN, both terms relate to practice at the
primary level of prevention. Box 11-3 later in this chapter describes
educational activities within both of these approaches in relation to primary
prevention. For instance, a C/PHN may plan an educational program for
community-dwelling older adults to learn about the need for a balanced diet,
rich in fruits and vegetables. This would be an example of a health promotion
focus, because there is no clear disease or condition at issue. As the nurse
continues to work with these individuals, the nurse learns that several clients
have had recent falls. Fortunately, none of the falls were serious, yet the
nurse recognizes the need to discuss foods that will help reduce bone loss
and promote healthy bone growth. To protect the clients' health, the nurse
provides information on a variety of foods rich in calcium and explains the
need for adequate vitamin D, a safe home environment, weight-bearing
exercise (Fig. 11-2), and medication review. This effort would be still
primary prevention, but with the purpose of health protection.

BOX 11-3 Theoretical Propositions of

the Health Promotion Model
1. Inherited and acquired characteristics along with prior behavior
influence beliefs, affect, and health-promoting behavior.
2. People engage in behaviors from which they anticipate deriving
personally valued benefits.
3. Perceived barriers can constrain action to change behavior and the
behavior itself.
4. Perceived self-efficacy to embrace a given behavior increases the
likelihood to commit to action and implementing the behavior.
5. Greater perceived self-efficacy results in fewer perceived barriers.

943
 6. Positive affect toward a behavior results in greater perceived self-
efficacy, which can result in increased positive affect.
7. When positive affect is associated with a behavior, commitment,
and action are increased.
8. People are more likely to commit to and participate in health-
promoting behaviors when significant others model the behavior,
expect it, and provide assistance and support for the behavior.
9. Others—family members, peers, and health care providers—are
important sources of influence that can positively or negatively
influence commitment to and implementation of health-promoting
behavior.
10. Situational influences can positively or negatively influence
commitment to and implementation of health-promoting behavior.
11. The greater the commitment to a behavior change, the more likely
the change will be maintained over time.
12. Distracting demands over which the person has little control may
affect commitment to a behavior change.
13. Commitment to a behavior change is less likely to be maintained
when other actions are more attractive and preferred.
14. People can modify the interpersonal and physical environments to
create incentives for behavior changes.

Source: Murdaugh et al. (2019).

FIGURE 11-2 A goal of health promotion is to encourage clients

to develop healthy behaviors.

For the C/PHN, teaching is the primary means to influence health at all
levels, primary, secondary, and tertiary. But consider the educational program
just described: The C/PHN has provided a well-developed educational

944
program that was well received by the participants. They listened attentively,
took the nurse's well-prepared handouts home, and even promised to add
more fruits, vegetables, and calcium-rich foods to their diet. A few weeks
later, in another educational program, the nurse learns from the participants
that they have not altered their dietary patterns in the slightest. This is an
example of how understanding the principles of behavior change may
provide guidance to this C/PHN in planning a more effective program, with a
greater chance for success.

945
The Nature of Change
To be a C/PHN is to be a health educator with the goal of effecting change in
people's behaviors. When nurses suggest that families adopt healthier
communication patterns, they are asking them to change. Teaching parenting
skills to teenagers is introducing a change. Promoting a community's self-
determination in choosing a safer environment requires that the individuals
involved must change. Therefore, it becomes imperative for C/PHNs to
understand the nature of change, how people respond to it, and how to effect
change for improved community health.

Definitions and Types of Change

Change is “any planned or unplanned alteration of the status quo in an
organism, situation, or process,” per Lippitt's (1973, p. 37) classic definition.
This definition explains that change may occur either by design or by default.
From a systems perspective, change means that things are out of balance or
the system's equilibrium is upset (Roussel, Harris, & Thomas, 2016). For
instance, when a community is ravaged by floodwaters, its normal
functioning is thrown off balance. Adjustments are required; new patterns of
behavior become necessary. The change process can also be described as
sudden or drastic (revolutionary) or gradual over time (evolutionary).
Evolutionary change is change that is gradual and requires adjustment
on an incremental basis. It modifies rather than replaces a current way of
operating. Some examples of evolutionary change include becoming parents,
gradually cutting back on the number of cigarettes smoked each day, and
losing weight by eliminating desserts and snacks. Gradual change may “ease
the pain” that change brings to some individuals. Sometimes, this type of
change may be viewed as reform.
Revolutionary change, in contrast, is a more rapid, drastic, and
threatening type of change. It involves different goals and perhaps radically
new patterns of behavior. Sudden unemployment, stopping smoking
overnight, losing the town's football team in a plane accident, removing
children from abusive parents, or rapidly replacing human workers with
computers are examples of revolutionary changes. In each instance, the
people affected have little or no advance warning and little or no time to
prepare. High levels of emotional, mental, and sometimes physical energy
and rapid behavior change are required to adapt to revolutionary change. If
the demands are too great, some may experience defense mechanisms such
as incapacitation, resistance, or denial of the new situation.
The impact of a proposed change on a system clearly depends on the
degree of the change's evolutionary or revolutionary qualities, a factor to be

946
considered in planning for change. Some situations lend themselves better to
one kind of change than to another. A community in need of improved
facilities for the handicapped (e.g., ramps, wider doors) can introduce this
change on an evolutionary, incremental basis, whereas a community that is
involved in an unsafe, intolerable, or life-threatening situation, such as a
hurricane or serious influenza epidemic, may require revolutionary change.
Two powerful examples of social and public health change occurred
during the last decades of the 20th century—dramatic decreases in both
motor vehicle crashes and tobacco consumption. These changes did not come
about simply through education alone. Rather, “multilevel and
multicomponent” approaches were used, and social norms were changed by
the use of epidemiology and surveillance as a basis for social marketing in
bringing the problems to the attention of the American public; with the social
influence of individuals, along with supportive legislation and policies,
changes in health behaviors occurred (Gielen & Green, 2015, p. 21). Because
of research, surveillance, monitoring of risk factors, and subsequent
interventions related to these two problems, more people became aware of
the significance of them. Although cigarettes had been proclaimed a health
risk in 1964, many people still smoked. It was not until smoking cessation
research began to show promise and new over-the-counter treatments and
medications became available that more people attempted to stop smoking.
In 1992, secondhand smoke was declared to be a carcinogen. Mass media
was used to educate the public on the risks and the benefits of quitting; this
also began to change public opinion. At the same time, legislation to control
the advertising of tobacco products and tighten sales to minors gained
momentum. Smoke-free policies were enacted, and higher cigarette taxes
made it more difficult for some to smoke. Counseling and education
strategies were increasingly empowering individuals and communities to
change health behaviors, and multiple attempts at quitting were accepted.
Cigarette sales began to drop, and stroke and heart attack death rates quickly
improved after smoke-free zones were established. Child asthma admissions
to hospitals and premature births also significantly declined within a year
after the United States enacted bans on smoking in public places.
Researchers point to the synergistic effect of the interventions (Gielen &
Green, 2015).

Stages of Change
The phrase stages of change refer to the three sequential steps leading to
change:

Unfreezing (when desire for change develops)

Changing (when new ideas are accepted and tried out)
Refreezing (when the change is integrated and stabilized in practice)

947
 Kurt Lewin first described these stages in the 1940s and early 1950s, and
they have become a cornerstone for understanding the change process
(Kaminski, 2011; Lewin, 1947, 1951; Lippitt, Watson, & Westley, 1958):

Unfreezing: The first stage, unfreezing, occurs when a developing need

for change causes disequilibrium in the system. A system in
disequilibrium is more vulnerable to change. People are motivated to
change either intrinsically or by some external force. The unfreezing
stage involves initiating the change.
Changing/moving: The second stage of the change process, changing or
moving, occurs when people examine, accept, and try the innovation
(Kaminski, 2011). This is the period when participants in a prenatal
class are learning exercises or when elderly clients in a senior citizens'
center are discussing and trying ways to make their apartments safe
from accidents. During the changing stage, people experience a series of
attitude transformations, ranging from early questioning of the
innovation's worth to full acceptance and commitment and then to
accomplishing the change. The change agent's role during this moving
stage is to help clients see the value of the change, encourage them to
try it out, and assist them in adopting it.
Refreezing: The third and final stage in the change process, refreezing,
occurs when change is established as an accepted and permanent part of
the system (Kaminski, 2011). The rest of the system has adapted to it.
People no longer feel resistant to it, because it is no longer viewed as
disruptive, threatening, or new. As the change is integrated, the system
becomes refrozen and stabilized. Refreezing involves integrating or
internalizing the change into the system and then maintaining it.

948
Planned Change
Leaders in community health nursing have been change agents for decades.
They have planned and managed change in a variety of systems. Planned
change is a purposeful, designed effort to effect improvement in a system
with the assistance of a change agent per Spradley's classic definition (1980).
Planned change, also known as managed change, is crucial to the
development of successful community health nursing programs, and various
models of change have been proposed over the years (Table 11-1; Roussel et
al., 2016). Regardless of the specific model used, the following
characteristics of planned change are a key to its success:
TABLE 11-1 Change Models

Source: Havelock and Havelock (1973); Kotter (2012); Lippitt, Watson, and Westley (1958); Rogers
(2003).

949
 The change is purposeful and intentional: There are specific reasons or
goals prompting the change. These goals give the change effort a
unifying focus and a specific target. Unplanned change occurs
haphazardly, and its outcomes are unpredictable.
The change is by design, not by default: Thorough, systematic planning
provides structure for the change process and a map to follow toward a
planned destination.
Planned change in community health aims at improvement: That is, it
seeks to better the current situation, to promote a higher level of
efficiency, safety, or health enhancement. Planned change aims to
facilitate growth and positive improvements. Plans to provide shelter
and health care for a homeless population, for example, are designed to
improve this group's well-being.
Planned change is accomplished through an influencing agent: The
change agent is a catalyst in developing and carrying out the design; the
change agent's role is a leadership role, often as an educator.

Planned Change Process

The planned change process involves a systematic sequence of activities that
follows the nursing process. The eight basic steps lead to the successful
management of change. These steps include (1) recognize symptoms; (2)
diagnose need; (3) analyze alternative solutions; (4) select a change; (5) plan
the change; (6) implement the change; (7) evaluate the change; and (8)
stabilize the change (Table 11-1; Spradley, 1980).

Applying Planned Change to Larger Aggregates

C/PHNs use the change process when managing change at organization,
population group, community, and larger aggregate levels. For example, as a
result of information gleaned from parents, C/PHNs, other community health
partners, and other data that track health outcomes, a nurse may suspect that
there is a widespread lack of confidence among young parents (Fig. 11-3).
This hypothesis could be tested through a social media survey to determine
parenting needs among the entire community's population of young parents.
If symptoms are present (step 1), the nurse, in collaboration with health
department personnel or other appropriate professionals, could analyze the
symptoms and reach a diagnosis (step 2) that many young parents in the
community are lacking in confidence and knowledge of parenting skills.
Several approaches to meeting this need could be considered, such as
instituting a parenting center in the community with satellite clinics,
organizing churches or clubs to sponsor parenting support groups, or
working through the community college system to hold workshops and
classes on parenting skills (step 3). The most feasible and useful alternative

950
could be selected (step 4), and a parenting program for the community could
be planned (step 5) and implemented (step 6). The nurse, with parents and
other professionals involved, would then evaluate the outcomes (step 7) and
make necessary adjustments in the parenting program before finally
stabilizing it (step 8), making certain that this change, undertaken to meet a
population group need, remains an established and effectively functioning
service (Table 11-1).

FIGURE 11-3 Parents and their young children in a play group.

Change and Health Promotion Within

Communities/Populations
Changes in behavior and health promotion can also be directed to even larger
audiences—communities and larger populations. Similar approaches can be
used but may be varied depending upon age, most pertinent issues, and how
to best reach targeted audiences. For instance, in an effort to address
cardiovascular health by encouraging prevention and health promotion,
researchers stratified their approaches based upon what they determined were
the most beneficial age ranges.

They began with 3-to 5-year-olds and a family-centered educational

strategy about hearts and how to keep them healthy by reducing obesity
and other risk factors.
Then, between 25 and 50 years of age, the focus changes to education
about screening and early detection of potential problems.
Over age 50, the approach is directed more toward education about
discovering cardiovascular disease and early treatment.
Physical activity programs for all age groups are important to reduce
cardiovascular disease. Additionally, cardiovascular risk factors,

951
 physical activity, and exercise assessments should be completed on all
individuals. Health care professionals should refer those with risk
factors to specialists for and exercise prescription (Fletcher et al., 2018).

Change and health promotion in communities begin with understanding

the basics of health communication and social marketing. The CDC provides
information regarding these areas (CDC, 2019b).
It involves six phases in health communication basics:
1. Problem definition and description (e.g., health problem of concern, who
this affects, how you can address it) 2. Problem analysis/market
research (e.g., analyze data on problem, target audience's values,
behaviors, beliefs, attitudes, and barriers/facilitators to changing
behavior) 3. Planning communication/market strategy (e.g., determine
target audience, what behaviors that you wish to address, benefits
offered [such as better health] with interventions to support change) 4.
Program planning/interventions (e.g., methods you will use to influence
change [for instance, a Web site to promote better nutrition/physical
activity for adolescents], plan, objectives) 5. Program evaluation (e.g., is
your program useful, feasible, accurate, ethical) 6. Implementation (e.g.,
plan for launching program, publicity, threats/opportunities)
This method has been used with many health problems and issues (e.g.,
arthritis, breast-feeding, drug abuse prevention, smoking cessation,
HIV/AIDS, colorectal cancer screening, chronic fatigue syndrome,
immunizations, influenza) and is a helpful means of reaching targeted
populations (CDC, 2019b). See Chapters 10, 12, and 15 for more on health
promotion, communication, and use of technology in assessing communities
and developing programs for health promotion.

Principles for Effecting Positive Change

C/PHNs introduce change every day that they practice. Every effort to solve
a problem, prevent another problem from occurring, meet a potential
community need, or promote people's optimal health requires changes. For
these changes to be truly successful, so that desired outcomes are reached,
they must be well thought out and managed. The following six principles
provide guidelines for effecting positive change: (1) participation; (2)
resistance to change; (3) proper timing; (4) interdependence; (5) flexibility;
and (6) self-understanding (Table 11-1).

Principle of Participation
Persons affected by a proposed change should participate as much as
possible in every step of the planned change process, including group

952
 meetings to discuss the proposed change (Fig. 11-4).
This involvement is important for several reasons. Collaboration with
those who have a vested interest in the change can produce a wealth of
ideas and insights that can greatly improve the change plan.
Furthermore, such participation can help remove obstacles and reduce
resistance.

FIGURE 11-4 A C/PHN leading a group.

Principle of Resistance to Change

Because all systems instinctively preserve the status quo, the change
agent can expect people to resist change.
The homeostatic mechanism operating in any system seeks to maintain
equilibrium; change poses a threat to that stability and security.
Furthermore, all systems experience inertia, that is, they resist beginning
movement. People do not undertake a change until they are convinced
of its worth.
Resistance may also come from a conflict over goals and methods or
from misunderstanding about what the change will mean and require.
Involving people in the planned change process, as discussed in the
previous section, is one way to overcome resistance.

Principle of Proper Timing

Proper timing is as important to a planned change as well-timed seed
planting is to a good harvest.
The change idea must be appropriate, the change recipient prepared, the
climate right, and the resources available before the change can be
fostered to grow into full maturity and usefulness.

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Principle of Interdependence
This principle of interdependence reminds the nurse that change does
not take place in a vacuum.
Every system has many subsystems that are intricately related to and
interdependent on one another. When workers learn new health and
safety practices associated with their jobs, their relationships with one
another, and their bosses, their overall productivity in the organization
may easily be affected.
One must anticipate and prepare for the impact of the proposed change
on the clients involved, other persons, departments, organizations, or
even geographic areas.

Principle of Flexibility
Unexpected events can occur in every situation. This fifth principle—
flexibility—emphasizes two points.

First, the nurse needs to be able to adapt to unexpected events and make
the most of them.
The second point to remember about flexibility is that a good change
planner anticipates possible blocks or problems by preparing strategies
and alternative plans.
Then, if the first choice does not work out for some reason, an
alternative is ready to be put into action. Flexibility involves a
willingness to consider a variety of options and suggestions from many
sources, and it is the hallmark of public health professionals.

Principle of Self-Understanding
Self-understanding is essential for an effective change agent (Michigan
State University, 2019). The community nurse (as change agent) should
be able to clearly define his or her role and seek to understand how
others define it.
It is important to understand your own values and motives in relation to
each change that you are asking people to make. Nurses should also
understand their own personality traits, so that they can capitalize on or
adjust them in order to be more effective change agents. Understanding
yourself is crucial to learning to make use of your best qualities and
skills in order to effect change (Jerome & Powell, 2016).

Change is inevitable. Understanding the principles of planned change can

assist the C/PHN in guiding individuals, families, and communities toward
achieving the highest level of health.

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CHANGE THROUGH HEALTH
EDUCATION
For the C/PHN, health education is a foundation of practice. Whether the
nurse is providing one-on-one education to a new mother about the benefits
of breast-feeding, briefing county officials on the need to maintain breast-
feeding support centers, or working with community partners and grant
funders to develop a Web-based social marketing campaign to promote
breast-feeding among adolescent mothers, educational techniques are being
used to promote health in the community. Knowledge of educational theories
and teaching methods can assist the nurse to frame these “health messages”
for the greatest impact and chance of success.

Teaching is a specialized communication process in which desired

behavior changes are achieved. The goal of all teaching is learning.
Learning is a process of assimilating new information that promotes a
permanent change in behavior. Learning is gaining knowledge,
comprehension, or mastery.

After learning, clients are capable of doing something that they could not
do before learning took place. Effective teaching is the cause; learning
becomes the effect. To teach effectively, especially in the community where
teaching is the focus of care, nurses need to understand the various domains
of learning and related learning theories.

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Domains of Learning
Learning occurs in several realms or domains: cognitive, affective, and
psychomotor. Understanding of the differences among the domains and of
the related roles of the nurse provides the background necessary to teach
effectively.

Cognitive Domain
The cognitive domain of learning involves the mind and thinking processes.
When the meaning and relationship of a series of facts is grasped, cognitive
learning has occurred. The cognitive domain deals with the recall or
recognition of knowledge and the development of intellectual abilities and
skills (Bloom, 1956), as follows:

Remember.
Recall basic facts.
Example: A school nurse asks adolescents in a weight loss group to
list foods high in fat.
Understand.
Comprehend concepts when they are explained.
Example: A school nurse asks adolescents in a weight loss group to
identify ways to lose weight.
Apply.
Transfer understanding into practice.
Example: A school nurse asks adolescents in a weight loss group to
keep a food and physical activity record for a week, draw up a diet,
and share this plan with the group at the next meeting.
Analyze.
Break down concepts into parts; establish the relationship among
the parts.
Example: A school nurse asks adolescents in a weight loss group to
distinguish the fat content in a variety of packaged foods.
Evaluate.
Validate information.
Example: A school nurse asks adolescents in a weight loss group to
select a menu that is low in fat.
Create.
Produce new or original work.
Example: A school nurse asks adolescents in a weight loss group to
develop a menu that is low in fat.

(Vanderbilt University Center for Teaching, 2019).

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How to Measure Cognitive Learning
Cognitive learning at any of the levels described can be measured easily in
terms of learner behaviors. Nurses know, for instance, that clients have
achieved teaching objectives for the application of knowledge if their
behavior demonstrates actual use of the information taught. Client roles in
cognitive learning range from relatively passive (at the knowledge level) to a
more active role (at the evaluation level). Conversely, as clients become
more active, the nurse's role becomes less overtly directive. Not all clients
need to be brought through all levels of cognitive learning, and not every
client needs to reach the evaluation level for each aspect of care. For some
clients and situations, comprehension is an adequate and effective level; for
others, the nurse should focus on the application level. Table 11-2 illustrates
client and nurse behaviors for each cognitive level (Iowa State University
Center for Excellence in Learning and Theory, 2019).

TABLE 11-2 Domains of Learning

Affective Domain
The affective domain involves learning that occurs through emotion,
feeling, or affect. This kind of learning deals with changes in interest,
attitudes, and values (Bloom, 1956; Miller, Linn, & Gronlund, 2012). Here,
nurses face the task of trying to influence what their clients may value and

957
feel. Nurses want clients to develop an ability to accept ideas that promote
healthier behaviors, even if those ideas conflict with the clients' own values.
Attitudes and values are learned. They develop gradually, as family,
peers, experiences, and culture influence the way a person feels and
responds. These feelings and responses are the result of imitation and
conditioning. In this way, clients acquire their health-related beliefs and
practices. Because attitudes and values become part of the person, they are
difficult to change unless the nurse is aware of how they develop.
Affective learning occurs on several levels as learners respond with
varying degrees of involvement and commitment:

At the first level, learners are simply receptive; they are willing to listen,
to show awareness, and to be attentive. The nurse aims at acquiring and
focusing learners' attention (Miller & Stoeckel, 2016; Miller et al.,
2012). This limited goal may be all that clients can achieve during the
early stages of the nurse–client relationship.
At the second level, learners become active participants by responding
to the information in some way. Examples are a willingness to read
educational material, to participate in discussions, to complete
assignments (e.g., keeping a diet record), or to voluntarily seek out more
information (Miller & Stoeckel, 2016; Miller et al., 2012).
At the third level, learners attach value to the information. Valuing
ranges from simple acceptance through appreciation to commitment
(Miller & Stoeckel, 2016; Miller et al., 2012).
The final level of affective learning occurs when learners internalize an
idea or value. The value system now controls learner behavior.
Consistent practice is a crucial test at this level (Miller & Stoeckel,
2016; Miller et al., 2012).

Affective learning often is difficult to measure and is often attempted

through self-report surveys or tools (Miller & Stoeckel, 2016; Miller et al.,
2012). This elusiveness may influence C/PHNs to concentrate their efforts on
cognitive learning goals instead. Yet, client attitudes and values have a major
effect on the outcome of cognitive learning—which is desired behavioral
changes. Therefore, both cognitive and affective domains must be linked
when teaching clients about health-related topics; otherwise, results may
quickly fade (Hales, 2016).

Psychomotor Domain
The psychomotor domain includes visible, demonstrable performance skills
that require some kind of neuromuscular coordination (Miller & Stoeckel,
2016; Miller et al., 2012). Clients in the community need to learn skills such
as infant bathing, temperature taking, breast or testicular self-examination,

958
prenatal breathing exercises, range-of-motion exercises, catheter irrigation,
walking with crutches, changing dressings, and performing cardiopulmonary
resuscitation (Fig. 11-5).

FIGURE 11-5 A C/PHN demonstrates cardiopulmonary

resuscitation to clients before having them return the demonstration
to show that they can put this learning into practice.

For psychomotor learning to take place, three conditions must be met: (1)
learners must be capable of the skill; (2) learners must have a sensory image
of how to perform the skill; and (3) learners must practice the skill.

C/PHNs must be certain that the client is physically, intellectually, and

emotionally capable of performing the skill. It may be difficult for an
elderly diabetic man with tremulous hands and fading vision to give his
own insulin injections; it could frustrate and harm him. He may need
some assistance or accommodations.
Clients' intellectual and emotional capabilities also influence their
capacity to learn motor skills. It may be inappropriate to expect persons
with significant developmental delays to learn complex skills. The
degree of complexity should match the learners' level of functioning.
However, educational level should not be equated with intelligence.
Developmental stage is another point to consider in determining
whether it is appropriate to teach a particular skill. For example,
most children can put on some article of clothing at 2 years of age
but are not ready to learn to fasten buttons until they are past their
third birthday.
Learners also must have a sensory image of how to perform the skill
through sight, hearing, touch, and sometimes taste or smell. This
sensory image is gained by demonstration. To teach clients motor skills

959
 effectively, the C/PHN has to provide them with an adequate sensory
image. It is best to demonstrate and explain slowly, one point at a time,
and sometimes repeatedly, until clients understand the proper sequence
or combination of actions necessary to carry out the skill.
Another condition for psychomotor learning is practice. After acquiring
a sensory image, clients can start to perform the skill. Mastery comes
over time as clients repeat the task until it is smooth, coordinated, and
unhesitating (Miller & Stoeckel, 2016; Miller et al., 2012).
During this process, the C/PHN should be available to provide
guidance and encouragement. In the early stages of practice, you
may need to use hands-on guidance to give clients a sense of how
the performance should feel.
When clients give return demonstrations, you can make
suggestions, give encouragement, and thereby maximize the
learning.
For example, a C/PHN demonstrates passive range-of-motion
exercises on a client's wife to show her how the exercises should
feel (giving her a sensory image). The wife then learns to perform
the exercises on her husband. During practice, feedback from the
nurse enables the wife to know whether the skill is being
performed correctly.
At this guided response stage, objectives may include action verbs
such as fastens, manipulates, measures, organizes, and calibrates.

The psychomotor domain, like the cognitive and affective domains,

ranges from simple to complex levels of functioning. It is necessary to
exercise judgment in assessing a client's ability to perform a skill. Even
clients with limited ability often can move to higher levels once they have
mastered simple skills. Nursing tasks that facilitate psychomotor learning in
the client include the following:

Determine the client's capability for learning by assessing the client's

physical, intellectual, and emotional ability.
Physically demonstrate and explain the skill, providing the client with a
sensory image.
Encourage practice by providing guidance and positive reinforcement.

960
Learning Theories
A learning theory is a systematic and integrated look into the nature of the
process whereby people relate to their surroundings in such ways as to
enhance their ability to use both themselves and their surroundings more
effectively (Schunk, 2020). Each nurse has and uses a particular theory of
learning, whether consciously or unconsciously, and that theory, in turn,
dictates the way the C/PHN teaches clients. It is useful to discover what each
nurse's learning theory is and how it affects the role of health educator. A
brief examination of these learning theories can be viewed in Table 11-3.

TABLE 11-3 Learning Theories

Source: Bandura (1977, 1986); Knowles (1984, 1989, 1990); Knowles et al. (2015); Maslow (1970);
Pavlov (1957); Piaget (1966, 1970); Rogers (1969, 1989); Skinner (1974, 1987); Thorndike (1932,
1969).

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Health Teaching Models
Theories on learning provide a general understanding of how people learn. In
addition, various health teaching models specifically focus on explaining
individual health experiences, behaviors, and actions. These models fit with
the learning theories to give nurses a more accurate picture of the client and
the clients' learning needs. Four useful models are described here: the health
belief model (HBM), Pender's health promotion model (revised) (HPM), the
transtheoretical or stages of change model, and the PRECEDE and
PROCEED models.

Health Belief Model

The HBM, which was developed by social psychologists and brought to the
attention of health care professionals by Rosenstock (1966), is useful for
explaining the behaviors and actions taken by people to prevent illness and
injury. It postulates that readiness to act on behalf of a person's own health is
predicated on the following (Skinner, Tiro, & Champion, 2015):

Perceived susceptibility to the condition in question

Perceived seriousness of the condition in question
Perceived benefits to taking action
Barriers to taking action
Cues to action, such as knowledge that someone else has the condition
or attention from the media
Self-efficacy—the ability to take action to achieve the desired outcome

Using the HBM, parental intention to participate in parenting classes was

examined. Researchers found that high intentions to participate was related
to low barriers to attend the program (Salari & Filus, 2017). C/PHNs may
find the use of the HBM (and variations) to be helpful in assessing the health
behaviors and beliefs of culturally diverse populations.

Pender's Health Promotion Model

First published in the 1980s by nurse Nola Pender, the HPM was envisioned
as a framework for exploring health-related behaviors within a nursing and
behavioral science context (Murdaugh, Parsons, & Pender, 2019). Reflecting
the growing body of literature relevant to the HPM, Pender revised the model
to reflect a number of major theoretical changes. The revised HPM includes
three general areas of concern to health-promoting behavior: Individual
characteristics and experiences are seen to interact with behavior-specific
cognitions and affect to influence specific behavioral outcomes (Murdaugh
et al., 2019). The revised HPM focuses on predicting behaviors that influence

962
health promotion. In addition, the HPM includes the variable of interpersonal
influence of others, including family and health professionals.
Being able to predict health promotion behaviors enhances the C/PHN's
ability to work with clients. Awareness of their characteristics, experiences,
comprehension of their health-related issues, perceived barriers, self-efficacy,
support (or lack of it) from significant others, and commitment provides the
nurse with a picture that clarifies the client–nurse role and gives direction for
action taking. The HPM (Fig. 11-6) is based on the theoretical propositions
found in Box 11-3.

FIGURE 11-6 Health promotion model. (Reprinted with

permission from Pender, N. L., Murdaugh, C.L., Parsons, M.A.
(2015). Health promotion in nursing practice (7th ed.). Upper
Saddle River, NJ: Prentice Hall. © 2015. Reprinted by permission
of Pearson Education, Inc., New York, NY.)

Using these propositions, researchers explored clients' health behaviors

in many studies conducted in the 1980s, 1990s, and into the 21st century.
Research using the model includes a study determining factors influencing
breakfast consumption in female high school students in the Yazd Province
of Iran. Results revealed that by including family and friends in breakfast and
being positive about breakfast reduces barriers and increases self-efficacy;
thus, improving female high school students' participation in breakfast
(Mehrabbeik, Mahmoodabad, Khosravi, & Fallahzadeh, 2017).

Transtheoretical or Stages of Change Model

The transtheoretical model (TTM) addresses change by anticipating relapses
and recognizing those as opportunities to better plan for how to sustain the
needed change in future attempts (Bartholomew, Markham, Mullen, &

963
Fernandez, 2015; Prochaska, Norcross, & DiClemente, 2007). The model,
sometimes called stages of change, is not linear but is depicted as a spiral,
with plateaus, relapses, and false starts. It can be used with individuals,
groups, and populations. The stages include the following (Prochaska et al.,
2007, p. 39):

Precontemplation—This is usually the normal state of denial or the

problem may not be perceived (either don't know about it or don't want
to think acknowledge it). Clients may say, “I don't really smoke that
many cigarettes, so I don't have to worry about lung cancer or the other
health problems.”
Contemplation—At this stage, the client is more realistic and may be
more open to discussing the problem of smoking. However, the client
may not be able to seriously consider behavior change or feel able to
confront the issue. The client may say, “I know I should probably try to
quit smoking, but I am really stressed right now and can't think about
it.”
Preparation—During this stage, the client is moving away from
contemplation toward action. The client may be trying to gather
information and may be talking to others about how they quit smoking.
They may be concerned that it may take more than one try in order to
accomplish their goal. A client may talk to the physician about
medications that are helpful, tell friends and family that they are
planning to quit smoking, and may even begin to cut back on the
number of cigarettes smoked each day.
Action—This stage is the beginning of the behavioral change. The
client sets a date to quit smoking, begins using a nicotine patch or
medication, and finds replacement behaviors for smoking (e.g., using
breath mints, exercising during usual smoking breaks). The client
knows that this attempt may not be successful the first time and should
be encouraged to acknowledge and plan for this.
Maintenance—In this stage, the behavior has been changed. The smoker
has stopped smoking, but now needs to be vigilant in avoiding a relapse.
The client needs a support system and rewards to encourage
maintenance. If the client relapses, the C/PHN and others can help the
client learn from this and begin their preparation and action stages again
until longer periods of maintenance are achieved.
Termination—This occurs when the former behavior is no longer
appealing. The smoker no longer has an interest in cigarettes and does
not have to exert the constant vigilance needed in the maintenance
stage. Prochaska et al. (2007) note that not everyone can truly reach this
stage, and therefore, it is not always included in health promotion
programs or research.

964
 Researchers have used this model with many topics related to health
promotion and prevention (e.g., substance abuse, smoking cessation, weight
loss, physical activity). One research study found that this model could help
determine physical activity behavior in women. Results found that stages of
change were significantly correlated with self-efficacy, processes of change,
and decisional balance (Pirzadeh, Mostafavi, Ghofarniphour, & Mansorian,
2017). Often, the nurse can determine the stage the client is in from the
client's statements; see Box 11-4 for some example statement and suggested
nurse responses.

BOX 11-4 Example Clients' Statements

That Reveal TTM Stage and Suggested
Nurse Responses
Precontemplation and Contemplation
Client statement: Jeff says: “I don't know why my wife is concerned
about my high blood pressure, I don't feel sick.”
Client stage: Client is in precontemplation, or stage one, in which
clients demonstrate they are not interested in help or thinking about
change.
Suggested C/PHN response: “Sometime symptoms are not always
present, so you may not feel sick. However, understanding your
diagnosis and what this means to your health is important.”
Client statement: Jessica comments, “I can see how quitting smoking
could improve my health, but I can't imagine never having another
cigarette.”
Client stage: Client is in contemplation, or stage two, in which clients
may think about their behavior and the personal consequences of it.
Suggested C/PHN response: “I know this is difficult, but taking steps
now to stop smoking can have positive outcomes for your health.”
Neither client is committed to making a change; each is unaware or
thinking of pros/cons.

Preparation
Client statement: Jamie states, “I feel good about setting a date to go into
rehab, but I wonder if I can really go through with it.”
Client stage: Client is in preparation, or stage three, in which clients think
about change and take small steps like gathering information.
Suggested C/PHN response: “I'm glad you are taking steps to improve your
health. What questions can I help answer about rehab?”

965
Action
Client statement: Kevin reports, “I have been on my low salt, low fat diet
for a month now, and my blood pressure is better, but I'd really like to be able
to eat fast food more often.”
Client stage: Client is in the action stage, or stage four; those in this stage
are actually moving toward their goal and feel more confident exercising
willpower.
Suggested C/PHN response: “Incorporating change into your daily life
takes time. You are taking positive steps to improve your health and modify
your eating choices.”

Maintenance
Client statement: Maria remarks, “These last few months of sobriety give
me a feeling of accomplishment, but I still question if total abstinence is
really mandatory.”
Client stage: In maintenance, or stage five, people are successful with
completing actions, avoiding temptations, and developing new habits. There
is awareness of potential relapse.
Suggested C/PHN response: “I see that you are determined to stick with
your sobriety. It is often too easy to slip into unhealthy choices, but I know
you can stay on track with this lifestyle change.”

Termination
Client statement: “I have modified my diet and exercise regularly now, and
I have decreased my BMI and lowered my A1C. I feel great and do not want
to go back to feeling unhealthy again.”
Client stage: In termination, or stage six, people do not want to return to
their previous unhealthy behaviors and will not relapse.
Suggested C/PHN response: “Your decision to include healthy behaviors in
your life has made a difference in how you now manage your diabetes. These
positive choices might also influence other family members.”

The PRECEDE and PROCEED Models

First published by Green in 1974, the PRECEDE model was developed for
educational diagnosis (Glanz, Rimer, & Viswanath, 2015). The acronym
PRECEDE has been slightly revised from the original to stand for
predisposing, reinforcing, and enabling constructs in educational/ecological
diagnosis and evaluation (Bartholomew et al., 2015; Green & Kreuter, 2005).

The PROCEED model (Green, Cross, Woodal, & Tones, 2019) works in
tandem with the PRECEDE model as the C/PHN proceeds to plan,
implement, and evaluate health education programs.

966
 This acronym stands for policy, regulatory, and organizational
constructs for educational and environmental development
(Bartholomew et al., 2015). The entire PRECEDE–PROCEED model
includes eight phases in the formulation and evaluation of health
educational programs.
The first five of these phases are included in the PRECEDE portion of
the model and include (1) social, (2) epidemiologic, and (3)
education/ecological assessments, followed by (4) administrative and
policy assessment and intervention alignment, and (5) implementation.
The PROCEED model is emphasized in the last three phases: (1)
process evaluation, (2) impact evaluation, and (3) outcome evaluation.

A hallmark of the PRECEDE–PROCEED model is the emphasis on the

desired outcome. The model both begins and ends with quality of life, which
includes “subjectively defined problems and priorities of individuals and
communities” (Green et al., 2019). The emphasis on what the individual or
community perceives as the problem, not what the professional believes it to
be, is crucial. Outcome evaluation is logically linked back to that same
individual or community in assessing achievement of the desired change.
The steps in this model are similar to those of the nursing process.
Because of this familiarity, the model has become a useful tool for nurses
teaching in the community. The nurse builds on the assessment formulated
from the PRECEDE model, determines the best interventions, and then
proceeds to evaluate the outcome of those interventions. The emphasis on the
perceived needs of the individual or community as the starting point for all
community efforts is consistent with public health nursing practice. The
model reminds us of the importance of an organized approach to health
educational programs, one that begins and ends with the “experts”—the
individuals, families, and communities we hope to help through our efforts.
The PRECEDE–PROCEED model can be seen in Figure 11-7.

967
 FIGURE 11-7 The PRECEDE–PROCEED model. (Reprinted with
permission from Green, J., Cross, R., Woodall, J., & Tones, K.
(2019). Health promotion: Planning and strategies (4th ed.). Los
Angeles, CA: Sage.)

This model has been used to address many public health problems. Over
1,000 examples of published applications of PRECEDE–PROCEED may be
found at www.lgreen.net, including studies on health care workers' hand
hygiene behaviors, follow-up with multicultural women with abnormal
mammograms, implementation of church-based heart health promotion
programs for older adults, developing a healthy-eating curriculum for
schools, evaluation of a physical activity and nutrition program for senior
citizens, and determining health promotion motivators in Asian populations.
Other models used in community assessment and intervention may be found
in Chapter 15.

968
Teaching at Three Levels of Prevention
C/PHNs should develop teaching programs that coincide with the level of
prevention needed by the client. The three levels of primary, secondary, and
tertiary prevention are demonstrated in the levels of prevention pyramid for
nurses who teach clients, families, aggregates, or populations (Box 11-5).

BOX 11-5 Levels of Prevention Pyramid

Application to Client Teaching SITUATION:
Several examples of teaching at three levels of
prevention.
GOAL: Using the three levels of prevention, avoid or promptly diagnose
and treat negative health conditions, and restore the fullest possible
potential.

Ideally, the C/PHN focuses teaching at the primary level. If nurses were
able to reach more people at this level, it would help to diminish years of
morbidity and limit subsequent incapacity. Many people experience

969
disabilities that could have been prevented if primary prevention behaviors
had been incorporated into their daily activities.

970
Effective Teaching
Teaching is an art. It can be performed with such skill and grace that the
client becomes part of a well-orchestrated event, with learning as the natural
outcome. Instead of relying on prescribed teaching methods, the skillful
C/PHN can make judgments based largely on client qualities, situations, and
needs that guide the experience. The desired changes emerge in the course of
the interaction rather than at a level conceived before the teaching. Before
the C/PHN can reach this level of artistry, there is much to learn about being
an effective teacher.

Teaching–Learning Principles
Teaching lies at one end of a continuum. At the other end is learning.
Without learning, teaching becomes useless in the same way that
communication does not occur unless a message is both sent and
received.
Both the teacher and the learner have responsibilities on that continuum.
Learners must take responsibility for their own learning.
Teachers obstruct that process if they assume complete responsibility
for bringing about changed behavior.
Clients can be directed toward health knowledge, but they will not
acquire knowledge unless they have the desire to learn.

Teaching, then, becomes a matter of facilitating both the desire and the
best conditions for satisfying it (Gilbert, Sawyer, & McNeill, 2015).
Teaching in community health nursing means to influence, motivate, and act
as a catalyst in the learning process. To do this, the C/PHN needs to
understand the basic principles underlying the art and science of the
teaching–learning process and the use of appropriate materials to influence
learning.

Client Readiness
The client's readiness to learn influences the C/PHN's teaching effectiveness.
Four facets of client readiness have been identified (Kitchie, 2019):
1. Physical readiness, which deals with their ability, task complexity,
environment, health status, and gender 2. Emotional readiness, which
deals with the state of receptivity to learning (e.g., motivation, anxiety,
developmental stage, risk-taking behavior) 3. Experiential readiness,
which reflects the learner's past experiences with learning (cultural
background, orientation, locus of control, coping mechanisms used) 4.
Knowledge readiness, which encompasses the learner's knowledge and

971
 understanding (e.g., learning disabilities, learning style, current
knowledge base)
For instance, one C/PHN found that a young primipara was not ready for
prenatal teaching on fetal growth and development. She had strong fears that
she would be unable to lose her baby weight and that this would make her
sexually unattractive to her partner. Until these anxieties were addressed, the
teaching would remain ineffective. Clients' needs, interests, motivation,
stress, and concerns determine their readiness for learning.
Another factor that influences readiness is educational background. If a
group of women who never completed grade school meet to learn how to
care for a sick person in the home, material should be presented in a factual
and easily accessible manner and in terms that they understand. To discuss
complex concepts of health, illness, and scientific research would be above
their level of readiness. However, you can begin to introduce more complex
concepts as you work with the women and assess their readiness for
additional knowledge.
Maturational level also affects readiness. An adolescent mother who is
still working on the normal developmental tasks of her age group, such as
seeking independence or selecting a career path, may not be ready to learn
parenting skills. Readiness of the client determines the amount of material
presented in each teaching session. The pace or speed with which
information is presented must be manageable. A small amount of anxiety
often increases client receptivity to learning; however, high levels of anxiety
can have the opposite effect.

Client Perceptions
Clients' perceptions also affect their learning, serving as a screening device
or filter through which all new information must pass. Individual perceptions
help people interpret and attach meaning to things.
Frequently, clients use selective perception. They screen out some
statements and pay attention to those that fit their values or personal desires.
For example, a C/PHN is teaching a client about the various risk factors in
coronary disease; the individual screens out the need to quit smoking and
lose weight, paying attention only to factors that would not require a drastic
change in lifestyle. Nurses must know their clients, understand their
backgrounds and values, and learn about their perceptions before health
teaching can influence their behavior (Kitchie, 2019).

Educational Environment
The setting in which the educational experience takes place has a significant
impact on learning (Kitchie, 2019). Students probably have had the
experience of sitting in a cold room and trying to concentrate during a lecture

972
or of being distracted by noise, heat, or uncomfortable seating. Physical
conditions such as ventilation, lighting, room temperature, view of the
speaker, and noise level should be controlled to provide an environment that
is conducive to learning.
Equally important for learning is an atmosphere of mutual respect and
trust. The nurse needs to convey this attitude both verbally and nonverbally.
The way the C/PHN addresses clients, shows concern, and gives recognition
makes a considerable difference in establishing clients' rapport and trust.

Both nurse and clients need to be mutually helpful and considerate of

one another's needs and interests.
All participants in the educational experience should feel free to express
ideas, should know that their views will be heard, and should feel
accepted despite differences of opinion and perspective.
According to the adult learning theorist Knowles, this requires that the
nurse refrain from seeming judgmental or inducing competitiveness
among learners. Knowles (1980, p. 58) adds that teachers should share
their own feelings and knowledge “as a co-learner in the spirit of
inquiry.”

Client Participation
The degree of participation in the educational process directly influences the
amount of learning (Moffett, Berezowski, Spencer, & Lanning, 2014). One
nurse discovered this principle while working with a group of clients who
were nearing retirement. After talking to them about the changes they would
face and receiving little response, the nurse shifted to a different method of
teaching. Handouts on Social Security benefits were distributed, and
everyone was asked to read them during the week and come the next week
with questions generated by the pamphlets. The C/PHN began the next
session with a story about an older couple unprepared for retirement and the
problems that they incurred. He then asked the group to share questions and
concerns they had about retirement. This strategy prompted the group to
slowly begin to participate in their own learning (Fig. 11-8).

973
 FIGURE 11-8 Client engagement is a key to successful health
promotion programs.

Learning is facilitated when the student is engaged and fully participates

in the learning process. C/PHNs should begin from the client's place of
interest.
When the client chooses own directions, helps to discover own learning
resources, formulates own problems, decides own course of action, and
lives with consequences of each of these choices, then the client has
significantly maximized his or her learning.
Contracting is a tool that allow the client to participate in the process as
a partner to determine goals, content, and time for learning. This can
contribute to client learning and active participation (see Chapter 10).

The amount of learning is directly proportional to the learner's

involvement. In another example, a group of senior citizens attended a class
on nutrition and aging yet made few changes in eating patterns. It was not
until the members became actively involved in the class, encouraged by the
nurse to present problems and solutions for food purchasing, understanding
how to read nutrition labels, and preparation of meals on limited budgets,
that any significant behavioral changes occurred.

Subject Relevance
Subject matter that is relevant to the client is learned more readily and
retained longer than information that is not meaningful. Learners gain the
most from subject matter that is immediately useful to their own purposes.
This is particularly true for adult learners, who have more life experiences
that can be related to learning and who tend to see the immediate relevance
of the material taught (Bastable, Gramet, Sopczyk, Jacobs, & Braungort,
2020; Knowles, 1980). When clients see the relevance in learning, they

974
accomplish it more promptly. When the subject matter is relevant to the
learner, more knowledge is retained.

Client Satisfaction
To maintain motivation and increase self-direction, clients must derive
satisfaction from learning. Learners need to feel a sense of steady progress in
the learning process. Realistic goals contribute to learner satisfaction.
Objectives should be set within the learner's ability, thereby avoiding the
frustration resulting from a task that is too difficult and the loss of interest
resulting from one that is too easy. Once objectives are met, it is important to
provide recognition or reward for the accomplishment. Setting objectives
requires agreement on goals, periodic reviews, and revision of goals if they
become too easy or too difficult (Bastable et al., 2020). Obstacles,
frustrations, and failures along the way discourage and impede learning.
Many clients who have had strokes and have potential for rehabilitation often
give up trying to regain speech or move paralyzed limbs because they
become frustrated and discouraged. On the other hand, clients who
experience satisfaction and progress in their speech and muscle retraining
maintain their motivation and may work on exercises without prompting.
C/PHNs can promote client satisfaction through support and encouragement.

Client Application
Learning is reinforced through application (Bastable et al., 2020). Learners
need as many opportunities as possible to apply the knowledge in daily life.
If such opportunities arise during the teaching–learning process, clients can
try out new knowledge and skills under supervision. Learners are given an
opportunity to begin integrating the learning into their daily lives at a time
when the teacher is there to help reinforce that pattern.

Teaching Process
The process of teaching in community health nursing follows steps similar to
those of the nursing process:
1. Interaction: Establish basic communication patterns between clients and
nurse.
2. Assessment and diagnosis: Determine client's present status and identify
client's need for teaching through surveys, interviews, open forums, or
task forces that include representative clients as members (keeping in
mind that clients should determine their own needs).
3. Setting goals and objectives: Analyze needed changes, establish the goal
(a broad statement of outcome), and prepare objectives that describe the
desired learning outcomes. Objectives should be stated in measurable
behavioral terms, using a grammatical structure that contains a subject,

975
 verb, condition/criterion, and time frame. That is, each objective should
include a single idea that describes an outcome that can be measured
within a certain time frame (see the example that follows these steps).
4. Planning: Design a plan for the learning experience that meets the
mutually developed objectives; include content to be covered, sequence
of topics, best conditions for learning (place, type of environment),
methods, and materials (e.g., visual aids, exercises). A written plan is
best; it may be part of the written nursing care plan.
5. Teaching: Implement the learning experience by carrying out the
planned activities.
6. Evaluation: Determine whether learning objectives were met, and if not,
why not. Evaluation measures progress toward goals, effectiveness of
chosen teaching methods, or future learning needs.
Here is an example of a short-term goal, a long-term goal, and a set of
objectives related to a specific client need:
Need: A group of smokers wish to end their addiction to nicotine.
Short-term goal: Within 1 month, all members of the group will reduce the
number of cigarettes smoked.
Long-term goal: Ninety percent of group members will remain tobacco-free
for 6 months.
Objectives: At the end of the program, all clients should be able to do the
following:

List three reasons why smoking is unhealthy.

Identify at least two factors that influence their smoking habit.
Apply a series of action steps leading to smoking cessation within 1
month.
Examine the steps as they work to live tobacco-free in the first 3
months.
Design a way to live a fulfilled, tobacco-free life.
Evaluate successful strategies to remain tobacco-free for 6 months.

Teaching Methods and Materials

Teaching occurs on many levels and incorporates various types of activities.

It can be formal or informal, planned or unplanned. Formal

presentations, such as group lectures, usually are planned and fairly
structured.
Lecturers tend to create a passive learning environment for the audience
unless strategies are devised to involve the learners.
Many individuals are visual rather than auditory learners. To capture
their attention, computer-generated slide programs or video
presentations can supplement the lecture.

976
 Allowing time for questions and discussion after a lecture also actively
involves learners. This method is best used with adults, but even they
have a limited attention span, and breaks should be given every 30 to 60
minutes.
Distributing printed material that highlights and summarizes, or
supplements, the shared content also reinforces important points.

Some teaching is less formal but still planned and relatively structured,
as in group discussions in which questions stimulate the exploration of ideas
and guide thinking. Informal levels of teaching, such as counseling or
anticipatory guidance (in which the client is assisted in preparing for a
future role or developmental stage), require the teacher to be prepared, but
there is no defined presentation plan. The C/PHN may use a handout or
agency protocol steps as a guide. C/PHNs use one or a combination of
methods, along with a variety of materials, to facilitate the teaching–learning
process. Two-way communication is an important feature of the learning
process. Learners need an opportunity to raise questions, make comments,
reason out loud, and receive feedback to develop deeper understanding.
When discussion is used in conjunction with other teaching methods, such as
demonstration and role playing, it improves their effectiveness.
Effective education also includes an understanding and awareness of
health literacy and the need to evaluate patient understanding of medical
information. Health literacy is defined as, “The degree to which individuals
have the capacity to obtain, process, and understand basic health information
needed to make appropriate health decisions” (HRSA, 2019, para. 1). Health
literacy can be prevalent among older adults, minority populations,
underserved populations, and those with low socioeconomic status (SES)
(HRSA, 2019). The populations C/PHNs serve may be poor and
underserved. Risk factors such as SES have been shown to have a casual
relationship with health literacy, which can then influence clinical and
behavioral choices, thereby affecting heath care use and outcomes
(Knighton, Brunisholz, & Savitz, 2017). Low literacy may be due to limited
English proficiency (LEP), cultural barriers, medical terms that patients may
not understand, or low educational skills, which can affect their
understanding of medication directions, their management of health
conditions, or their ability to fill out forms (HRSA, 2019). C/PHN must be
aware of health literacy levels when providing education to patients and their
families. Examples of how health professionals can mitigate low literacy
may include the following:

Assume all patients may have difficulty understanding medical

information, and implement health literacy universal precautions.
Supplement instruction with appropriate materials.

977
 Ask open-ended questions (how and what) rather than closed-ended
questions (yes and no).
Have patients “teach back” or demonstrate a procedure.
Teach so that age, culture, and ethnic diversity are considered.
Provide information in the primary language for LEP patients (HRSA,
2019).
Use health literacy tools (such as those found on to provide
information that patients can understand (AHRQ, 2016, 2019; CDC,
2019b; Readability Formulas, 2020).

Demonstration
The demonstration method often is used for teaching psychomotor skills and
is best accompanied by explanation and discussion, with time set aside for
return demonstration by the client or caregiver. It gives clients a clear
sensory image of how to perform the skill. Because a demonstration should
be within easy visual and auditory range of learners, it is best to demonstrate
in front of small groups or a single client. Use the same kind of equipment
that clients will use, show exactly how the skill should be performed, and
provide learners with ample opportunities to practice until the skill is
perfected.

Role Playing
At times, having clients assume and act out roles maximizes learning. A
parenting group, for example, found it helpful to place themselves in the role
of their children. In doing so, their feelings about various ways to respond
became more apparent. Reversing roles can effectively teach conflicting
couple's better ways to communicate. To prevent role playing from becoming
a game with little learning, it should be planned with clear objectives in
mind.

What behavioral outcomes should be achieved?

Define the context (the “stage”) clearly, so that everyone shares in the
situation. Then define each role ahead of time, making sure that
participants understand their performance roles.
Emphasize that no wrong or right performance exists and that
participants should behave the way people behave in everyday life.
Avoid having people play themselves, because it can embarrass them
and make it difficult for them to achieve objectivity.
After the drama has concluded, begin discussion with carefully prepared
questions.

This technique can be used with staff, coworkers, young children,

teenagers, and adults. However, it can be a risk-taking experience for some

978
people, and they may be reluctant to participate. The nurse should use
judgment, begin with volunteers, and avoid pushing this technique on
unwilling or nonreceptive people. It is best to build up to full participation.

Teaching Materials
Many different kinds of teaching materials are available to the nurse (Fig. 11-
9). They often are employed in combination and are useful during the
teaching process. Visual images—such as PowerPoint presentations (using
graphics, photos), pictures, posters, chalkboards, flannel boards, DVDs,
online videos, bulletin boards, flash cards, pamphlets, flyers, charts, and
gestures—can enhance most learning. Americans readily learn from
television and the Web, as there is visual and auditory appeal. Other tools,
such as anatomic models and improvised or purchased equipment, provide
clients with both visual and tactile learning experiences. Still others, such as
interactive computer games or instruction, actively involve the learners.

FIGURE 11-9 Teaching materials help to make your point.

The choice of teaching materials varies with the client's interests and
abilities and the resources available. Teaching often occurs in casual
conversations, spontaneously in situations when clients raise unexpected
questions, or when a crisis arises. In these instances, C/PHNs draw on their
background of knowledge and exercise professional judgment in their
selection of content, methods, and materials.
Printed educational support materials are available, such as pamphlets,
brochures, booklets, flyers, and informational sheets. Each should be
evaluated for appropriateness and effectiveness with particular individuals,
families, or groups. Many come from state and local public health sources.
Nurses can create their own handouts, customizing them to the needs of
individual clients. The nurse can get educational information from state,
federal, and international health agencies. Example include state health

979
departments, the U.S. Food and Drug Administration (FDA), the Centers for
Disease Control and Prevention (CDC), the National Institutes of Health
(NIH), and the World Health Organization (WHO). Other materials come
from nonprofit national agencies such as the American Diabetes Association
(ADA), the March of Dimes, the American Association for Retired Persons
(AARP), and the American Heart Association (AHA).
Factors to be considered with all educational literature include the
material's content, complexity, and reading level. There are several ways to
assess the readability of the printed word. One easy way is to use the Fry
Readability Graph or the Gunning-Fog formula. These tools are rough way
of determining the years of schooling needed to understand printed material.
It works by analyzing words and sentence length; the higher the number, the
more difficult the reading level. A Gunning-Fog Index of 6 is a sixth grade
reading level, and a score of 11 is at the junior year in high school.
Fortunately, most word processing programs now include a feature to allow
assessment of the reading level in text. Another very common tool is the
Flesch Reading Ease program, available in Microsoft Word grammar
checker, which evaluates reading material. Similar to the Fry Graph, the
Flesch-Kincaid Grade Level readability score rates the material in terms of
typical grade level; however, it may not be as accurate and you may need to
adjust results downward (Medline Plus, 2019). The nurse should always
consider the population when selecting a reading level, as many individuals
cannot understand materials at even the 6th grade level. Also, clients,
including those speaking a language other than English, may not be able to
read and write in their dominant language.
Culturally appropriate health education materials must be acquired or
developed for the predominant cultural and linguistic minority populations
taught by the nurse. Developing printed materials is an important first step,
but the development of video, audio, and public service announcements in
community-appropriate languages is also necessary. When translating printed
materials from English into another language, it is strongly suggested that a
separate translator “back-translate” the materials. This added step helps
assure that the meaning from the original has not been distorted or lost in the
translation. Essentially one person or group translates the material, and
another individual or group translates it back into English. This can add time
and cost to the project, but it may prevent inaccuracies in the final material
(Huff, Klein, & Peterson, 2015).
Finally, nurses teach by example. Actions speak louder than words. If a
nurse teaches the importance of washing hands to reduce disease
transmission and then begins a newborn assessment without hand washing,
the message of observed actions carries more impact than the words. Nurses
who exhibit healthy practices use themselves as teaching tools and serve as
role models as well as health teachers.

980
Clients With Special Learning Needs
At times, the nurse experiences a challenging teaching situation with an
individual, family, or group. These challenges may involve clients who have
cultural or language differences, hearing impairments, developmental delays,
memory losses, visual perception distortions, and problems with fine or gross
motor skills, distracting personality characteristics, or demonstrations of
stress or emotions. Culture can play a role in communication because it
influences belief systems, communication styles, and understanding and
response to health information (National Network of Libraries of Medicine,
n.d.). The inability to see, hear, and understand health information places
those with disabilities at a greater disadvantage impacting their health and
health outcomes. Regardless of the situation, C/PHNs will feel most
comfortable and confident if they are prepared to deal with these situations
before they are experienced.
Before beginning to teach a client, family, or aggregate, thorough
preparation is important for successful learning to occur. This includes
finding out whether it is possible to teach in English or whether other
modifications are needed as the teaching plan is being developed. C/PHNs
should never assume anything, including the primary language spoken by
clients, their visual or hearing ability, or their capacity to understand. When
teaching unfamiliar groups, the nurse can obtain information regarding the
interests and abilities of the members from a center manager, caretaker, or
program director. These human resources are invaluable in planning any
teaching when English may be a second language or when other barriers
exist that may impede success if they are not known by the nurse.
Interpreters may be needed, and the C/PHN should work closely with the
interpreter to assure that the intended message is sent and received by the
clients (Huff et al., 2015). The phases of the nursing process continue to
guide the nurse as a teacher.
Another difficulty that can arise is unexpected behavior from a client
who disrupts the group process. The client may monopolize the discussion,
answer questions asked of others, burst out with personal experiences that
have no relevance to the topic, become irate at the comments of others, or sit
silently and never speak. This can be unnerving to even the most experienced
nurse. The C/PHN must tactfully diffuse any behavior that has the potential
to distract the other learners. This is accomplished by considerately giving
the recognition sought by the person while also setting limits.

981
SUMMARY
Healthy People 2030 objectives recognize the health and well-being of
all people and communities, which is an essential component of a
thriving, equitable society.
The purpose of health education is to effect change, which alters the
equilibrium in a system.
Change occurs in three stages: unfreezing when the system is ready for
change, changing when the innovation is implemented, and refreezing
when the change is stabilized.
The cognitive domain refers to learning that takes place intellectually. It
ranges in levels of learner functioning from simple recall to complex
evaluation. As learners move up the scale of cognitive learning, they
become more self-directed; the nurse then assumes a more facilitative
role.
Affective learning involves the changing of attitudes and values.
Learners may experience several levels of affective involvement, from
simple listening to adopting the new value. Again, as the client
increases involvement, the nurse uses a less directive approach.
Psychomotor learning involves the acquisition of motor skills. Clients
who learn psychomotor skills must meet three conditions: they must be
capable of the skill, they must develop a sensory image of the skill, and
they must practice the skill.
Learning theories can be grouped into four broad categories:
Behaviorist theories, which view learning as a behavioral change
accomplished through stimulus–response or conditioning;
Cognitive learning theories, which seek to influence learners'
understanding of problems and situations through promoting their
insights;
Social learning theories, which explain dysfunctional behavior and
facilitate learning; and
Humanistic theories, which assume that people have a natural
tendency to learn and that learning flourishes in an encouraging
environment. Knowles' adult learning theory provides a framework
for understanding adult characteristics and appropriate teaching
interventions.
Health teaching models work together with the learning theories to give
nurses a more accurate picture of the client and the client's learning
needs.
The health belief model is useful in explaining the behaviors that
are triggered by people with an interest in preventing diseases.

982
 The health promotion model helps to predict behaviors that lead to
health promotion and includes concepts about the interpersonal
influence of others, such as health professionals, friends, and
family.
The transtheoretical or stages of change model is not a linear
model but recognizes that behavior change occurs more like a
spiral, with plateaus, relapses, and false starts.
The PRECEDE–PROCEED model is designed to guide health
educational program development. The model has a strong focus
on the perceived problems and priorities of a particular individual
or group as they impact quality of life.
The teaching process in community health nursing is similar to the
nursing process, including steps of interaction, assessment and
diagnosis, goal setting, planning, teaching, and evaluation.
The teaching may be formal or informal, planned or unplanned, and
methods may range from structured lecture presentations and
discussions to demonstration and role playing.

983
ACTIVE LEARNING EXERCISES
1. Using “Assess and Monitor Population Health” (1 of the 10 essential
public health services; see Box 2-2 ), identify the leading cause of
adult mortality in your community. Discuss the social determinants of
health that may influence this mortality statistic.
2. As a staff C/PHN, you have been asked to develop a sexual health
educational program for group of students aged 14 to 16. Explain
your educational plan (include the domain of learning and the
learning theory along with the need, goal, objectives, implementation,
and evaluation methods).
3. Using behavioral objectives that match the learning level desired,
develop a flyer or program for an educational presentation for clients.
4. Select a patient educational handout from CDC:
https://www.cdc.gov/hepatitis/resources/patientedmaterials.htm
Determine the readability level of the handout and discuss the
implications for a nurse using this handout in an educational program.
Explain how it best meets the educational needs of your target
population.
5. Select a current research article that demonstrates application of one
of the health teaching models. How do the results compare with the
constructs of the model?

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984
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992
CHAPTER 12
Planning, Implementing, and Evaluating
Community/Public Health Programs
“True genius resides in the capacity for evaluation of uncertain, hazardous, and conflicting
information.”

—Winston Churchill (1874–1965), British Prime Minister (1940–1945;

1951–1955)

KEY TERMS
Advisory group Authoritative knowledge Benchmarking Community action
model Enabling factors Grant
Grant writing Letter of inquiry Predisposing factors Quality indicators
Reinforcing factors Request for proposal (RFP) Social marketing Target
population

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. List sources of information that can be used to identify group and
community health problems.
2. Describe methods to gain input from target populations to define the
scope of a health problem.
3. Identify change strategies that maximize cooperation of target
populations.
4. Identify quality of care models that are useful in program evaluation.
5. Describe the role of social marketing and potential uses of social media
in health promotion programs.
6. Locate appropriate grant funding sources for select health promotion
programs.

993
INTRODUCTION
In the early 20th century, after suffering several personal tragedies, Mary
Breckinridge committed herself to a noble cause—bringing effective health
care to one of the poorest, most remote regions of the United States. A
trained nurse and daughter of a politician, she used her skills and influence to
establish a public health program, the Frontier Nursing Service (FNS) in
rural Appalachia (Fig. 12-1). During the humble beginnings of the FNS,
Breckinridge and her team of nurse–midwives rode through the hills of
Leslie County, Kentucky, on horseback, providing primary care and
midwifery services to the impoverished residents. Breckinridge dedicated the
rest of her life to the effort, ultimately developing a network of clinics, a
hospital, and a school to train midwives, as well as becoming an advocate for
the region's economic development (Goan, 2015). Thanks to the FNS, the
maternal mortality rate in Appalachia dropped from among the highest in the
country to well below the national average. The school Breckinridge founded
continues to operate today as Frontier Nursing University, which trains some
of the nation's most influential nurse–midwives and nurse practitioners (see
Chapter 3).

994
 FIGURE 12-1 The Frontier Nursing Service used a public health
program approach in improving the health of poor families in rural
Kentucky. (Photo Courtesy of Frontier Nursing University
Archives. Used with permission. Retrieved from
https://frontier.edu/about-frontier/history-of-fnu/)

In the early 21st century, the emerging role of the community/public

health nurse (C/PHN) offers opportunities to plan and implement programs
that not only improve the health of individuals but of entire communities.
Due to shrinking health department budgets and high demand for services,
C/PHNs now provide health promotion and educational programs to larger
and larger constituencies. Nurses must develop unfamiliar skills such as
writing grants, creating social marketing campaigns, and collaborating with a
variety of organizations to effectively address new challenges that are just as
significant in our generation as those faced by the FNS. These activities and
challenges might include the following:

Writing a grant proposal to fund a naloxone distribution program for a

community struggling with widespread opioid misuse and overdose
deaths.
Collaborating with local school districts to reduce the use of e-cigarettes
and vaping among school children.
As a global health specialist, assisting a nongovernmental organization
in India to create a social marketing campaign aimed at discouraging
violence against women and girls.

Communities are rarely in a position to fund all needed health programs,

so they must carefully prioritize those that are important and feasible and
then turn to a variety of agencies for financial support through grants or
contracts. The C/PHN frequently assumes responsibility for locating,
securing, and maintaining grant funding.
Evaluation of program outcomes is a requirement of most funding
sources, whether public or private. A nurse who receives $500 to start an
emergency preparedness program for low-income families may not be
expected to provide the level of evaluation data that a million-dollar effort to
address postdischarge care of hospitalized homeless patients would require.
Nevertheless, the nurse will need to provide evidence that demonstrates the
impact of the program.
The populations served may also want to know whether the programs
were successful and why. For instance, a mother who enrolls her daughter in
an after-school program to increase self-esteem may want to know the results
of the first 6-week session before granting permission for a second session,
particularly if her daughter is interested in attending a dance class that

995
conflicts with the program session. With competing alternatives, the mother
may want details about what was accomplished in the first session and what
will be the future results. With this information, the mother and daughter can
weigh the options. For future planning, funders, consumers, and nurses
should all be aware of the demonstrated program outcomes.
You were previously introduced to theories and models that are
commonly used in the community setting. In this chapter, we'll build on
concepts discussed in prior chapters and describe the resources, knowledge,
skills, and actions that help nurses plan and develop effective community
health programs. These include the following:

National, state, and local health objectives, initiatives, and resources

that will help you identify high-priority health issues
How to recognize community problems that lead to poor health
How to partner with community members, organizations, and leaders to
better understand the community, determine priorities for improving
community health, and develop successful programs
Factors that influence the changes in individual behavior that are
necessary to improve the health of communities as a whole
Tools and models that can organize your thinking about health program
aims and development
How to set measurable goals and objectives
Quality assurance and improvement tools and models that will help you
evaluate community health programs
Social marketing for community health and program promotion
How to obtain and manage grants to fund health programs

996
PLANNING COMMUNITY HEALTH
PROGRAMS: THE BASICS
In the classic writings of Ottoson and Green (2008, p. 590), public health
education programs are defined as interventions “designed to inform, elicit,
facilitate, and maintain positive health practices in large numbers of people.”
Likewise, the American Nurses Association's Public Health Nursing: Scope
and Standards of Practice (2013) focuses on the role of the nurse in
planning, implementing, and evaluating population-focused health
promotion/health education programs (Fig. 12-2).

FIGURE 12-2 Contemporary public health nurses plan public

health programs that improve the health of entire communities.

Standard 5B calls on the PHN to “employ multiple strategies to promote

health, and a safe environment” (p. 37), through programs and services
that include appropriate teaching–learning methods, that are culturally
and age appropriate, and that also include an evaluation component.
Advanced PHNs plan “evidence-based health promotion programs and
services” and engage with consumers and advocacy groups in
promoting health and modifying programs (p. 38).

With so much emphasis on planning and developing health

education/health promotion programs, the process can seem overwhelming to
the new C/PHN or even to the acute care nurse who is involved in some
aspect of health initiative development. The first part of this chapter is
designed to take some of the mystery out of the process. You will be guided

997
through the complex problem of teen vaping, which poses significant health
risks for school children and young adults. The principles applicable to this
example can be used in other situations and programs, even those that are
very broad in scope and involve many practice partners.
In your nursing program, you may have been tasked with developing a
health program, working on an existing community program, or simulating
the process in a written assignment. Whatever your experience level, the
essential elements are the same. As you begin this next section, think about
your past experiences, such as taking blood pressures at a local health fair or
developing a pamphlet on the need for prostate screening for non–English-
speaking residents. Did these actions have the impact you hoped for?
Successful health promotion programs do not occur by accident; they take
skill, time, patience, and most of all listening to and understanding the needs
and opinions of the individuals who are the focus of your program (the
target population).

998
IDENTIFYING GROUP OR
COMMUNITY HEALTH PROBLEMS
Student nurses are educated in the care of individuals, families, and
communities, yet nurses most often practice at the individual and family
levels. When is it appropriate for a nurse to expand his or her practice to the
community level? Perhaps the most natural time is when a nurse identifies an
ongoing issue that does not change with traditional interventions.
Examples include the following:

Overuse of the emergency room for pain medication prescriptions

Recurrent hospitalization of the elderly from several nursing homes for
dehydration, sepsis, and malnutrition
Hospitalization of unvaccinated children with vaccine-preventable
diseases

These types of recurrent problems might lead nurses to investigate the

feasibility of community-based interventions.

999
National and State Health Objectives and
Initiatives
Individually or in a group, identify a possible issue to explore—one you
believe is leading to poor health outcomes in your community. How do you
know if this problem is widespread or if others also find it to be a problem?
Several methods can be used to validate the importance of the issue. One
method would be to consider Healthy People 2030 objectives for the nation
(Office of Disease Prevention and Health Promotion [ODPHP], 2019).
What are the major areas of concern for improving health outcomes in
the United States? What are the priorities of the state in which you live? Take
some time to review federal agency Web sites to identify programs that are
being developed to meet the Healthy People 2030 goals and objectives (Box
12-1). Your state or local health department may also publish Healthy People
2030 objectives on its Web site, highlighting those issues that are high
priorities in your region. You can monitor progress on meeting the Healthy
People 2020 objective targets by searching for current results for national-
and state-level data on the Healthy People 2020 widget
(https://www.healthypeople.gov/2020/data-search/Search-the-Data#hdisp=1).
The overarching national goals of Healthy People 2030 are found in Box
1-4 in Chapter 1.

BOX 12-1 HEALTHY PEOPLE 2030

Recommended Leading Health Indicators and
Objectives

1000
aCMS-2 is a chronic conditions composite measure developed by the Centers for Medicare &
Medicaid Services.

Reprinted with permission from National Academies of Sciences, Engineering, and Medicine. (2020).
Leading health indicators 2030: Advancing health, equity, and well-being. Washington, DC: The
National Academies Press.
Retrieved from https://www.nap.edu/catalog/25682/leading-health-indicators-2030-advancing-health-
equity-and-well-being

1001
Local Health Priorities and Initiatives
Community agencies and organizations frequently network to establish
community-wide goals, with the local health department spearheading the
effort. It may also be organized by community-based health agencies and
volunteer organizations. Improved outcomes for individuals who have
diabetes or asthma is an example of a goal a local community might want to
set. Another topic of concern may be adolescent suicide. Nurses can work
collaboratively with these special interest groups to find solutions for
affected individuals and families.
As a specific problem is identified, it is crucial to analyze the scope of
the problem within the community. It is a poor use of resources to set up a
program if the condition or situation is rare. For example, it would be a waste
of resources to establish a program on diabetes and pregnancy for a local
homeless shelter that only serves 35 women a year. Of those 35 women, none
may be pregnant, and only 5.6% of pregnant women develop gestational
diabetes (Deputy, Kim, Conrey, & Bullard, 2018), so it may be several years
before an eligible client is found. A better use of resources would be to target
a community with a high proportion of individuals at risk for diabetes during
pregnancy, such as a community with a large population of non-Hispanic
Asian mothers, among whom the prevalence of gestational diabetes is higher
(11.1%) than other racial/ethnic groups. Another target group may be
pregnant women age 40 years or older, who are also at increased risk of
gestational diabetes (Deputy et al., 2018).

1002
Using Data to Confirm Needs
There are many ways a nurse can determine whether a problem affects
enough of the population to warrant intervention. The best way to start is to
review the local, state, and national data available through government
repositories. This can be done by going to a university library for assistance,
asking for specific data from local health and social service agencies, police
and judicial departments, and local school districts, or by searching the
Internet. The National Center for Health Statistics (NCHS) offers public-use
data files through the file server of the Centers for Disease Control and
Prevention (CDC). The NCHS data collection systems include (CDC, 2019a)
the following:

Population surveys, such as the National Health and Nutrition

Examination Survey and National Survey of Family Growth
Vital records, such as the National Death Index
Provider surveys, such as the National Hospital Care Survey and other
national health care surveys
Historical surveys, which provide an overview of surveys and programs
administered by the NCHS that have been completed

The U.S. Department of Health and Human Services (USDHHS) makes

high-value health data accessible to the public via HealthData.gov. The data
are collected from agencies within the USDHHS as well as its state partners
and include U.S. data on (USDHHS, 2019b):

Environmental health
Medical devices
Social services
Community health
Mental health
Substance abuse
Medicare and Medicaid

Hospital discharge data are also reported to state agencies, and this
information is sometimes available at the local level (Lane et al., 2017). For
more information on data collection systems, see .

1003
Target Groups and Neighborhoods
As nurses and community groups narrow their focus, they can identify target
groups and neighborhoods by using geographic information system (GIS)
technology. Many organizations use GIS to identify target groups by race,
age, and family status. GIS data can be found through a variety of federal
sources (see Chapter 10), including the CDC, the National Cancer Institute,
the Center for Mental Health Services, the National Library of Medicine, the
Environmental Protection Agency, and, as previously mentioned, the NCHS,
which maintains GIS maps on the major causes of mortality in the United
States (USDHHS, 2019a). GIS mapping can depict deaths by regions or in
clusters, such as one depicting drug overdose mortality that can be found at
https://www.cdc.gov/pcd/issues/2019/18_0405.htm.
Earthquake seismic hazard maps may be helpful in disaster planning.
National and state maps are available
(https://earthquake.usgs.gov/hazards/hazmaps/), and Figure 12-3 displays a
map highlighting major populations exposed to potentially damaging
earthquakes.

FIGURE 12-3 Population exposed to potentially damaging

earthquake ground shaking. (Reprinted from U.S. Geological
Survey. (October 11, 2016). Population exposed to potentially

1004
damaging earthquake ground shaking. Retrieved from
https://www.usgs.gov/media/images/population-exposed-
potentially-damaging-earthquake-groundshaking)

1005
Collaborating With Other Health Care
Professionals
Talking about the problems you have identified in your community with
other nurses and health care professionals may help you identify resources
and solutions as you brainstorm ideas about the problem and what should be
done to alleviate it. Find out what has been tried in the past and why those
interventions may have failed. A very helpful source of information is the
Community Preventive Services Task Force (CPSTF) Web site,
thecommunityguide.org The CPSTF developed a federally sponsored
resource, the Guide to Community Preventive Services: What Works to
Promote Health—now known as The Community Guide. Originally
published in 2005, The Community Guide is an online collection of evidence-
based findings and other resources that C/PHNs can use to select and
implement interventions to improve health and prevent disease within
communities or at state and national levels (CPSTF, 2019).
The interventions with limited evidence may be very effective but need
to be confirmed by further research; perhaps your idea is among those listed.
For example, as a means of increasing community demand for vaccinations,
client reminder and recall systems are recommended, yet there is not enough
evidence to support client or family incentives, or the use of patient-held
medical records. If a C/PHN develops a program to implement these
interventions, the additional step of publishing the program results would add
to the body of evidence that determines the value of such a program.

1006
Engaging the Target Population
The next step is the most important of all, as it will determine whether your
interventions succeed or fail. A nurse may think, “I know what the problem
is—now I will think up an intervention to alleviate it!” This is a well-
intentioned, but doomed, approach. At this point, only part of the assessment
is complete; the most important component of the assessment is to find out
the views of the target population about the identified problem. What do they
think are the causes? What ideas do they have about solving it? Which
approaches do they think will work?
It is crucial to hear and respect the views of the target population (Fig.
12-4). Anthropologists talk about a concept called authoritative knowledge.
This is based not on whose knowledge may be right but rather on what is
accepted as substantial and legitimate because it comes from authoritative
sources, such as health care providers (Anderson, Mah, & Sellen, 2015;
Henley, 2015). Nurses may think they know more about a topic (e.g.,
diabetes) than their target population and therefore conclude that their
solutions must also be superior. Members of the target population may hold
just as strongly to their own beliefs. If nurses don't learn about the target
population's beliefs and only consider their own, they will not be able to
work out an acceptable and appropriate solution. Interventions that fail to
engage the target population will likely be unsuccessful. It is imperative that
positive working relationships be established with high-risk target
communities and that chosen interventions involve effective use of health
resources (see the story of the shoemaker and shoe customer in Chapter 10).

FIGURE 12-4 It is crucial to hear and respect the views of the

target population.

1007
Understanding the Target Population
When working with target groups, it's important to get as much information
about the population as possible. Start by asking those you know, as
colleagues and as patients/clients, about their local community (Gordon,
2018). What are their thoughts about the problem of interest? What do they
think about the quality of services currently available? What do they see as
barriers to services? What about barriers to adherence to treatment and other
health care recommendations? In Chapter 15, you will learn that nurse
interaction with the community is an essential first consideration in
promoting community health.
Additional issues to explore include the following:

Who else can provide insights about this problem?

Who are key people with whom you should build relationships?
What are their customs regarding health care?
Who are the leaders within families?
What is the best way to form collaborations and linkages within this
community?
Who are their formal and informal leaders?
What types of events bring them together?
What are the roles of family, church, and health care providers within
their community?
Should you approach church groups, school groups, or other
organizations?
What radio stations do they listen to, and what television stations are
they most likely to watch?

Which Web sites do they visit when seeking health information? The
answers to these questions will provide insight into factors influencing the
health problem and will also help you understand how to reach out to the
target population (Community Tool Box, 2019a). Mobilizing Action through
Planning and Partnerships (MAPP) is one of many tools that begin with this
community mobilization step; it can be found at the Community Tool Box
Web site: https://ctb.ku.edu/en/table-of-contents/overview/models-for-
community-health-and-development/mapp/main.
As you gain insight into relevant environmental and social factors, you
are also building interest among the community members about the issue. As
you participate in discussions with others, be open to their input. Your
original ideas will likely change in response to feedback from members of
the target and service communities. For example, an experienced C/PHN was
involved in a project developed to serve Hispanic women with gestational
diabetes. When interviewed, the Spanish-speaking women expressed concern

1008
that they were told to go on a diabetic “diet” and were then chastised for not
eating enough. To these women, going on a “diet” meant they should eat less.
They were also told that if they followed the diabetic diet, they wouldn't have
such “big babies.” They thought a “big” baby was a healthy baby and
couldn't understand why they were being told to avoid having a larger baby.
These were simple issues to fix but required knowledge of how the “diabetic
teaching plan” was interpreted by the target audience. Another key factor
was that the clinic was a family event; thus, all of the children were brought
along. The clinic staff had been irritated by the presence of large groups of
children but learned they should alter the clinic setup and resources to
accommodate their clients' expectations. Modifications were made based on
dialogue with members of the target population that contributed to the
eventual success of the clinic's program.
This example demonstrates how use of local knowledge can increase the
effectiveness of a community-based intervention. Working with community
partners is a technique that has been used in providing services within
developing countries. This type of approach ensures community buy-in for
an intervention. It also builds networks that increase the capacity of
communities to resolve other health care issues, both current and emerging
(Bolton, Moore, Ferreira, Day, & Bolton, 2016; Piltch-Loeb, Abramson, &
Merdjanoff, 2017; Worthman, Tomlinson, & Rotheram-Borus, 2016).

1009
Using Evidence to Guide Interventions
The search for evidence-based guidelines and interventions is important to
program success. It is essential to review literature regarding health
problems, factors influencing the outcomes of interventions, and the role of
families and communities in adhering to interventions. The literature review
can offer insights that may shape interviews with community members
(Leadbeater, Gladstone, & Sukhawathanakul, 2015). How does the target
group compare to other target groups? Are there issues that should be
addressed that are not found in the literature?
Consider this situation: A C/PHN wanted to know why parents were
using emergency rooms for after-hours urgent care. A literature review found
studies focusing heavily on the “misuse” of emergency rooms by parents to
treat urgent ambulatory care health problems, such as otitis media. Based on
input from an emergency room nurse, the C/PHN decided to go directly to
the source and asked families what their doctors had told them to do if their
child became ill at night. The families said they were told to take their
children to the emergency room! None of the literature addressed what the
families had been told to do for after-hours care. This is an example of how
being open to information from a variety of sources (in this case, the
emergency room nurse) enhanced the C/PHN's understanding of the problem
beyond what could be learned by solely relying on the literature.

1010
Community Action Model
Facilitating community action is most effective when using participatory
action research approaches (Cusack, Cohen, Mignone, Chartier, & Lutfiyya,
2018; deChesnay, 2015). One such approach is known as the Community
Action Model, which aims to identify actions that are achievable and
sustainable and propels changes for the well-being of all. This model builds
on concepts presented in the planned-change process described in Chapter 11
and includes a cyclical five-step process (Fig. 12-5). The C/PHN educator
can use this model to facilitate community participation and ownership of
change that improves the community's health.

FIGURE 12-5 Community action model: Creating change by

building community capacity. (Reprinted with permission from San
Francisco Department of Public Health, Tobacco Free Project, and
Bright Research Group. (September 2016). Community action in
public health policy. Retrieved from
https://sanfranciscotobaccofreeproject.org/wp-
content/uploads/CAM-Case-Study-Final-9.12.16-to-TFP.pdf)

1011
 An example of a successful application of the Community Action Model
is Pennsylvania's School Nutrition Policy Initiative, targeted to combat
obesity in 4th to 6th graders. About 48 hours of interactive nutrition lessons
are presented in classrooms yearly, with participation from families and local
community partners. Incentives are offered to students who choose healthier
snacks. Program evaluation revealed a 50% reduction in the number of
students who were overweight (The Food Trust, 2012). Other successful
programs incorporate farm-fresh foods into school lunches and snacks or aim
to reduce consumption of soda (Duggan, 2017).

1012
Advisory Groups
As nurses work with community members to identify factors contributing to
a health problem, individuals will begin to stand out because of their
knowledge, networking capabilities, and interest in the subject. A key factor
for ensuring the success of any intervention is to appoint an advisory group
that includes representatives from the target and service communities.
Findings from interviews, literature reviews, and data analyses should be
reviewed with this advisory group (Sharma, Huang, Knox, Willard-Grace, &
Potter, 2018).
To ensure success of the advisory group, all meetings should be carefully
planned, so that they are well organized, punctual, and efficient. Strategies to
encourage input from the advisory group should be employed; meetings
should focus on getting the advisory group to interpret findings and
community feedback and to develop possible solutions. Contributions from
each member should be sought and valued equally (Chapter 10). Depending
on the size of the group, it may be most effective to hold breakout sessions as
well as larger group sessions. Every member should do an evaluation at the
conclusion of each meeting, so that any problems can be addressed before
the next meeting. Maintaining a record of these meetings—in the form of
minutes or a brief written overview—is also very helpful. Be certain to also
keep a record of attendees. Maintaining a paper trail is always important.

1013
Delineating the Problem(s)
With the help of the advisory group, it's important to define the problem or
problems to be addressed. The process of determining the real or perceived
needs of a defined community is called community assessment. There are a
variety of assessment tools and methods that help nurses delineate
community health problems by collecting, analyzing, and interpreting
information—these are discussed in detail in Chapter 15. The following is a
case example.
A group of school nurses identified teenage use of e-cigarettes (“vaping”
or “JUULing”) as a problem (Fig. 12-6). Input from community members, as
well as a review of data, demonstrated a high rate of teen vaping in a local
high school. Although the original plan made by the school nurses was to
establish a special educational presentation for all high school students, input
from members of the service and target community indicated significant
problems with this approach:

FIGURE 12-6 There are risks associated with e-cigarette use.

1. Many of the high school students began using e-cigarettes in middle

school.
2. There was a widespread belief in the community that vaping was a
safer alternative to tobacco use.
3. The e-cigarette users were predominantly male, and the nurses did not
understand the association between gender and vaping within the
targeted community.

The use of an advisory group helped the nurses first identify what
behavioral factors contributed to vaping in the target population. These
behavioral factors included the following:

1014
 There was a high rate of tobacco use among adults in the community,
and vaping was becoming increasingly popular.
Smoking cessation programs in the area promoted the idea that vaping
was less harmful than smoking, which supported a common belief that
vaping was not risky.
A high proportion of high school students began vaping during middle
school.
Teenagers in the target population were attracted to the flavors available
with e-cigarettes, such as fruit, mint, and chocolate.
Although the legal age to purchase e-cigarettes was 18, local vendors
were lax in enforcing the restrictions and vaping products were easily
accessible online.
Teenagers in the target group indicated they enjoyed vaping with their
friends as an after-school activity.
Many males in the target group were high school athletes who used e-
cigarettes to appear “cool” without the risks of smoking.

What nursing diagnoses can you identify from these behavioral factors?
Would you begin with deficient knowledge or risk for injury? Are family
relationships or self-concept involved? Although you may be most familiar
using nursing diagnoses with individual clients, nursing diagnoses can be
advanced for aggregate clients or populations, especially in conjunction with
community assessments, and may be helpful guides in proposing
interventions and outcomes, as described in Chapter 15 (da Silva et al.,
2018).

1015
Rating the Importance and Changeability of
Identified Behavioral Factors
To achieve success, community health programs must narrow their focus to a
limited number of health behaviors that can be addressed successfully within
a specific time frame (Green & Kreuter, 2005; Green et al., 2014). To
prioritize which behaviors to address, the authors suggest rating them in
terms of importance and changeability. The final list should include problems
that are both important and easy to change.
Importance is determined by the frequency of the identified behavior and
how strongly it is linked to a health problem. The advisory group for teen
vaping, mentioned previously, ranked the importance of the identified
behaviors; their ranking and rationale (basis) for the ranking can be seen in
Table 12-1. The attractiveness of e-cigarette flavors was rated highly
important because the advisory group learned that flavors are the primary
reason youth begin using e-cigarettes (CDC, 2019b). The widespread use of
tobacco among adults in the community, which modeled unhealthy practices
for the youth, was not rated very highly by the advisory group because the
members felt the influence of peers was a more important factor.

TABLE 12-1 Importance Ratings of Behaviors Contributing to

Teen Vaping at a Local High School

1016
 The advisory group was then asked to rate the changeability of the
behaviors. In their classic book, Green and Kreuter (2005) indicate that
behaviors that are easiest to change:

Are usually still developing

Are more recently adopted
Do not have deep roots in culture or lifestyle
Have been attempted before with some success

In this round of assessments, the advisory group believed that the

smoking cessation programs' promotion of inaccurate information about
vaping could potentially be changed. This rating was based on the fact that
the smoking cessation program leaders were well-intentioned, but
misinformed, and could easily change the program content. The program
leaders could, in fact, become valuable allies in disseminating accurate
information about the risks of vaping. The advisory group also determined
that it may be more effective to target middle school rather than, or in
addition to, high school students, because they had not yet begun using e-
cigarettes or had vaping habits that were not yet deeply ingrained (Fig. 12-7).

FIGURE 12-7 Vaping is increasingly popular among school-age

children and is associated with significant health risks.

1017
 After rating the identified problems based on changeability and
importance, the nurses and advisory group sought to narrow their focus to
specific goals. Ranking the behaviors in a simple table, as seen in Table 12-2,
is suggested (Community Tool Box, 2019b; Green & Kreuter, 2005; Green et
al., 2014). This effort yielded a table with the problems categorized in four
groups: more important/more changeable, less important/more changeable,
more important/less changeable, and less important/less changeable (Table
12-2). One issue seen as most important and changeable was the use of e-
cigarettes among male athletes, who represented the subpopulation most
likely to vape (high school males) and who were influential among other
male teens. This had support from coaches, so there was greater motivation
to abandon unhealthy behaviors.

TABLE 12-2 Changeability Ratings of Behaviors Contributing

to Teen Vaping at a Local High School

The use of this grid enabled the advisory group to focus on more
changeable and important issues. They wrote behavioral objectives for each
identified factor they hoped to change. These objectives identified who was
targeted, what they hoped would change or what action would be taken, how
the change would be measured, and what the time frame was for achieving
the expected outcome. The following are their behavioral objectives:
1. By the end of the fall semester, all local smoking cessation programs
will discontinue the promotion of vaping as a safer alternative to
tobacco.
2. By the end of the fall semester, 90% of all high school athletes will sign
a “no-vaping” contract as a condition of participation in high school
sports.
3. By the end of the school year, 90% of 6th through 12th grade students
will attend a presentation aimed at preventing or discontinuing
participation in vaping.

1018
Factors That Influence Behavior Change:
Predisposing, Reinforcing, and Enabling Factors
Three categories of factors affecting individual behavior can contribute or
create barriers to successful behavioral change (Green & Kreuter, 2005;
Green et al., 2014). Per the PRECEDE–PROCEED model, discussed in
Chapter 11, these factors are as follows (Fig. 12-8):

FIGURE 12-8 Predisposing, enabling, and reinforcing factors that

categorize various behavioral influences. (Source: Hood, S.,
Linnan, L., Jolly, D., Muqueeth, S., Hall, M. B., Dixon, C., &
Robinson, S. (2015). Using the PRECEDE planning approach to
develop a physical activity intervention for African American men
who visit barbershops: Results from the FITShop study. American
Journal of Men's Health, 9(4), 262–273. doi:
10.1177/1557988314539501.)

Predisposing factors provide the rationale or motivation for subsequent

behavior.
Reinforcing factors provide a continued motivation to repeat or persist
in the behavior.
Enabling factors promote or facilitate the behavior based upon
availability.

The advisory group followed the PRECEDE–PROCEED model and

identified the predisposing, enabling, and reinforcing factors that affected
each behavioral objective. For the behavioral objective:

1019
 By the end of the fall semester, 90% of high school athletes will sign a
“no-vaping” contract as a condition of participation in sports.
A predisposing factor seemed to be the athletes' belief that vaping
would help them look “cool” among their peers.
Reinforcing factors included the common use of tobacco and e-
cigarettes among adults in the community, as well as the belief that e-
cigarettes were a relatively safe alternative to tobacco.
An enabling factor that promoted the change was the support of high
school athletics coaches who agreed to monitor the conduct of the
athletes while at school and enforce the no-vaping contract.
On the other hand, the apathy of local vendors in enforcing restrictions
on the sale of vaping products to children under the age of 18 was seen
as inhibiting change.

In addition to the vaping education presentations, the advisory group

decided to establish a peer-mentoring program, in which student leaders
would work with the advisory group and provide mentoring and support to
students who wanted to quit vaping (Fig. 12-9). The advisory group had
teachers nominate students for this intervention. The principal allowed the
nominated students to attend educational classes conducted by the nurses to
increase their knowledge about vaping cessation. The nurses worked
collaboratively with the students to ensure that their mentoring and support
approaches were effective. Student peer mentors suggested rewards that the
students could work for that would encourage them to persist. One of the
rewards that students felt should be offered is sports equipment for student
use during recess and lunch periods. One local community-based
organization offered to sponsor a fund-raising event that would allow them to
purchase sports equipment for the school.

FIGURE 12-9 Peer mentoring can aid individuals in changing

unhealthy behaviors.

1020
 Working with the advisory group, the nurses developed a program that
outlined activities for each objective, as well as the individual responsible for
the activity, the date by which the activities were to be accomplished, and
how outcomes would be documented. This allowed the group to stay
focused, share responsibilities, and monitor outcomes. For instance, student
mentors were asked to meet with their assigned students to evaluate their
progress and provide support at least once a week. The nurses were tasked
with meeting each week with the student leaders to provide peer-mentoring
training.
Working with the advisory group allowed the nurses to contextualize the
problem of teen vaping within the target community. The advisory group
ensured that the nurses identified solutions that were culturally acceptable,
appropriate, and ultimately effective. This process also helped them develop
outcome measures that were consistent with the concerns of the community.
As data were gathered, findings could be interpreted with input from the
advisory group. This approach grounded the findings and ensured that
interpretations were culturally consistent with the target population.
Evaluation was facilitated by clearly defined goals that could be measured
against actual results.

1021
EVALUATING OUTCOMES
The previous section of this chapter discussed the issues of program
planning, implementation, and evaluation as they related to a small health
program. This section focuses on programs and services provided by
agencies. Although the scope of the effort to address outcome evaluation is
understandably broader, the concepts are essentially the same (Kidder &
Chapel, 2018). According to the CDC (2017, para. 1), “Effective program
evaluation is a systematic way to improve and account for public health
actions by involving procedures that are useful, feasible, ethical, and
accurate.” The CDC proposes a framework and standards for program
evaluation in public health, which includes six steps, usually taken in order
(Fig. 12-10). There are several approaches and tools for evaluating health
care agencies, programs, and outcomes, a few of which will be discussed in
this section.

FIGURE 12-10 The framework of the Centers for Disease Control

and Prevention for program evaluation in public health. (Reprinted
from Centers for Disease Control and Prevention. (1999).
Framework for program evaluation in public health. Morbidity and
Mortality Weekly Report, 48(RR-11), 4. Retrieved from
https://www.cdc.gov/eval/framework/index.htm)

1022
Accreditation
The Institute of Medicine (IOM) report, The Future of the Public's Health in
the 21st Century (IOM, 2002), called for examining the benefits that
accreditation of governmental public health departments might bring. The
benefits of and requirements for accreditation are discussed in Chapter 6
(IOM, 2004).
The Public Health Accreditation Board (PHAB) is a nonprofit entity that
is the independent accrediting body. With support from the CDC, Office for
State, Tribal, Local, and Territorial Support (2018), and the Robert Wood
Johnson Foundation, the PHAB was launched in 2011. By August of 2019,
PHAB accredited or re-accredited a total of 275 U.S. health departments,
which included 36 state, 3 tribal, and 236 local health departments. Eighty
percent of the U.S. population is now served by a PHAB-accredited health
department (PHAB, 2019). The National Association of County and City
Health Officials (2020) and PHAB offer resources that assist health
departments to assess the feasibility of becoming accredited and tools to
further support a successful accreditation process if departments choose to
seek accreditation. Of the 12 domains in Standards and Measures version 1.5
for accreditation, 3 are particularly applicable to program development and
outcome measurement (PHAB, 2014, p. 3):

Domain 4: Engage with the community to identify and address health

problems.
Domain 9: Evaluate and continually improve health department
processes, programs, and interventions.
Domain 10: Contribute to and apply the evidence base of public health.

A review of the impact of the accreditation process suggests that one of

the leading benefits is strengthening health departments' quality
improvement efforts (Kronstadt, Bender, & Beitsch, 2018). As more agencies
seek accreditation, there will likely be increased pressure to achieve this
status at all levels (local, county, or state) to demonstrate excellence.
Accreditation promotes the provision of high-quality services to the public
and commitment to meeting the specific needs of communities. It also
supports the need for community/public health nursing services to meet those
challenges.
The accreditation initiative has raised the issue of demonstrating in real
and objective terms the outcomes resulting from health promotion programs
provided through public health agencies. The principles discussed have
relevance in many community settings and should be considered whenever
health promotion programs and services are provided. PHNs at local, state,
and global levels are instrumental to many of the health promotion programs

1023
and services offered through health departments; their expertise with and
understanding of the communities served are invaluable in assuring ongoing
quality assurance and outcome evaluation.

1024
Logic Models
An important step in evaluating any program entails constructing a clear
model of what the program is meant to achieve (Cornell University, 2016).
Logic models, or pathway logic models, are often used to articulate the
causal relationship between planned program activities and the expected
outcome. While community problems may be easy to recognize, it is harder
to determine which strategies offer the highest likelihood for successful
change and, more importantly, what evidence will indicate progress or
success. It is important to develop a framework for change and use it as a
road map in planning and implementing individual and community change
(Community Tool Box, 2019c). Based on change theory, logic models offer a
clear picture of the desired outcome, the changes that must be realized in
order to achieve the outcome, the activities and outputs that will affect the
change, and the inputs necessary to carry out the planned activities. In other
words, logic models provide a process for planning backward in order to
implement forward (Ball et al., 2017).
In developing a causal framework or pathway, you are able to map out
what will be done to produce a desired effect. It demonstrates how inputs
(e.g., community resources), outputs (e.g., potential interventions), impact
(e.g., initial results of intervention), and outcomes (e.g., improvement in
behaviors or population statistics) are interrelated. A visual roadmap can be
examined by starting with intended outcomes and “walking back” through
the steps that are needed to produce the intended result. A logic model is a
type of flow chart and usually takes up one page or less. The left side deals
with process and the right side with outcomes. To be effective, a logic model
should (Community Tool Box, 2019c):

Logically link activities and effects

Demonstrate appropriate level of detail about the program (enough to
clearly understand but not too much to overwhelm)
Be thought-provoking and visually engaging
Include the known forces needed to promote program outcomes

See Figures 12-11 and 12-12 for more on developing program logic
models and evaluating program outcomes.

1025
FIGURE 12-11 A series of “If…Then” statements to develop the
program logic model by connecting inputs to interventions and
outcomes to impacts. (From the Centers for Disease Control and
Prevention, Division for Heart Disease and Stroke Prevention.
(n.d.). Evaluation guide: Developing and using a logic model.
Retrieved from https://www.cdc.gov/dhdsp/docs/logic_model.pdf)

FIGURE 12-12 Mapping evaluation questions and indicators to a

logic model to determine the effectiveness of a program. (From the

1026
Centers for Disease Control and Prevention, Division for Heart
Disease and Stroke Prevention. (n.d.). Evaluation guide:
Developing and using a logic model. Retrieved from
https://www.cdc.gov/dhdsp/docs/logic_model.pdf)

1027
Setting Measurable Goals and Objectives
Using the logic model as a guide, planned programs should have specific
goals to help identify who the program is supposed to serve, what services
are provided, the length of time the services are to be provided, and the
resources that are needed. Then, measurable objectives are developed that
describe the expected outcomes. Use of selected verbs indicates the expected
level of achievement, such as “clients will be able to demonstrate safe
administration of insulin after three home visits” or “parents will have their
infants' recommended immunizations up to date by 24 months of age.” Goal
setting is imperative when developing an educational program for an entire
health program or service (see Chapter 11). These statements of measurable
goals are then examined during the program evaluation. Without such
statements, accurate evaluations cannot be conducted. Consider the
overarching goal of your program, what you plan to accomplish, as well as
why this program is important. The timeline and personnel resources must be
considered, along with which actions must be taken to achieve your intended
results (CDC, n.d.).
One helpful acronym, SMART is frequently used in developing outcome
measures. The general consensus is that SMART stands for Specific,
Measurable, Attainable, Relevant, and Time Bound, and may include
Evaluate and Reevaluate—SMARTER when added (CDC, 2018).
Box 12-2 describes specific questions that must be asked and answered
at each step of the SMART process.

BOX 12-2 Developing SMART

Objectives
Specific
What: What do we want to accomplish?
Why: Specific reasons, purpose, or benefits of accomplishing the
goal.
Who: Who is involved?
Where: Identify a location.
Which: Identify requirements and constraints.

Measurable
How much?
How many?

1028
 How will we know when it is accomplished?

Attainable
How can the goal be accomplished?

Relevant
Does this seem worthwhile?
Is this the right time?
Does this match our other efforts/needs?
Are we the right group or agency?

Time-Bound or Timely
When?
What can we do 6 months from now?
What can we do 6 weeks from now?
What can we do today?
Source: Doran (1981).

In evaluating programs and care, outcomes must be measured against

certain standards. Standards are generic guidelines of expected functioning.
They can focus on the client, the caregiver, or the organization (finances). All
care and services must also be measured against these guidelines. The core
standards of care, practice, and finance must be integrated and compatible if
they are to ensure quality care.

1029
Quality Indicators and Benchmarks
Quality indicators of client outcomes are the quantitative measures of a
client's response to care (Gordon, 2016). Defining and quantifying client
outcomes from these indicators are worthwhile processes that enable the
nursing staff to evaluate the results of the care they provide. The goal of care
in the community is successful client outcomes. By starting with measurable
indicators, successful outcomes can be demonstrated in quantifiable terms.
When client care meets the standards set, client satisfaction—another quality
outcome indicator—is greater.
Quality indicators are part of the broader quality management program
and are used to determine goal achievement. Chart auditing is a useful
method by which to measure the frequency of quality indicator occurrence
(Bissonnette, 2016). For example, an agency may have a quality indicator
such as “all infants younger than 6 months of age are weighed on each home
visit.” Every fifth chart of infants visited in March, June, September, and
December during a designated year is audited for documentation of the
number of home visits and the number of infant weights recorded. A
sampling of charts is sufficient to measure goal achievement and specific
quality indicators. It is generally accepted that a review of a random selection
of 10% of eligible cases, with a minimum sample of 20, will provide useful
information (Bissonnette, 2016; Nock, 2016).
Indicators are necessary when setting standards in order to measure the
success and quality of programs at home or in the community. The same
types of indicators are used in acute care settings, with the focus appropriate
to that population. If the standards are being met, but client outcomes are
unacceptable, the process indicators are explored for possible areas of
weakness. Such areas may need further study to identify the cause of the
poor client outcomes. For example, a process such as the catheter-care
protocol used by an agency, or the communication between hospital and
health department or home health nurses, may be examined to determine why
there is a high incidence of catheter-associated urinary tract infections among
home care patients. In addition, Medicaid and Medicare regulations in some
states mandate that a percentage of records be audited each year.
While striving for excellence and best practices, agencies may use the
benchmarking process. Benchmarking compares the performance of an
individual practice, department, or agency with an external standard (Fig. 12-
13). In quality improvement, a benchmark is considered achievable because
it has already been achieved by another agency or institution (Agency for
Health Care Research and Quality [AHRQ], 2016). Internal benchmarking
occurs within organizations, between departments or programs. External
benchmarking occurs between similar agencies providing like services. Good

1030
sources for external benchmarks include local quality collaboratives where
several practices or agencies collect and compare similar performance data
among themselves (Seow et al., 2018). Other sources include data reports
from federal agencies such as the Health Resources and Services
Administration's Uniform Data System, which evaluate services or
interventions aimed at improving the health of vulnerable populations and
underserved communities (Health Resources and Services Administration
[HRSA], 2019). In this way, an agency identifies what is achievable while
comparing and contrasting how others provide quality services.
Benchmarking is a key feature of the Quality and Safety Education for
Nurses (QSEN) project discussed later in this chapter and throughout this
book.

FIGURE 12-13 Benchmarking compares the performance of one

entity against that of another entity or standard.

1031
The Nurse's Role in Quality Assurance and
Improvement
Some quality improvement activities for C/PHNs include daily prioritizing of
care needs for a caseload of clients, seeking supervision or skills
development for a difficult case, systematizing charting so that needed
documentation is efficiently completed, proposing better ways to organize
care of chronically ill clients, and establishing new agency procedures. Staff
meetings, peer review, and case conferences are common settings for nurses
to bring the lessons of their practices to the larger group for examination and
potential adoption. In particular, nursing peer review shows promise as a
means to improve quality and safety in health care (Herrington & Hand,
2019).
It is the role of nursing administration to develop a formalized quality
management program that includes a three-pronged focus, based on a classic
approach to quality management: (1) review organizational structure,
personnel, and environment; (2) focus on nursing care standards and delivery
methods (process); and (3) focus on the outcomes of that care (Donabedian,
2003; Pelletier & Beaudin, 2018). In its essential competencies for health
care quality professionals, the National Association for Healthcare Quality
(NAHQ) identifies six key components of a robust quality management
program, which are as follows:

Performance and process improvement

Population health and care transitions
Health data analytics
Patient safety
Regulatory and accreditation
Quality review and accountability (NAHQ, n.d., para. 2)

The issue of quality and safety has more recently been addressed through
the QSEN project (QSEN, 2019). The QSEN competencies are consistent
with the Donabedian approach to quality improvement and provide a
framework for nursing education. They also form a sound basis for
community health program evaluation, especially as it relates to quality.
More details about the QSEN project follow.
Nurses should recognize the value of quality improvement efforts and the
importance of their role in ensuring that quality care is delivered. Direct
service providers are the best judges of care problems and potential solutions.
For this reason, it is critical that quality assurance reviews and other quality
improvement activities focus on issues relevant to staff and client concerns
and are structured to be accomplished quickly and with minimal effort. When

1032
these activities are clear, concise, and well-integrated into daily routines, they
become less time-consuming, and staff members may recognize the positive
client outcomes as rewards for their efforts. Moreover, when health care
providers have the opportunity to systematically examine the care they
provide, they can identify problems and generate potential solutions sooner.

1033
Program Evaluation: Concepts and Tools
Studies of community health programs suggest that they are often successful
in changing community policies and individual behavior but may not have a
significant impact on health outcomes over time (Fry, Nikpay, Leslie, &
Buntin, 2018). This may have more to do with the complex causes of health-
related issues, involving both “proximal risk factors as well as upstream
determinants of health” (Andermann, Pang, Newton, Davis, & Panisset,
2016, p. 3). Whether small or large, health care agencies are complex
organizations with many interrelated components. Assuring they provide
services that protect or promote health can be an equally complex task.
Avedis Donabedian, a physician credentialed in public health, offered a
conceptual framework for evaluating health care, which is foundational to
21st century quality initiatives (Backer, 2019). The concepts of structure,
process, and outcome offer the basis for his own and related models of care
evaluation.

Structure, Process, and Outcomes

The organizational structure should:

Fulfill its mission statement or philosophy (Dunham-Taylor, 2015)

Be client-focused, with enough resources to maintain present services
and introduce additional services as needed
Operate efficiently and within budget, maintaining financial stability
and promoting trust and confidence among stakeholders
Have a well-developed system of acquiring additional funding for new
services through grants and contract expansion if needed
Attract and retain clients and qualified, highly motivated staff

The agency should integrate processes which:

Provide client services in a manner that is safe, effective, client-

centered, timely, efficient, and equitable (Agency for Healthcare
Research and Quality [AHRQ], 2018)
Maintain standards set by the professional staff that comply with or
surpass those recommended by relevant accrediting bodies (Sills, 2015)
Encourage staff to contribute to the evaluation and revision of standards
Assure that staff members maintain current skills and knowledge
pertinent to their job requirements
Foster a collaborative work environment in which quality of care is
continuously monitored and improved using a variety of participative
management tools (e.g., audit instruments, peer review, incident
reporting systems)

1034
 Minimize staff turnover by providing a supportive work environment in
which administration and staff have compatible working relationships
Assure that employee values are compatible with the goals of the
agency and that the conduct of all employees is consistent with
organizational values
Maintain effective feedback mechanisms for clients to share their
perceptions about the care and services received (e.g., questionnaires,
surveys, interviews)
Act upon suggestions and opportunities for improvement that are
identified by clients

The client health outcomes reflect the impact of the services provided by
the agency (AHRQ, 2015). Outcomes are the result of numerous factors,
including structure and processes, and others that are often beyond the
agency's control. Examples include the following:

Review the charts of hospitalized clients to identify any opportunities

for improvement in the agency's teaching or care that could have
prevented hospitalization.
Review clinic or home visit records when poor client outcomes are
reported to determine whether any aspect of the clinic's or home visit
care might have prevented these occurrences.
Focus on outcomes among commonly served high-risk populations in
order to optimize care delivery as well as to benefit high-risk clients.
Review national, state, and local health care initiatives and objectives
(discussed earlier in this chapter) to identify priority health indicators or
outcomes in the agency's client population.
Develop SMART goals (discussed earlier in this chapter) focusing on
the priority health indicators and outcomes in the client population.
Develop aim statements—the tactics to achieve the SMART goals—
which are outcome-focused (Institute for Healthcare Improvement
[IHI], 2019).
Enlist individuals with health care analytics skills, within or outside the
agency, who can offer expertise in measuring and analyzing outcomes.
Identify the metrics, or measures, that will show the agency has
achieved its goals for client outcomes.
Develop and implement strategies to improve and monitor client
outcomes.
Modify and improve structure and/or processes when client outcome
targets are not met.

Models Useful in Program Evaluation

Donabedian Model

1035
As previously mentioned, Donabedian (2003) was the original proponent of
using the concepts of structure, process, and outcome in evaluating quality of
care (Fig. 12-14). The Donabedian model is:

FIGURE 12-14 Structure, process, and outcome of quality model.

Essentially linear in form, suggesting that structure influences processes

which, in turn, produce outcomes
Recognized as a simplistic and basic method of measuring quality
Widely used as the framework for more elaborate models
Relevant to common domains of nursing

Omaha System
Also discussed and graphically displayed in Chapter 15, the Omaha System
includes measurement approaches that make it a useful model for evaluating
the quality of nursing care provided to individuals, families, and
communities (Box 12-3).

BOX 12-3 STORIES FROM THE

FIELD
Application of the Omaha System in Reducing
Community Transmission During an Influenza
Outbreak During the holiday season, a
metropolitan county of 120,000 people in
Minnesota experienced concern and panic after
a local store clerk at a regional mall contracted
influenza and died 5 days later. The local health

1036
department quickly used their supply of
vaccine, and the next week received enough
vaccine for all residents from the CDC. Public
health clinics were flooded with worried
residents, and security became a concern.
Cough and fever are early symptoms of flu and
other less serious illnesses. It was difficult to
determine if someone needed to be quarantined
in order to thwart the spread of influenza.
In conjunction with the state health department and other partners,
the local health department launched a vigorous media campaign about
prevention and treatment of the flu and how to get the flu vaccine.
Information was also given about the limitations of the vaccine and the
importance of reducing contact with others (e.g., avoiding public places,
using the ER). However, residents were hesitant to cancel holiday
events and were continuing to visit the ER. PHNs completed contact
investigations and “attempted to quarantine exposed family members”
(para. 5). As the influenza outbreak ended, there were over 200
confirmed cases and 31 deaths.
DOMAIN: PHYSIOLOGICAL
Problem: Communicable/infectious condition (high priority)
Problem Classification Scheme (Community and Actual):

Signs/Symptoms (Actual): infection, fever, positive screening/labs,

inadequate policies to prevent transmission, refusal to follow
infection control regimen, inadequate immunity.

Intervention Scheme:

Teaching, Guidance, and Counseling (Targets/Client-Specific

Information): anatomy/physiology (transmission), communication
(media campaign), education (reduce risk of transmission),
infection precautions (voluntary quarantine, MD not ER),
medical/dental care (correct use of MD vs. ER).
Treatments and Procedures (Targets/Client-specific Information):
medication administration (antiviral medication for those with the
flu).
Case Management (Targets/Client-specific Information):
communication (media campaign/many partners), infection

1037
 precautions (enforced quarantine for those exposed).
Surveillance (Targets/Client-specific Information): Infection
precautions (contact investigations, monitoring of adherence,
tracking reported cases and deaths).

Problem Rating Scale for Outcomes:

Knowledge: 2—minimal knowledge (residents aware of outbreak,

residents with the flu knew they needed antiviral medication but not
aware of other precautions; some residents were “overly
concerned”) (para. 10).
Behavior: 3—inconsistently appropriate behavior (most of the ill
residents were given antiviral medication; many residents refused to
restrict their activities/follow voluntary quarantine advice).
Status: 2—severe signs/symptoms (extensive flu infections, many
cases and deaths, statistics monitored).

1. How could compliance with voluntary quarantines be improved?

2. How could the Omaha System help PHNs evaluate the
effectiveness of the media campaign and other interventions?
3. How could a PHN use Omaha System measures (i.e., Knowledge,
Behavior, and Status) to evaluate the impact of the interventions
to reduce teen vaping (discussed earlier in this chapter)?
Adapted with permission from Olson Keller, L., & Minnesota Omaha System Users Group.
(2019). Solving the clinical information puzzle: Influenza outbreak. Omaha Systems. Retrieved
from www.omahasystem.org/casestudies.html

Evaluation focuses on process indicators, client outcome measures, and

satisfaction with care (Martin, 2005; The Omaha System, 2019).

The model is currently used in “home care, public health, and school
health practice settings, nurse-managed center staff, hospital-based and
managed care case managers, educators and students, occupational health
nurses, faith community staff, acute care and rehabilitation hospital/long-
term care staff, researchers, members of various disciplines, and computer
software vendors” (The Omaha System, 2019, para. 10). The evaluation
components of the Omaha System include the following:

Outcomes that are rated in terms of knowledge (what the client knows),
behavior (what the client does), and status (how the client is)
Quantification of outcomes in a range of severity, as well as on a
continuum toward or away from optimal health
Ongoing monitoring of individual, family, or community health to
assess the quality of nursing interventions

1038
Quality and Safety Education for Nurses
The QSEN project, which is frequently referenced in this book, arose from
the groundbreaking IOM (1999) report on medical errors and the subsequent
2004 report focusing on nursing quality and safety. This recognition
prompted funding from the Robert Wood Johnson Foundation for what
would become known as the QSEN project. The purpose of the project is
“preparing future nurses who will have the QSEN competencies (knowledge,
skills, and attitudes, or ‘KSAs’) necessary to continuously improve the
quality and safety of the health care systems within which they work”
(QSEN, 2020, para. 1). See Figure 12-15. Some have called for these
competencies to move beyond the individual to systems of care, bringing it
more in line with the population-based focus of public health (Dolansky &
Moore, 2013; Dolansky, Schexnayder, & Patrician, 2017).

FIGURE 12-15 The knowledge, skills, and attitudes associated

with the QSEN competencies facilitate learning and competence of
the nursing student. (Source: QSEN. (2019). QSEN competencies:
Overview. Retrieved from https://qsen.org/competencies/pre-
licensure-ksas/)

The KSAs can be used across all settings where a nurse may be
employed, whether hospital, outpatient center, home care, hospice, or
community/public health nursing services.
The KSAs are similar to the Omaha System outcome measures of
knowledge, behavior, and status.

1039
 The QSEN competencies are significant in community/public health
nursing because they provide a method of evaluating both individual
nurse performance and the use of aggregated data to assess
programmatic outcomes.

The CDC's model for continuous program improvement cycle or its

National Public Health Improvement Initiative is other example of quality
improvement methods for public health. Additional information on program
evaluation and related resources can be found at:
https://www.cdc.gov/eval/index.htm.

1040
MARKETING AND COMMUNITY
HEALTH PROGRAMS
Each of the program evaluation models presented provide a mechanism to
plan, implement, and evaluate community-based programs and services.
Demonstrating quality through measurable outcomes is a crucial aspect of
community health. Health promotion and health education programs must
demonstrate achievement of stated goals to justify continuation. Community
health services are also challenged to provide programs in ways that reach
and engage their target populations. In this section, the roles of social
marketing and social media are explored as additional tools for influencing
health behaviors and lifestyle choices. These methods must be selected
carefully and evaluated against the same standards as previously presented,
perhaps more so, because of the potentially higher costs of this type of
intervention.

1041
The Value of Marketing
During the 2019 Super Bowl broadcast, television networks charged between
$5.1 million and $5.3 million for a 30-second commercial spot (Calfas,
2019). Businesses have long recognized the value of “catchy,” memorable
advertisements. Marketing can literally make or break an enterprise. If the
message is effective, the business often thrives; if not, it may dwindle.
Children as young as 3 years have been found to be “branded” with
current fast-food items and beverages, meaning that they recognize and
prefer one particular brand or logo over another (Enax et al., 2015; Kelly et
al., 2019; Tatlow-Golden, Hennessy, Dean, & Hollywood, 2014). The
techniques used by some corporations have contributed to health issues we
currently face as a nation (e.g., obesity in children, teen vaping). For
instance, research examining awareness among 3-to 6-year-old children of
products high in salt, fat, and sugar found that brand knowledge was a
significant predictor of the child's BMI. After controlling for gender, age, and
amount of television viewing, the researchers concluded that the link
between brand knowledge, consumption of the products, and higher BMI had
policy implications (Cornwell, McAlister, & Polmear-Swendris, 2014). In
another study, products with cartoon characters were chosen by 8-to 10-year-
olds when comparing the taste of yogurt–cereal–fruit snacks with plain
labels, health-focused labels, or labels with unknown cartoon characters
(Enax et al., 2015). An analysis of e-cigarette brand Web sites found
marketing claims of being healthier, having fewer restrictions for public use,
and being less expensive than cigarettes. E-cigarettes were also touted as
helpful in smoking cessation (Eysenbach, 2018).
The health care sector has also recognized the power of marketing.
Although health message marketing has been used in some capacity since the
1960s, it was not recognized as a potential health promotion tool until the
1990s, when federal agencies, such as the CDC, spearheaded efforts to utilize
it (Lee & Kotler, 2020).

1042
Social Marketing of Community Health Programs
The term social marketing refers to using marketing principles to influence
or advance “the voluntary behavior of target audiences” (Leuking et al.,
2017, p. 1426). You may have seen brief examples on television (or in print)
of the CDC's Tips from Former Smokers campaign (Howard, 2019). An
example of a very successful social marketing campaign was the ALS
Association's “Ice Bucket Challenge,” which raised over $115 million during
an 8-week period in 2014 for amyotrophic lateral sclerosis (ALS) research
(ALS Association, 2019). The objective of social marketing in public health
is to improve society's health by influencing changes in individual health
behaviors (e.g., healthy eating) and implementing policies that improve
health behaviors of populations (e.g., seat belt laws). The integration of
marketing with public health is seen as a means to enhance the effectiveness
of public health practitioners (Leuking et al., 2017; Resnick & Siegel, 2013);
nevertheless, this has yet to be confirmed by substantial research (Giustin,
Ali, Fraser, & Boulos, 2018).

Key Social Marketing Concepts

Concepts that are important in marketing are also applicable to social
marketing as noted in a seminal book by Resnick and Siegel (2013). These
include the following:

Exchange: Individuals give something to get something; they weigh the

costs and perceived benefits.
Self-interest: People act in their own best interests in most cases.
Behavior change: Change in behavior is the focus; thoughts and ideas
may also need to change but are not the ultimate goal.
Competition: Selecting one option (or action) inherently involves giving
up another option (or action).
Consumer orientation: Problem-solving process is directed at the target
—the consumer (this could be an individual, group, or organization).
Four Ps (product, price, place, and promotion): Also called the
marketing mix; each can be altered to increase market share.
Partners and policy: Organizations with similar interests may form
partnerships to achieve mutual objectives; identification of policy
changes necessary for behavioral change, those supportive of the
change, and those that the organization could help influence.

These principles seem rather straightforward, yet public health

practitioners are often at a disadvantage when attempting to implement social
marketing campaigns (Resnick & Siegel, 2013). They may lack training in
the necessary skills, be outspent by the competition (e.g., the fast-food

1043
industry), or have limited options for distributing their message (e.g., public
service announcements). Another example of a very successful social
marketing campaign is the Go Red for Women initiative begun in 2004 by the
American Heart Association (2020). Using a red dress as the symbol of the
program, the initiative seeks to raise awareness of heart disease among
women. Both of these health issues are equally important (heart disease,
ALS), but one has a more broadly recognized campaign; the other was
humorous but not necessarily educational. Ultimately, the issues are whether
public health practitioners will take full advantage of social marketing to
promote community or population health and whether behaviors and health
outcomes will improve as a result.
Zahid and Reicks (2018) reported on a quantitative study of messaging
that promotes healthy beverage intake among children. The study evaluated
the effectiveness of gain-framed messaging (outcomes framed in positive
light), on parenting practices that affect child intake of sugar-sweetened
beverages (SSBs). Gain-framed messaging aimed to support parental
motivation for reducing child SSB intake, as opposed to loss-framed
messaging (outcomes framed in negative terms), which aimed to undermine
it. Parents completed a survey after viewing gain-and loss-framed messages.
The gain-framed messages were associated with higher parental motivation
to decrease child intake of SSBs. This study exemplifies the importance of
framing health-related messages in a manner that is appealing, relevant to the
situation, and acceptable to the audience.

Social Media
In 2017, the National Institute for Health and Care Excellence (NICE) in the
United Kingdom became the first major public health agency to use
Snapchat, an instant messaging app used by millions of young people, to
educate them on a health topic—antibiotic resistance (Owen, 2017). The
cost? $500! There is, as yet, a lack of evidence confirming the effectiveness
of social media in promoting public health programs (Giustin et al., 2018);
nevertheless, there is no doubt that social media can be very cost-effective
and has the capacity to reach vast populations. In 2017, over 2.7 billion
people—37% of the world's population—were considered active social
media users (Hart, Stetten, Islam, & Pizarro, 2017). In 2019, approximately
72% of Americans used social networking tools, such as Facebook,
Snapchat, Instagram, Twitter, and YouTube (Pew Research Center, 2019).
The capacity of social media to reach individuals with strategic and
effective health messages is immense (CDC, 2019c) and must be harnessed
(Fig. 12-16). A thematic analysis of research on the use of social media in
public health and medicine suggests that patients, health care professionals,
and the general public are already using social media for a variety of health-

1044
related purposes including behavioral change support and disease
surveillance, prevention, and management (Giustin et al., 2018). The
example below, in Box 12-4, demonstrates how social marketing principles
can be utilized when you have a limited budget, limited time, and limited
creativity. What role can social media play in these efforts?

FIGURE 12-16 Social media and technology have the capacity to

reach and influence the health behaviors of a wide audience.

BOX 12-4 STORIES FROM THE

FIELD
Nursing Students and a Social Marketing
Campaign University campuses hold a wealth
of often-untapped expertise. For nursing
students working on a health promotion
program, the substance of the effort (the health
issue) is often pretty straightforward, but the
presentation is more challenging. Many schools
of nursing are providing collaborative
experiences for students, supporting
partnerships with nonnursing students and
faculty in addressing health education needs.
The following is one example of how
collaboration can be effective: In conversation

1045
with an instructor, two nursing students learned
that university administration was concerned
about a surge in measles cases statewide. The
university recommended students be current on
all standard immunizations prior to admission;
nevertheless, it was not a requirement. After
further discussion with their instructor, the
nursing students sought input from several
student organizations. From those discussions,
they identified a low level of knowledge and
concern about the issue among the students.
Recognizing that college students are not prone to worrying about
measles, the nursing students sought help from the university's student
health center. The health center administration agreed this was an
important issue and collaborated with the public health department to
offer free measles, mumps, and rubella (MMR) immunizations at the
student health center. The student health center posted information
about the free immunizations on its Web site, but there was very little
response from students.
The nursing students realized they needed to spread the word about
the importance of the issue and the availability of the free
immunizations. Based on input from the student groups, they decided to
develop social media messaging that was informative, engaging, and
brief. In conjunction with their instructor, they contacted the university's
animation department and found an instructor who was willing to assign
his or her students to develop an animated video promoting MMR
vaccination. The nursing students provided information about the
current measles outbreak, educational materials about the MMR
vaccine, and details about its availability at the student health center.
The animation students then developed brief videos within those
parameters. In the end, several outstanding videos were submitted.
The animation student's videos were posted on several of the
university's social media outlets, including Facebook and Instagram.
The campus newspaper also published an article about the MMR
campaign and the collaborative efforts of the health center and students
from different colleges. In response, there was a surge in students
visiting the health center for free MMR vaccination. The campaign also
reached parents who saw the videos on the webpages and social media.

1046
 Many messages were sent to the university by the parents regarding the
campaign, and the responses were handled by the nursing students.
The campaign was not expensive, it engaged the most skilled
individuals for each task, and it provided much-needed information to
the university students and their parents. Even though they had targeted
the college students, the nursing students found that the parents were
just as interested in the campaign.

1. In what ways has social marketing influenced your actions or

behaviors?
2. Can you think of an issue on your university campus that could
benefit from social marketing?
3. Do you recognize any social marketing efforts sponsored by your
university or your school of nursing?

When planning and beginning development of a social marketing

approach, there are many resources available to the C/PHN and other public
health professionals.

The CDC offers an excellent Web site, Gateway to Health

Communications and Social Marketing (CDC, 2019d), that includes
links to a wide variety of resources. For instance, one of the social
marketing resources, Social Media at CDC, offers guidelines and best
practices, including a social media toolkit and a guide to writing for
social media (CDC, 2019a, 2019d).
The European Centers for Disease Prevention and Control (2014) offers
a comprehensive Social Marketing Guide for Public Health Programme
Managers and Practitioners. Another very helpful publication What
Works: Health Communication and Social Marketing—Evidence-Based
Interventions for Your Community (CPSTF, 2014).
Social Media Toolkit: A Primer for Local Health Department PIOs and
Communications Professionals (National Association of County and
City Health Officials (NACCHO) (2019) provides information on the
importance of social media tools to “reinforce and personalize
messages, reach new audiences, and build a communication
infrastructure based on open information exchange” (p. 2). However,
there are also downsides to this approach.

Ethical Issues in Social Marketing

The plethora of social marketing campaigns have raised a spotlight on ethical
issues that must be carefully considered when designing, implementing, and
evaluating social marketing programs for good causes (Olson, 2018). The
International Union for Health Promotion and Education (2016) is dedicated

1047
to seeing optimum health and well-being globally. Their values highlight the
importance of ethics in this arena:

Respect—for the innate dignity of all people, for cultural identity, for
cultural diversity, and for natural resources and the environment
Inclusion and involvement of people in making the decisions that shape
their lives and impact upon their health and well-being
Equity in health, social, and economic outcomes for all people
Accountability and transparency—within governments, organizations,
and communities
Sustainability
Social justice for all people
Compassion and empowerment (International Union for Health
Promotion and Education, 2016, para. 3)

Social media platforms, which are potent social marketing tools, are
powerful but often unreliable sources of information. It may be difficult for
consumers to discern truth from fiction in social media posts about health
and wellness, many (or perhaps, most) of which may originate from sources
that are not authoritative or credible. Social media platforms are also
vulnerable to nefarious uses such as hacking and fraud, which also makes
them potent sources of misinformation. In 2019, Facebook and Twitter took
action against China for using hundreds of fake accounts to sow political
discord during protests in Hong Kong. As Olson (2018) points out, social
marketers should resist the temptation to use questionable tactics, even when
it might seem justified from their perspective about “the greater good.”
Social marketing is not a panacea, but it does provide techniques that can
support health education and promotion programs. The method can be very
expensive and elaborate, or it can provide simple, straightforward messages.
The point is that well-presented marketing can prompt behavior change.
Media messages are not a replacement for a sound health promotion
program; but they are a tool that can be used for great impact.

1048
SECURING GRANTS TO FUND
COMMUNITY HEALTH
PROGRAMS
Public health departments and other community agencies often require
outside funding to develop new health intervention programs. A common
practice is to seek grant funding. What is a grant? A grant is, very simply,
one individual or group providing another individual or group with the
support (i.e., money) for a specified purpose. Some basic knowledge about
grants can demystify the topic.
In health promotion and education, grants offer a source of funding for
program development or project support. These types of grants fall into the
following common categories:

Planning grants (i.e., initial project development)

Start-up grants (i.e., seed money)
Management or technical assistance grants (e.g., for fund raising or
marketing)
Research grants
Facilities or equipment grants (National Institutes of Health, 2019)

Grants are a reality in public health efforts, similar to a new program or

research proposal. They are not easy to locate, secure, or manage (once you
have one), but they are vital in providing a wide range of programs and
services to a community. Grants are available from government sources,
private philanthropic sources, and corporations. Private organizations often
have sections on their Web sites with information on available grant funding.
Grant money is not typically paid back; however, it is a contractual
agreement, and the terms and conditions are usually clearly delineated.

1049
Federal Grants
Federal grants award government funds to implement projects that provide
public service and stimulate the economy (Grants.gov, n.d.) and are available
from 26 grant-making agencies. The funding categories most applicable to
community health include the following:

Community development
Disaster preparation and relief
Food and nutrition
Health

Federal grants are available to a wide variety of groups, but typically,

health-related grants are available to state or local governments, which
include public health departments, public housing organizations, educational
organizations, and nonprofit organizations (Grants.gov, n.d.). Nonprofit
means the organization was not established to earn a profit. This does not
mean it doesn't generate income, but only that there are restrictions on how
its funds can be used. Federal grants can be found on the Web site
www.grants.gov or on individual federal agency Web sites.
Of particular importance to the discussion of grants is the term 501c3.
This is a designation that refers to the Internal Revenue Service (IRS) tax-
exempt status granted to certain nonprofit organizations. To be granted this
designation, an entity must be organized and operated exclusively for
specific purposes, which include charity, science, education, or the
prevention of cruelty to children or animals (IRS, Department of the
Treasury, 2020). Some grants are only available to 501c3 organizations, and
the funders will request proof of this in the grant application. Only
corporations, community chests, funds, or foundations can receive this
designation; individuals or partnerships do not qualify (IRS, Department of
the Treasury, 2020). Essentially, the 501c3 organization can be the provider
of the grant funding or the organization seeking the funding.

1050
The Grant Process
The grant process, although arduous, provides the opportunity to focus
clearly on what you intend to accomplish, why it is needed, and what part
you will play in the successful outcome of the project. Here are some of the
steps involved:

Select a funder that is a good match for your organization and your
program/project. For instance, applying to a faith-based organization
that supports abstinence-only educational programs would not be a good
fit for your program that seeks to provide contraceptive information in
an after-school program for teens.
Be prepared to provide proof of interdisciplinary or community
involvement; many grant funders favor or require grant applications that
show collaboration with others.
Submit a letter of inquiry; this may be by invitation-only or be part of
the original advertisement of the grant funding. This letter is brief, yet
clearly lays out your plan.
Read the request for proposal (RFP) carefully and write a clear, well-
prepared grant proposal that carefully follows the guidelines; failure to
submit all required items prior to the deadline means your grant
application is unlikely to be reviewed or funded.
If your grant is not selected, contact the funder to request a review of
your submission; this is common with government-sponsored grants.
Understanding what hampered your selection puts you in a better
position to be successful in future submissions to this or other funding
sources.

It is wise to seek the help of an experienced mentor—someone who has

been successful in grant writing—as they can critique your proposal and
offer suggestions prior to submission. In grant funding, experience counts! A
proven record in securing grants and completing the requirements, means
you or your organization will have an easier time securing additional funding
(Jaykus, 2017). For the new grant seeker, this can be discouraging.
So, where to begin? Don't start with complicated grants. Begin building
your reputation with small local grants. Work with partners. A school of
nursing could partner with a home health agency to write a grant to provide
worksite wellness programs for uninsured agricultural workers. Or several
faith-community groups could partner in a grant application to provide free
health screenings for uninsured adults in their area.
Finally, be certain that the grant will allow you to meet the mission and
goals of your program. With limited funds available, funders are looking for
proof of the sustainability of your program after their support ends. For

1051
instance, a breast-feeding support program sought funding in a high-risk area
where there was a clear need. Although the need was demonstrated, the
agency had no plan for continuing the program after the funding ended, so
they did not receive funding. Grant support is often seen as funding to get
programs started—not to provide for long-term operations (Jaykus, 2017;
Karsh & Fox, 2019).
Many courses are available on how to successfully locate and write
grants. A wide variety of information is available online. Helpful Web sites
are included in the Internet resources found on thePoint.

1052
The Nurse's Role in Grant Applications and
Management
Many health departments see grants as an integral part of their service
delivery, even hiring grant writers and managers in some cases. For the small
nonprofit organization seeking funding, one effective approach is to partner
with a local university, which allows for more access to grant-locating
programs, as well as the expertise offered on the campuses (e.g., content area
experts, experienced researchers, statisticians, business plan experts).
For most health agencies, the task of locating grant funds, writing the
grant application, and doing the work stipulated by the grant falls on the
nurses and other professionals within those agencies. On the positive side, it
provides an opportunity for C/PHNs to explain to others what they can
provide in terms of services and programs targeting the community's health.
The following tips may be helpful as you begin the process of seeking
grant funding (Federal Grants Wire, 2020):

Gain a sound understanding of the grant and specific criteria required,

ensuring your interests and intentions are in line with the grantor
agency.
Seek input from the community the services are intended to benefit.
Compile all required documents, such as articles of information, tax
exemption certification, etc.
Conform the proposal to the RFP requirements. The order of contents
may vary but usually include a proposal summary, problem statement,
project goal and objectives, project methods or design, project
evaluation, and budget.
Review, proofread, and ensure all requirements are met prior to
submitting your proposal.
Submit the proposal prior to the deadline.

Even if you are never required to write a grant, you will likely be
involved in some part of a programmatic grant at some point in your career,
either in the delivery of services stipulated by the grant (product) or in
evaluating the outcomes of the services provided (e.g., satisfaction surveys).
You may even be asked to provide ideas for services to be included in the
grant application. Take advantage of these opportunities. The experience you
gain will enhance your knowledge of the process and prepare you for future
opportunities.

1053
SUMMARY
The first step in developing effective community health programs is
identifying the problems which should be addressed.
National health objectives and initiatives, such as Healthy People 2030,
as well as state and local priorities and programs, offer ideas for
community health aims.
There are a variety of tools for identifying local health needs, including
federal resources.
Establishing partnerships with other health care professionals and
community organizations, leaders, and members is a crucial element in
planning community health programs.
Nurses must integrate their own “authoritative knowledge” with the
target population's “local knowledge” into the community health
program.
The Community Action Model is a form of participatory action research
that identifies actions that are achievable and sustainable.
A key factor in ensuring the success of an intervention is to appoint an
advisory group, including representatives from the target community.
The changeability and importance of health behaviors should be
considered when developing community health programs.
Successful community health programs require that the nurse listen to
the target population and not determine the problem and solution
without their assistance.
Outcome measures should be consistent with the concerns of the
community, and evaluation can be facilitated by clearly defined goals
that can be measured against actual results.
The PRECEDE–PROCEED model offers a framework for
understanding the predisposing, reinforcing, and enabling factors that
influence behavior.
Accreditation is an evaluation process that promotes high-quality
services among health departments.
Quality indicators are measures of a client's response to care. The goal
of community health programs is successful client outcomes.
Benchmarking compares the performance of an individual entity with
an external standard. Good sources for external benchmarks include
local quality collaboratives.
The concepts of structure, process, and outcome offer the basis for
Donabedian's and other related models of health care evaluation (e.g.,
QSEN). The Omaha System provides standardized language for
classifying problems, interventions, and outcomes.

1054
Social marketing in public health can promote changes in individual
health behaviors and/or policies that improve health behaviors of
populations.
Social media has immense potential for reaching individuals with public
health messages; however, there is a lack of evidence confirming its
effectiveness.
Grants offer a source of funding for program development or project
support. Nurses play a key role in grant writing and management.

1055
ACTIVE LEARNING EXERCISES
1. With the information provided in the teen vaping example, work with
a group of students to complete the planning of a viable program that
meets the stated goals. List nursing diagnoses and develop
measurable objectives (SMART objectives). Use Figure 12-10 as a
guide to develop predisposing, reinforcing, and enabling factors
related to teen vaping. Use the logic model diagrams in Figures 12-13
and 12-14, and other information on evaluation, to determine
resources and activities, as well as available data that could be used to
evaluate short-term and long-term outcomes.
2. Inquire about past and present public health programs targeted to
specific populations in your area (or at the state level). How was the
need discovered? What steps did they take to understand community
concerns about this issue? Was a model or framework used to develop
an intervention (if so, which one)? How were the outcomes
measured? Did program evaluation determine if the intervention was
effective? Describe how 4 of the 10 essential public health services
(see Box 2-2 ) were used in this process.
3. Compare common quality improvement measures found in acute care
(hospital) settings and potential areas for quality improvement in
public health (e.g., CDC's continuous program improvement cycle or
National Public Health Improvement Initiative). Is your local public
health agency accredited? If so, ask an administrator how this has
changed PHN practice and client outcomes. If not, ask for examples
of public health quality improvement measures or benchmarks.
4. Identify a health-related social marketing campaign that you viewed
recently on television, social media sites, or in print (e.g., the
National Institute for Health and Care Excellence [NICE] Snapchat
campaign about antibiotic resistance). Alternately, find a research
article on the use of social marketing in public health. Who is the
target audience? What is the main message it is sending? What is the
target behavior or problem? Does it reach the target audience? What
works? What doesn't seem to be effective? How could you improve
on methods to reach the target audience?
5. Talk with PHNs or PHN supervisors at your local or state public
health department or other community health agency. How many and
what types of grants do they have? What programs do they fund
exclusively from grant writing? How are they involved in grant
writing? How do they manage grant funding and data gathering to
justify outcomes for grant funders?

1056
 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!

1057
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for public health departments. Retrieved from https://phaboard.org/who-is-
accredited/
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competencies: Overview. Retrieved from https://qsen.org/competencies/pre-
licensure-ksas/
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Sutradhar, R. (2018). Benchmarking time to initiation of end-of-life
homecare nursing: A population-based cancer cohort study in regions across
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(2018). Patient engagement in community health center leadership: How
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1067
CHAPTER 13
Policy Making and Advocacy
“Never doubt that a small group of thoughtful citizens can change the world. Indeed, it is the only
thing that ever has.”

—Margaret Mead

KEY TERMS
Advocacy Community empowerment Health policy Lobbying Polarization
Policy
Policy analysis Policy competence Political action committee (PAC) Politics
Power
Public policy Special interest groups

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Describe the relationship between social policy and health outcomes.
2. Define health policy and explain how it is established.
3. Provide one health-relevant example of policy in each jurisdiction: local,
state, and federal.
4. Describe how a bill becomes a law on the federal level.
5. Discuss policy examples for legislation, regulation, and policy
modification.
6. Contrast the rational framework with Kingdon's framework for policy
analysis and identify when each would be most useful for public health
nurses (PHNs).
7. Identify three ways a PHN can engage in policy activism.
8. Identify the difference between advocacy and lobbying, as well as the
influence of both on policy.
9. Describe three components of the Patient Protection and Affordable
Care Act that impact the health of the public.
10. Discuss power and empowerment and the roles these concepts play in
policy development.

1068
INTRODUCTION
Public health policy consists of the rules, regulations, legislation, and
funding that we, as members of the public, choose to establish to govern the
provision, regulation, and research of health care for our fellow Americans.
All legislation and health care regulation decision making include
discussions over priorities and how they will be addressed. In all legislative
activities and reforms, social and political factions are at work—special
interest groups, business, and industry each bring their influence into play
(Payne, 2017).
Because the outcomes determine the availability and quality of all health
and social services, nurses need to develop a working knowledge of health
policy formation and the political process in order to advocate for and protect
the individuals, families, and communities they serve, as well as support their
own nursing practice. For community/public health nurses (C/PHNs), policy
outcomes impact the communities in which we practice, our personal health,
and the health of our neighborhoods and country. The C/PHN needs to
understand how to provide input to policy through advocacy and leadership
in decision making.
In this chapter, we will discuss the current state of the health of people in
the United States, how policy impacts health, how policy is developed, and
how C/PHNs can be involved in health policy formation. We will discuss
specific examples of C/PHN policy involvement and potential action, given
the current health care policy environment in the United States.

1069
HEALTH IN THESE UNITED
STATES: HOW HEALTHY ARE WE?
The US health care system is recognized worldwide for medical
achievements such as the mapping of the human genome, advances in
biomedical technologies, and increasing numbers of pharmaceuticals that
hold promise for addressing the myriad chronic and acute illnesses that affect
the world's populations. The US health care system is also known to be
expensive. Current data indicate that the United States spends 17.8% of its
gross domestic product on health care costs; this is twice as much as the
average health care expenditures from countries with similar levels of
economic development (Rapaport, 2018). High expenditures are not
necessarily problematic as long as the nation can afford them and they result
in positive health outcomes. However, for the amount the United States
spends on health care, are we achieving the results we desire (Box 13-1)?

BOX 13-1 What Do You Think?

Access to Health Care

Martin Luther King, Jr. Memorial.

“Of all the forms of inequality, injustice in health is the most shocking and
the most inhuman because it often results in physical death.”

—Dr. Martin Luther King

1070
In the decade or so leading up to President Clinton's attempt at health care
reform in the 1990s, the debate about access to health care centered on
whether health care was a right or a privilege. What do you think? Should
there be some basic rights regarding access to services as found in most other
developed nations (e.g., a safety net)? Or is this a privilege that is accessed as
a primary good that people budget for out of their personal resources? With
the Patient Protection and Affordable Care Act (ACA), those with
preexisting conditions were protected, but this and other provisions of the
law are being challenged. What changes have happened in the ACA since it
was enacted? Have these new changes affected you or someone you know?
The United States performs better than comparable countries in some
areas and grossly underperforms in others. According to the Organization for
Economic Cooperation and Development (OECD, 2017) the United States
performs poorer than peer countries in the areas of

Infant mortality and low birth weight

Injuries and homicides
Adolescent pregnancy and sexually transmitted infections (STIs)
HIV and AIDS
Drug-related deaths (Box 13-2)
Obesity and diabetes
Cardiovascular disease
Chronic lung disease
Disability

BOX 13-2 STORIES FROM THE

FIELD OPIOIDS IN AMERICA
In the United States, from 1999 to 2017, more than 700,000 people died
as a result of a drug overdose. In 2017, 68% of overdose-related deaths
involved an opioid (including prescription and illegal opioids), making
this six times higher than in 1999. On average, 130 Americans die each
day as a result of an opioid overdose (CDC, n.d.).
The causes of this epidemic are complex. One contributor was the
increase in prescription of opioid medications, which lead to misuse,
before it was known that these medications are highly addictive (DHHS,
2019; NAM, 2017). Established addiction leads many prescription
opioid users to seek nonprescription opioids (NAM, 2017). In fact, 80%
of heroin users started with prescription opioid use (Muhuri, Gfroerer,
& Davies, 2017). There is a complex interaction between obesity,
disability, chronic pain, depression, and substance use that has not been
fully explored in relation to opioid misuse (Dasgupta, Beletsky, &
Ciccarone, 2018). Further, the communities in which people live are

1071
influential factors in the opioid epidemic. Risk is compounded by
overall poor health, poverty, lack of opportunity, and inadequate living
and working conditions. The contributors to the opioid epidemic are
public health policy issues.
Taylor is a 35-year-old who visits her primary care provider (PCP)
for a chronic pain follow-up visit. During this visit, the PCP notes that
the patient was prescribed an opioid for pain management 6 months ago.
The patient has requested refills 4 to 7 days early each month. The
patient reports limited pain relief and becomes agitated when the PCP
offers alternative, nonopioid pain management options. By using
motivational interviewing techniques, the PCP engages the patient in a
discussion about her medication use. During this discussion, the patient
shares that she has been misusing her opioid prescription for the past 5
months and has resorted to using nonprescription opioids when her
prescriptions run out. After much discussion, the patient acknowledges
her misuse of opioids and asks for assistance in seeking treatment.
Together, the PCP and patient develop a plan for next steps of care.
The health care system, in this case, functioned well in that Taylor
had access to care and her care provider provided high-quality,
evidence-based care to assist her in seeking treatment.
However, when Taylor leaves the clinic, there are additional
resources necessary to help her reach her goals.
1. Does she have access to transportation necessary to seek
treatment? Such access could be related to where she lives, or her
income level.
2. Will her health insurance cover necessary follow-up and treatment
options?
3. What community factors influence her opioid use? Does she live in
poverty, with few opportunities for safe work and housing?
The ability of Taylor to carry out a plan for treating her opioid
misuse is related to policies that impact adequate housing, safe working
conditions, social and economic stability, health insurance coverage,
and access to illegal opioids.
1. How does the health care system use its knowledge to influence
such policies in ways that combat the opioid epidemic?
2. How can and should health professionals be involved in the
development or implementation of policies to promote healthy
lifestyles?
Source: CDC (n.d.); Dasgupta et al. (2018); DHHS (2019); Muhuri et
al. (2017); NAM (2017).

1072
 The OECD report (2017) also documents areas where the Unites States
compares favorably to peer countries. These areas include

Cancer mortality
Stroke mortality
Control of blood pressure and cholesterol levels
Suicide
Elderly survival
Self-rated health

Areas of strength for the United States include cancer and stroke
mortality and control of blood pressure and cholesterol (OECD, 2017). These
are a result of advances in early diagnosis and development of new, more
effective pharmaceutical treatments. Elderly survival is also likely related to
medication therapy and technological advances in old age. For those who
live to age 75 years, their odds of living longer are greatly increased. Self-
rated health is high in the United States, possibly because our technological
developments provide consumers with the perception of great medical
advances from which it is logical to conclude that one's health outcomes are
positive. Lastly, although the United States compares favorably in the area of
suicide, the US population does not compare favorably in the category of
gun-assisted suicide, for which our numbers far exceed those in our peer
countries.
More recent data indicate similar trends. The Peterson-Kaiser Health
System Tracker shows that although mortality rates have fallen for all
developed countries, they remain slightly higher in the United States than in
similar countries. In addition, measures of potential years of life lost (PYLL)
(Fig. 13-1), disease burden, and hospitalizations for preventable conditions
are all higher in the United States than in comparable countries (Sawyer &
Gonzales, 2017). The Commonwealth Fund presents data on health care
system performance across 11 developed countries. The United States ranks
last among the countries in this study. Five aspects are ranked, including
access, equity, administrative efficiency, care process, and health care
outcomes. Among these, the United States ranks last in access, equity, and
health care outcomes and next to last in administrative efficiency, as reported
by patients and providers (Schneider, Sarnak, Squires, Shah, & Doty, 2017).

1073
 FIGURE 13-1 Global health outcomes rankings. (© 2019 Peterson
G. Peterson Foundation. Used with permission. Retrieved from
https://www.pgpf.org/sites/default/files/0011_health-outcomes.pdf)

These rankings all highlight outcomes related to problems with the health
care system in the United States. The authors present a variety of
explanations for these health inequities, including a lack of attention within
the current health care system to the social determinants of health, the
challenges to access to health care, and public policies that do not address the
nonclinical causes of poor health.
PYLL is a measure of premature death and provides a method to measure
deaths that occur at a younger age and that may be preventable. PYLL is
calculated by multiplying the number of deaths that occur at each age by the
number of years left to live, up to a specific age limit. The age used by the
OECD is 70 years old. This measure is used across countries to compare
preventable mortality (OECD, 2017; see
https://data.oecd.org/healthstat/potential-years-of-life-lost.htm).
This raises the question: what is health policy and how it is relevant to
community/public health nursing? If C/PHNs are to promote and protect the
health of populations (American Public Health Association [APHA], PHN
Section, 2013), they need to understand health policy as it relates to the
health of the public. Policies affect our daily lives, regardless of whether they
are related to health or work. Thus, C/PHNs need an understanding of health
policy to better address the issues affecting the health of the communities
they serve and improve health outcomes. Relevant questions include the
following:

How does health policy impact the health of the population?

1074
 How is policy important in addressing both issues of access to care and
of creating and supporting the social conditions that support health?
What is the relationship between politics and health policy?
What do C/PHNs need to understand about health policy and its
formation?
How can nurses become involved in the political process and in
promoting effective health policies?

In the remainder of the chapter, we will discuss policy, how it is formed,

how C/PHNs can gain policy competence to impact policy in their practice,
and the policy changes resulting from the Patient Protection and Affordable
Care Act (ACA) and its implementation over time (U.S. Department of
Health and Human Services [USDHHS], 2015). We will also discuss the
relationship of politics and health policy.

1075
HEALTH POLICY ANALYSIS
What Is Policy?
To effect changes in the health care system requires changes in health care
policies. What does that mean? Policy analysts define policy as

A relatively stable, purposive course of action taken over time to deal

with a problem or matter of concern
Actions that emerge in response to needs or demands; can be negative
or positive; authoritative
Actions that relate to government action, not stated intention; based on
law/regulation (Anderson, 2015)

Policies lead to laws, regulations, or administrative rulings. When issued

by national, state, or local governments, they are called public policy.
Health policy refers to specific policies involving health and health care.
There are also different types of policies:

Substantive policy: This refers to policy that involves an action or

activity, such as funding for a health program or health-related agency.
One example would be federal funding for the Indian Health Service
and its activities.
Procedural policy: These involve the procedure by which an outcome is
sought. An example of this would be voting rights policies, which
stipulate the process for voting eligibility.
Distributive policy: These include policies that allocate services or
benefits to specific groups of people. Medicare, for example, distributes
resources to people who meet age and/or physical condition criteria.
Regulatory policy: These put limitations on the activities or behaviors of
certain groups or individuals, such as age limits for purchase of alcohol
or health professional licensing regulations (Birkland, 2019).

Nancy Milio, a well-known PHN, wrote extensively on policy and public

health nursing practice, coining the term healthy public policy. In her classic
work on health policy, Milio (1981) defined policy as option setting:
To bring about the largest improvement in health requires the development of
policies that will change the options that organizations and individuals face
today… It would provide new, easier opportunities, or reduce the cost of
current options, in areas that now lack healthpromoting resources. (p. 76)

1076
 Neal Halfon illustrated how the US health care system has evolved over
time in its policy options, moving from a focus on short-term system of
episodic nonintegrated care to a system of community integrated care—with
an increased focus on population health strategies that address the social
determinants of health (2014; see Fig. 13-2).

FIGURE 13-2 Health delivery system transformation critical path.

(Adapted with permission from Halfon, N., Long, P., Chang, D. I.,
Hester, J., Inkelas, M., & Rogers, A. (2014). Applying A 3.0
transformation framework to guide large-scale health system
reform. Health Affairs, 33(11), 2003–2011. doi:
10.1377/hlthaff.2014.0485.)

1077
What Is Politics?
While defining policy is important, understanding policy also requires
attending to policy formation, implementation, and evaluation. An essential
aspect of this is knowing the role politics plays in the policy process.
Politics is defined as the process by which society determines who gets
what, when they get it, and how they get it (Birkland, 2019). It is often
discussed as the art of using influence to bring about change, which includes
the efforts in which groups or individuals engage to influence, gain power, or
get their way.

The legislative and regulatory process may start with lofty goals, but the
final product is usually the result of compromise often encouraged by
special interest groups, coalition groups, political realities, or the current
economic environment.
Politics includes discussions related to the values or ethics of a society,
such as the conflict between individual needs and the needs of a
community. Examples include the debate around assisted suicide or the
continuing dispute regarding universal health care.
The classic understanding of politics was stated by the late
Massachusetts Congressman and former Speaker of the House, Tip
O'Neill, in his book, “All Politics Is Local” (1993). No matter the
definition of politics or the topic of debate, the role of C/PHNs is to be
responsive to the needs of the community they serve.

1078
Local, State, and National Level Policy
One of the first policy questions to address is that of jurisdiction. Public
policy is decided and impacts health and wellbeing at local, state, and
national levels (Box 13-3). Because of this, it is essential to know whether
the key decision makers are local, state, or national policymakers.

BOX 13-3 Policy Impacts at the Local,

State, and National Levels
Local Policy In January 2016, the mayor of the
city of Chicago called for legislation to increase
the minimum age for purchasing of tobacco
from 18 to 21 years. Teenagers are the largest
group of new smokers, and research suggests
that increasing the legal age to purchase
tobacco is part of an overall strategy to
discourage teens from using tobacco products
(Rhodes, 2016).
State Policy As of 2017, two states have signed
into law new regulations about prescription
drug pricing. California enacted legislation to
require advance notice and justification to
public and private health plans about
significant prescription drug price increases—
those of 16 percent or more over 2 years.
Maryland passed a law allowing the state's
attorney general to sue generic drug
manufacturers who engage in price gouging
and rveturn that money to consumers and
others who pay for the drugs or make the drug

1079
 available at its previous price (Families USA
Blog, 2017).
National Policy Data indicate that climate
change can have detrimental health effects on
populations including increased respiratory and
cardiovascular disease, injuries and premature
deaths related to extreme weather events,
changes in the prevalence and geographical
distribution of food-and water-borne illnesses
and other infectious diseases, and threats to
mental health (NIEHS, 2018). National policy
efforts, implemented by the Environmental
Protection Agency (2019), included voluntary
business participation resulting in cost savings
of $37 billion and avoided emissions of 470
million tons carbon dioxide equivalent.
Source: Environmental Protection Agency (2019); Families USA (2017); NIEHS (2018);
Rhodes (2016).

Local Policy
Many policies that impact health care are developed and implemented at the
local level. Although local policies may also be subject to guidelines from
other jurisdictions (e.g., state, federal), a hallmark of the US governmental
system has been to have robust local policy authority (National League of
Cities, 2016). While the U.S. Constitution specifically details state authority,
each state also gives powers to local governments. This means the policy-
competent C/PHN needs to know what jurisdiction governs any relevant
issue.

Public policies such as tobacco use in public places, requirements for

gun ownership, or speed limits on public roads are often made by local-
level governing bodies.
At the local level, these policies are very open to public involvement,
because often the legislative and regulatory bodies are easily accessed
and composed of community residents. The C/PHN is often able to

1080
 collect or interpret data relevant to the health impact of local policies
and can talk directly to decision makers about local policy concerns.

State Policy
There is a limit to municipal powers and some policies are developed and
regulated at the state level. Longest (2016) notes that the role of states in
health policy includes being public health guardians (e.g., protect public
health and welfare through laws and regulations), health care service
purchasers (often in conjunction with the federal level; safety-net providers),
and providers of education and public health laboratory services.

Health and related policies such as Medicaid eligibility and services,

health professional license regulation and scope of practice, and public
health codes, including immunization regulations, are some of the
functions that fall within state powers.
With the passage of the ACA in 2010, participation in the marketplace
of insurance plans and expanded federal funding for Medicaid were
decisions made by some state legislatures and had significant impacts
on access to care (Kaiser Family Foundation, 2019).

National Policy
Public health policies are also developed and implemented at the
national level. Funding for the health insurance plan, Medicare, the
ACA, parts of Medicaid, and health research are all national-level
policies.
This level of policy has the advantage of being broadly applicable
across the country, with the potential for significant impact on
population health.
It can be challenging to work at this level because there are a large
number of stakeholders and an enormous political and policy
bureaucracy for creation implementation and evaluation of legislation.
However, federal funding and regulatory requirements impact the role
and practice of C/PHNs, and C/PHN practice includes being aware of,
and in compliance with, federal policies.

1081
Legislative Process at the National Level
The federal model for how an idea becomes a bill and how a bill is passed
into legislation is relevant across the country. States each have their own
mechanism.

The first step in becoming policy competent on any issue is to know

under which jurisdiction the issue falls (local, state, or federal) and then
know how policy is developed and regulated at that level. There are a
wide variety of Web sites and descriptions of the legislative process, but
the definitive version can be found on the House of Representatives
Web site: http://www.house.gov/content/learn/legislative_process/.
It is estimated that 5% or less of bills introduced into any session of
Congress actually become laws (Govtrack, 2019). The two session of
Congress between 2013 and 2017 only enacted 3% of bills into law
(Civic Impulse, 2018).

How a Bill Becomes a Law

This section will review the process for how a bill becomes a law at the
federal level, but the process is very similar at the state level. See Figures 13-
3 and 13-4 for state and federal examples.

1082
FIGURE 13-3 How a bill becomes a law—state process. The
process may vary by state, but generally the schematic shows how
the process unfolds. (Source: California Legislative Counsel.)

FIGURE 13-4 How does a bill become a law?—federal level.

(Reprinted from How laws are made and how to research them.
(2020). Retrieved from https://www.usa.gov/how-laws-are-made)

1083
 Ideas for legislation can originate anywhere and be introduced as
legislation at the state and federal levels. For federal legislation, the bill is
introduced in either the House of Representatives or the Senate. Only budget
bills must originate in the House of Representatives. This was done to keep
the budget process closest to the “people's house,” the body of the legislature
where members represent relatively small numbers of constituents for 2-year
terms and thus are thought to be more responsive to their constituents
(Longest, 2016).

When a bill is introduced to either house, it is assigned to a committee

based upon the general area of focus (e.g., appropriations, agriculture).
The committee structure is designed to allow members of each house to
focus on a smaller number of issues in depth and then vote, as a whole,
on issues that are deemed worthy of going before the whole legislature
(i.e., going to the “floor”) for a vote.
Often, bills never leave the committee, stalling there because of lack of
interest from the majority party, whose members chair committees and
thus set the committee's agenda in both houses.

Some bills have hearings, where experts are brought in to testify to facets
of the bill and answer questions from the committee members. For bills
where there is sufficient interest or political will, the bill will be discussed,
amended as needed, and voted upon in the committee. If the bill passes in
committee, it is sent to the full house for further discussion, possible
amendments, and an ultimate vote (Longest, 2016).

If the bill passes the full house, it is sent to the other chamber, and the
process begins again. Sometimes, bills are introduced simultaneously to
both houses, which can speed the process, as each committee and house
reviews and votes on the bill during the same time period.
If the bill is passed in each house, but in a slightly different version, a
conference committee, composed of members of both houses, is
convened to discuss, amend, and vote on the bill.
The bill can stall in the conference committee until the session of
Congress ends, and then it would need to be reintroduced in the
next session, as bills do not carry over from one session to the next.
Alternatively, the bill may be passed by the conference committee
and then be returned to each chamber for a final vote. At this point,
amendments would not be added or the bill would be stalled again
and have to go back through the process once again (Longest,
2016; U.S. House of Representatives, n.d.).
After both chambers of Congress pass the same version of a bill, it goes
to the president for signature.

1084
 The president can sign the bill, in which case it becomes law and is
sent to the appropriate administrative agency for rulemaking.
The president can actively or passively veto the legislation, in
which case the bill needs to be sent back to each chamber for a 2/3
vote to override the president's veto, or the bill stalls again, and the
process begins anew.

In summary, passing legislation is a complex process, designed for

maximum debate and representation to avoid frivolous, dangerous, or
unnecessary legislation (U.S. House of Representatives, n.d.).
There are other important aspects of the legislative process of which the
C/PHN needs to be aware. These include the rulemaking process,
implementation, evaluation, policy modification, and judicial action.

Rulemaking and Implementation

After a bill is passed and signed into law, it is sent to the appropriate
administrative agency to develop rules and processes for
implementation.
After these rules are developed, they are published in the Federal
Register with a designated time period for public comment. Comments
are reviewed and used to revise and edit the rules as needed.
The rules are then published, along with an effective date for
implementation, and are used to guide organizations and individuals in
implementing the policy; rules provide the “who, what, where, when,
how, and why” of the law.

These rules can be critical to the actual impact of legislation, as they

guide how the policy intent will be carried out (Office of the Federal
Register, n.d.). Subtle changes to one or two words can significantly alter the
legislature's intent.

Evaluation and Judicial Action

Evaluation of policy is sometimes written into the law and sometimes
requested as part of the rulemaking process as a step in implementation.
These evaluation data can be used for policy modifications or for
modifications of the rules for implementation. Policy evaluation is designed
to help the legislature know whether a policy is having the intended impact
on the problem or condition it was designed to address. See Box 13-4 for an
example of policy evaluation.

1085
BOX 13-4 An Example of Evaluating
Policy Changes: Paying for Performance
In the past, injury or illness related to
hospital stays were often recognized as
inevitable consequences. However, the
Patient Protection and Affordable Care
Act created a Hospital-Acquired
Condition (HAC) Reduction Program.
The goal of this program is to reduce the
number of HAC and improve overall
patient outcomes (CMS, 2019). This is
encouraged through reduced Medicaid
payments for hospitals that do not meet
benchmarks for HAC (CMS, 2019). The
promise of reduced reimbursement has
led to a number of nurse-led
interventions to reduce HAC and
improve patient outcomes. A nurse-led
effort to combat a common HAC is
explored below.
Central line–associated bloodstream infections (CLABSIs) are
defined as “a laboratory-confirmed bloodstream infection not related to
an infection at another site that develops within 48 hours of a central
line placement.” CLASBIs increase patient mortality and health care
costs. In fact, they are the most expensive of all hospital-acquired
infections, costing approximately $46,000 per case (Haddadin &
Regunath, 2019).
Nursing leadership at a Tennessee pediatric medical facility
developed, implemented, and evaluated an intervention to prevent

1086
CLASBIs in their pediatric and neonatal intensive care units. Nurses
created an evidence-based CLASBI prevention bundle that included a
variety of insertion, maintenance, and prevention strategies. After the
implementation of this nurse-led intervention, the hospitals CLASBI
rate decrease from 3.80 out of 1,000 lines day to 0.45 (p < 0.001). The
project resulted in decreases across all units to below national
benchmarks. This project demonstrates the success of a nurse-led
intervention to decrease CLASBIs for a vulnerable population (Savage,
Hodge, Pickard, Myers, & Powell, 2018).

1. Do you think nurses are generally aware of legislation that

affects their workplace, practice, and patient outcomes? Why?
Why not?
2. How could nurses become involved in the implementation of new
laws/regulations and policy evaluation?
Source: CMS (2019); Haddadin and Regunath (2019); Savage et al. (2018).

The judicial branch of government is designed to interpret laws and

ensure they align with the constitution. In some cases, laws are
challenged, and the challenge works its way through various levels of
judicial decision making.
Courts can void a law or require that it be changed in some way to
comply with the constitution. If this involves omitting part of the law,
this can be done while implementation continues.
If such a change negates the intent or desired outcome of the law,
the legislative process would have to begin again to make any
substantive changes.
This process is designed to minimize the power of any branch of
government: the legislators who wrote the law, the executive
branch who administers the law, or the judicial branch who
interprets the law. This is known as the American system of checks
and balances (White House, 2016).
Policy modification may occur, such as those related to the ACA,
and may involve adjusting regulations to reflect changes in
political climate or cost impacts (Commonwealth Fund, 2018). See
Box 13-5 for an example of policy modification.

BOX 13-5 A History of Tobacco

Legislation in the United States The
tobacco industry has been regulated
through state and national legislation

1087
since the early 1900s, with several
policies and policy modifications.
Policies have been created and modified
as a result of new scientific discoveries
about the negative impact of tobacco use
and in an effort to protect the health of
the public. With the recent advent of
electronic cigarettes, many tobacco
policies have been created or modified to
include new methods of tobacco use.
1906 The Food and Drugs Act of 1906 did not include mention of
tobacco. However, a 1914 advisor groups recommended that
tobacco be included in modified legislation but only when
used to prevent or treat disease.
1914 The Federal Trade Commission (FTC) Act of 1914 empowers
the FTC to take action preventing people or organizations
from using “unfair or deceptive acts or practices in
commerce.” This is important legislation as it allowed the
FTC to regulate advertising of tobacco products. The FTC
completed seven formal cease-and-desist order proceedings
for medical or health claims of cigarettes between 1945 and
1960.
1938 The 1906 legislation was superseded by the Federal Food,
Drug, and Cosmetic Act (FFDCA) of 1938, which allowed the
government to regulate tobacco products used to prevent or
treat disease. For example, in 1959, the FDA asserted
jurisdiction over Trim Reducing-Aid Cigarettes that claimed
to aid in weight reduction due to the additive tartaric acid.
1965 Federal Cigarette Labeling and Advertising Act of 1965
required cigarette packages to include a warning label stating,
“Caution: Cigarette Smoking May Be Hazardous to Your
Health” but did not require this warning to be included on
advertisements.
1969 The Public Health Cigarette Smoking Act of 1969 required
the following to be place on all cigarette packing and print
advertising: “Warning: The Surgeon General Has Determined

1088
 that Cigarette Smoking Is Dangerous to Your Health.” This
Act also prohibited radio and television advertising.
1984 The Comprehensive Smoking Education Act of 1984 requires
four rotating warning labels on cigarettes about lung cancer,
heart disease, pregnancy, and carbon monoxide. The Act also
requires cigarette companies to provide a confidential list of
ingredients to the government.
1986 The Comprehensive Smokeless Tobacco Health Education
Act of 1986 required warning labels and prohibited radio and
television advertising for smokeless tobacco products.
1987 Public Law 100–202 bans smoking on domestic airline flights
2 hours or less.
1992 The Synar Amendment to the Alcohol, Drug Abuse, and
Mental Health Administration (ADAMHA) Reorganization
Act of 1992 requires that all states adopt and enforce
restrictions the sale and distribution of tobacco to minors.
2009 The Family Smoking Prevention and Tobacco Control Act of
2009 gives the Food and Drug Administration (FDA) the
authority to regulate cigarettes, smokeless, and roll-your-own
tobacco.
2016 The “Deeming Rule”: Tobacco Products Deemed to be
Subject to the Federal Food, Drug, and Cosmetic Act
extended the reach of the FDA to regulate “hookah, e-
cigarettes, dissolvables, smokeless tobacco, cigarettes, all
cigars, roll-your-own tobacco, pipe tobacco, and future
tobacco products that meet the statutory definition of a
tobacco product” (USFDA, 2016, para 2).
The history of tobacco legislation in the United States is an example
of how policies are created and/or modified in response to science to
protect the nation's health.
1. Can you think of an example of a current policy that requires
modification based on new or emerging science?
2. What modifications would you suggest?
Source: Centers for Disease Control and Prevention (CDC) (2017);
Public Health Law Center (2019); U.S. Federal Drug Administration
(FDA) (2016).

1089
Policy and Public Health Nursing Practice
Now that we have some basic definitions of policy and politics, we can
explore how policy is relevant to public health nursing practice. The
definition of PHN practice developed and disseminated by the PHN Section
of the APHA in 1996 and reaffirmed in 2013 is as follows:
Public health nursing is the practice of promoting and protecting the health
of populations using knowledge from nursing, social, and public health
sciences. (APHA, PHN Section, 2013, para. 5)
The definition, and its background statements, includes several key
elements:

A focus on the health needs of an entire population

Assessment of population health using a comprehensive, systematic
approach
Attention to multiple determinants of health
An emphasis on primary prevention
Application of interventions at all levels—individuals, families,
communities, and the systems that impact their health

Therefore PHNs, by definition, are interested in health policy broadly,

including both health care services and also policy as it relates to creating
conditions in which people can be healthy by addressing the social,
physiological, and behavioral determinants of health. Assessing and treating
the social determinants of health includes working with communities to
develop policies that impact living conditions for families and communities.
Thus, C/PHN practice must address policy implications of health needs and
conversely look at creating policies to promote and maintain health for
communities and populations.
The term public health nursing was coined in 1893 by Lillian Wald, who
described PHNs as nurses who worked outside the hospital “to provide
decent health care” to those people living in poor communities and
tenements (Jewish Women's Archive, 2016, para. 2). See Chapter 3 for more
information on PHN nursing history. These nurses specialized in both
preserving health and implementing prevention measures as they responded
to referrals from patients and physicians; they were only paid for their
services if the patient was able to afford payment. In 1893, Lillian Wald and
Mary Brewster established the Visiting Nurse Service, and a year later, the
famed Henry Street Settlement House was established. Wald's exposure to
the plight of newly arrived immigrants to the Lower East Side and the
appalling living conditions there spurred her to action. She was determined
that these immigrants and other poor people, regardless of ethnicity or

1090
religious affiliation, would have access to health care and adequate housing.
Wald went on to encourage the establishment of the Department of Nursing
and Health at Columbia University's Teachers College through a series of
lectures she presented starting in 1910. She was also instrumental in creating
the U.S. Children's Bureau in 1912, an agency that oversaw fair child labor
laws (see Chapter 3). Her work exemplifies how public health nursing and
policy go hand-in-hand.
A recent movement in public health of interest to nurses is that of Health
in All Policies (California Dept. of Public Health, 2018). The APHA presents
this as embedding health considerations into decision-making processes
across all sectors. An example of a Health in All Policies approach is a city
planning policy that determines zoning for a new retirement community for
seniors. In the planning phase for the project, a health impact assessment
would be done.

A health impact assessment (HIA) is a process that accesses potential

health impacts of a plan, project, or policy prior to implementation.
Results of a HIA are used by including public health impact in the
decision-making process for projects and policies that fall outside of
traditional public health arenas. Conducting a HIA reveals possible
positive and negative health impacts (California Department of Public
Health, 2018; CDC, 2016).

In this case, the HIA would look at health implications of different site
options. For example, what are the health implications for the residents if the
facility is built just off a major highway? Is the population being served
particularly vulnerable to noise or auto exhaust? What about building the
facility on the outskirts of a town? Does this population have unique
transportation needs? Health in all Policies as an approach helps guide
decision making across sectors to maximize health-enhancing options and
minimize options that increase health risks for the populations involved.
For C/PHNs to be effective in the policy process, they need to be aware
of policy implications on health planning and healthpromoting interventions
and be prepared to provide data to support policy recommendations that
enhance the health opportunities for a target group or community. This is
called being policy competent (Longest, 2016). Policy competence means
being able to:

Assess the impact of public policies on one's domain of

interest/responsibility
Understand policy and the policy process sufficiently to be able to exert
influence on the process and impact policy
Exert influence on the policymaking process

1091
 For Community/public health nursing practice, this means that the
C/PHN is able to assess relevant policies and determine where the policy is
in the policymaking process. The C/PHN must also be able to determine
where action is needed to influence the policy process: data support,
lobbying, development/testing of potential policy solutions, stakeholder
convening, etc. The C/PHN might not be able to lobby due to his/her position
(for instance, working for a government agency), but there are many other
policy process activities that are relevant in planning and implementing
health policy. There are few studies documenting the impact of C/PHN
involvement in policy efforts, but those that exist demonstrate the importance
of policy efforts in PHN practice.

A study of African nurse leaders found that having knowledge of policy

and practicing health policy development enhanced nursing's image,
whereas a lack of policy involvement promoted a more negative nursing
image and promoted processes and structures that excluded nurses
(Shariff, 2014).
Another study of Canadian PHNs in a rural community presented
perspectives from the PHNs on how much of their role involved
interpreting health policy to be able to meet the needs of rural women
(Leipert, Regan, & Plunkett, 2015).

As we shall see later in the chapter, there are many activities relevant to
the policy process in addition to lobbying for legislation.

1092
POLICY ANALYSIS FOR THE PHN
Once C/PHNs understand how an idea becomes law, and how that law is
implemented, they can begin to analyze the policy process to determine
where they might become involved to create “healthy public policy.” Policy
analysis is the technique of understanding a policy from a variety of
perspectives. Such analysis can provide results for better understanding
policy, finding ways to impact policy development, understanding the values
behind policy, tracking the history of policy in specific areas, and other
policy-relevant research and practice questions. Policy analysis can be done
using a variety of approaches and methods. Here, we will present policy
analysis for practicing C/PHNs to help them develop policy competence.

1093
Developing Policy Competence
Policy competence means understanding policy and the policy process
sufficiently to be able to exert influence on the process and impact
policy (Longest, 2016).
This can be done at a variety of levels. Because policy sets the context
for much of C/PHN practice, policy competence is particularly
important for C/PHNs, but all nurses should have some concept of how
policy affects nurses, patients, and population health.
For example, changes in Medicaid funding, at either the national or state
level, might directly impact which clients the C/PHN is allowed to
include in certain health promotion/disease prevention programs.
Therefore, the C/PHN should understand this impact, the reasons for the
Medicaid changes, and where useful input might be provided.
This might be as straightforward as explaining to agency administrators
what the impact of these changes will be on individuals in the
community, or it may be more complicated and involve policy
evaluation mechanisms or development of alternative policy solutions to
meet the health goals of the community.

1094
Frameworks for Policy Analysis
For the purposes of policy competence in C/PHN practice, we will discuss
two frameworks for policy analysis, the rational framework and John
Kingdon's framework. These frameworks provide two interrelated
mechanisms for looking at the policy process and are combined into a useful
diagram by Longest (2016) (Fig. 13-5).

FIGURE 13-5 Longest's model. (Adapted with permission from

Longest, B. B. (2016). Health policymaking in the United States
(5th ed., p. 82). Chicago, IL: Health Administration Press.)

The Rational Framework

The rational framework is commonly found in policy texts as a
straightforward way to comprehend the intent and effect of a particular
policy.
The framework involves defining the policy problem to be addressed.
The more clear and measurable this problem definition is, the more
specific any policy response can be.
The second step in this framework is to understand possible solutions to
this policy problem and compare and contrast them to each other in
order to determine which is optimal in terms of being politically
feasible, easily implemented, and likely to result in the desired outcome.
The third step, based on comparing and contrasting the possible policy
alternatives, is to select an alternative, implement it, and evaluate for its
effectiveness (Kingdon, 2011).

1095
 This logical analytic framework is very similar to the nursing process, in
its structure and components, and as such is easily understood by
C/PHNs (ANA, 2016b).

Policy researchers use policy analysis frameworks to guide research on

policy impacts and outcomes. One classic example of Longest's framework
in practice is as follows: An example from Sri Lanka involves achieving a
consensus on the public health problem of high rates of suicide (47 overall
and 80 for males per 100,000—the highest in the world at that time). A
presidential committee of experts was convened to examine and make
recommendations about the problem, using the rational framework approach.
A large proportion of suicides were deemed self-poisoning, and suggestions
ranged from reducing access to lethal pesticides, research to decrease the
lethality level of pesticides, changing the culture to discourage suicides,
repackaging pesticides into nonlethal doses, and increasing access to care to
improve survival rates after suicidal poisoning. Once the data and the
potential interventions were discussed, policy analysis was used to determine
weaknesses, strengths, and costs of options. Interventions that required
further political actions, such as taxation, new programs, or private sector
self-interest, were weighed. The influence of expert evidence and data are
not sufficient to change policies—political action is needed with an
understanding of “context, networks, knowledge, implementation, and
impact” (Pearson, Anthony, & Buckley, 2010, para. 37). Understanding of
technical feasibility, budgets, marketability, and dominant cultural values is
necessary, along with evidence and data, in order to exert political influence
and change cultural practices.
There are several challenges to using this framework. Much like the
nursing process, it examines policy as a structured, linear process, and that is
often not the case. Challenges in defining the problem or in comparing viable
solutions might often influence policy to be formed with insufficient data or
based on the power and influence of specific stakeholders, meaning that all
elements may not be considered carefully and in the order presented in the
framework (Kingdon, 2011), Additionally, this framework doesn't assist the
C/PHN in addressing the politics involved or in determining why one issue
might be addressed when another—equally important to the community—
might languish with no policy activity taking place.

Kingdon's Framework
The second framework to be discussed here is that developed by John
Kingdon (2011) in his classic book (Fig. 13-6). Kingdon set out in his
research to address the question of why some issues came to the forefront in
policy development and others did not.

1096
FIGURE 13-6 Kingdon's model of the policy process.

Kingdon argued, based on his research results, that policy was enacted
when a window of opportunity was opened. During the period of this
open window, bills could be voted on and new legislation made.
The window of opportunity opened when there was a confluence of a
policy problem, a viable solution or solutions, and political will on this
issue. This confluence opened a window of opportunity for the issue to
be acted upon (however briefly).

Kingdon presented each component of the framework specifically.

The problem, he contended, should be defined using indicators, that is,

data to document its existence. However, he also said problems could be
defined by focusing events, or attention-getting incidents, which
highlighted a problem for a large portion of the population.
An example of a focusing event would be the terrorist attacks on
the World Trade Center and Pentagon in September 2001, which
brought national and international attention to the problems of
terrorism and airline safety.
Kingdon also argued that it was important to understand the
problem from multiple perspectives, recognizing how others can
interpret the same problem and data. In this way, he contended that
the analyst could understand multiple perspectives and how they
might impact the solutions and politics (Kingdon, 2010).
Identifying a policy solution is the next component of the Kingdon
framework. Kingdon stated that there are always policy solutions
floating around in what he called the “policy primeval soup” (2010,
para. 10).
He provided some parameters for assessing solutions: technical
feasibility, acceptability in terms of public values, acceptable costs,
alignment with the current size and role of government, fairness,
and equity. He used these parameters to compare solutions for

1097
 those most likely to align with problems and politics (Kingdon,
2011).
When analyzing the politics of an issue, Kingdon had several facets to
consider. First, being the political climate at the current time.
For example, immediately after the 9/11 terrorist attacks, the US
political climate was focused almost entirely on safety and security,
and very few other issues were being seriously addressed.
Kingdon (2010) also advised looking at stakeholders on both sides
of an issue and assessing relative power and influence. This can be
done by looking at the numbers of people they represent, resources
available for lobbying, and political reputation and past
achievements.
When a window of opportunity does open, Kingdon (2010, 2011)
cautioned that it does not remain open forever.
Sometimes, other issues take precedence. Sometimes, partial action
is taken, and the public perceives the problem has been resolved, at
least in the near term.
Other times a window closes because the public loses interest in
unresolved issues that have been around for a long time.
In Kingdon's terms, policy activists should look for opportunities to
open windows and, when windows are open, should act to capitalize on
the opportunity.

An example of Kingdom's framework in practice: A global example

involves tobacco control. As the United States utilized decades of research
and began legislating no-smoking ordinances and tax increases on tobacco
products and rates of tobacco-related morbidity and mortality dropped, a
window of opportunity opened for countries around the world to enact
tobacco control policies (Gneiting, 2016). Employing Kingdon's framework
and an international treaty on tobacco control (Framework Convention on
Tobacco Control) established by the World Health Organization, the
Framework Convention Alliance (FCA) began working globally toward
raising awareness of tobacco as a public health threat and utilizing new
funding sources (e.g., Gates Foundation, Bloomberg Initiative) to shape
national policy agendas. Smoke-free legislation gained the most “advocacy
momentum and policy traction,” with 120 member countries on board
(Gneiting, 2016, p. i80). The tobacco industry has responded by marketing e-
cigarettes, influencing trade and governmental partnership agreements, and
aggressively lobbying against tobacco tax increases. Some of these measures
are not part of the original treaty and now must be addressed. Measures to
increase tobacco taxes have not been as successful as smoke-free initiatives.
The relative political power of the tobacco industry has been difficult to
overcome, but the FCA members continue their work.

1098
 Drawbacks to Kingdon's framework include the fact that his framework
analyzes policy only to the point of passing a bill into law. His framework
does not address the issue of implementation, evaluation, or policy
modification. As mentioned earlier, Longest combined the rational
framework and Kingdon's framework into a figure encompassing all facets of
policymaking (Fig. 13-5).
For the policy analyst, both frameworks present important components of
understanding an issue. The rational framework allows the analyst to look
post hoc at an issue and learn from the process as it unfolded. For policy
activists, or C/PHNs who want to use policy effectively in practice (policy
competence), the Kingdon framework allows you to examine a current issue
in real time and determine if a window of opportunity exists or if one could
be created. This helps the C/PHN, or a public health organization, to
prioritize its time and resources and focus policy efforts where they can be
most effective.

1099
Policy Analysis for Activism
Now, we will put this altogether to demonstrate how a C/PHN can use this
information to be policy active in practice.

The first step is to select a policy issue to address. Consider what health
concern in your community has policy implications or is being impacted
by current health policy or the lack thereof.
Perhaps there are water quality concerns in the community, or the
most recent community assessment has identified an increase in
STIs among adolescents and young adults. These are public policy
issues; that is, they are issues that involve public decisions about
laws and regulations related to funding, services, or rights and
behaviors.
The second step, once the C/PHN has determined that the issue is
indeed one of public policy, is to conduct a brief policy analysis using
Kingdon's framework initially: What is the problem? Are there
solutions, and are they adequate and appropriate? What are the politics
—or who are the stakeholders and what is their level of influence?
This preliminary analysis will inform the C/PHN whether this is a
new issue on the agenda or whether it is an issue of implementation
or evaluation of existing legislation or regulations.
Given this analysis, the C/PHN can determine the next steps. First, the
C/PHN needs to know under what jurisdiction the policy falls (local,
state, federal) and who key stakeholders and the target audiences are for
any action. Perhaps, the key concern is the problem; it may not be well
defined, the definition may need to be expanded, or more data may be
needed.
The goal may be to get the issue on the policy agenda via outreach to
policymakers. Action may be necessary to develop and test solutions
based on practice standards and population needs.
Developing policy solutions is a fundamental role for nurses—for
the welfare of patients and communities, as well as the profession
(Mason, Gardner, Outlaw, & O'Grady, 2016).
Perhaps, the issue is the way a regulation is being implemented,
and thus, change could be made by working with legislators to
identify the problem and develop implementation modifications.
The policy evaluation may lack clarity.

Once the C/PHN considers all of these factors, then the level of
involvement necessary can be determined. Given constraints on time,
lobbying, access to data, and the priority of the issue, the level of
engagement can be established. A number of avenues for activism are

1100
available, based on the above criteria. Table 13-1 demonstrates how the
analysis framework relates to concerns of the C/PHN and possible actions in
response.

TABLE 13-1 C/PHN Practice Mechanisms to Address Policy

Issues

1101
POLITICAL ACTION AND
ADVOCACY FOR C/PHNS
The definition of C/PHN practice describes efforts to promote and protect the
public's health. When looking at Healthy Public Policy, C/PHN efforts to do
so can take many forms from active participation as an informed citizen to
actions taken as part of C/PHN practice to promote Healthy Public Policy.
The Association of Public Health Nurses (APHN) put out a booklet for their
C/PHN members to help understand advocacy and policy in their practice
(APHN, 2016).
The C/PHN as an informed citizen, who has valuable knowledge and
experience in health and health promotion, can be involved at a basic level
by being aware of health policy and using this awareness for informed voting
in elections across levels of jurisdiction.

Individual C/PHNs might choose to increase their involvement by

serving in a campaign to support a legislator that espouses public
policies promoting health and preventing disease.
Additionally, the C/PHN might choose to share their expertise with
others, as a means to inform their voting and citizen involvement.
The C/PHN could also choose to be involved in professional
organizations or citizen organizations to advocate for Healthy Public
Policies and the legislators who promote them.

C/PHN practice, looking broadly at health and the social determinants of

health, can provide background that is valuable in any number of
professional and civic organizations. For example:

At the state level, the C/PHN can ensure that the state nursing
organizations maintain a broad-based focus on the health of the public.
Locally, C/PHNs can serve on health boards but can also provide
valuable input into health and education by serving on school boards or
parent–teacher organizations. Working toward eliminating health
inequities, healthier built environments, HIAs, and sharing knowledge
are all worthwhile endeavors for nurses who want to affect population
through health policy work (Kostas-Polston, et al., 2015).
C/PHN researchers can influence policy by focusing on research
questions related to the social determinants of health or health in all
policies and sharing results in a clear and persuasive manner with
policymakers and legislators. C/PHN research might include assessing

1102
the impact of public policies on community health outcomes or on
evaluating public health promotion efforts in the community (Williams,
Phillips, & Koyama, 2018).
Lastly, C/PHNs can provide input by serving on policymaking bodies. A
C/PHN serving on a hospital board could be critical in helping the
hospital better understand population health and the role of the hospital
in enhancing it.
Alternatively, the C/PHN could serve on state or national advisory
groups such as MedPAC (www.medpac.gov) or the Community
Preventive Services Task Force
(https://www.thecommunityguide.org/task-force/what-task-force). The
organization, Nurses on Boards, is campaigning to put 10,000 nurses on
various boards at all levels by 2020. Types of boards may include
advisory, elected, appointed, constituency, and regulatory. The
organization provides a wide variety of examples across each state,
along with guidance on how to prepare to serve on a board
(http://nursesonboardscoalition.org/).

1103
Public Health and Social Justice
The concept of social justice is seen as the very foundation of
community/public health and C/PHN (deChesnay & Anderson, 2016). The
American Association of Colleges of Nursing (2017) emphasizes that the
guiding values of nursing include social justice at all levels of educational
preparation, and the ANA Code of Ethics with Interpretive Statements (2015,
preface) states that nurses should “act to change those aspects of society that
detract from health and wellbeing.” The ANA's Public Health Nursing:
Scope and Standards of Practice document also highlights the basic value of
social justice in community health nursing (2013). The many definitions of
social justice depend on the discipline involved; for purposes of this chapter,
social justice is focused on health equity, which is ensuring that individuals
have an equal opportunity to maximize their health (deChesnay & Anderson,
2016). See Chapter 23 for more information on social justice.

As a C/PHN, you are expected to give voice to the health and social
inequities found in the communities you serve (e.g., substandard
housing, high rates of unemployment, death, and disability).
These are disparities that often could be prevented or alleviated at
early stages. In order to promote and protect the health of
populations, your nursing interventions will need to address not
only health issues but also the educational, social, and economic
issues that give rise to these disparities (deChesnay & Anderson,
2016).
The nexus between social justice, advocacy, and policy is
interrelated, complex, and one that will affect every aspect of your
community health nursing career.

1104
History of Public Health Nursing Advocacy
Nurses have a long history of action in social justice and advocacy, which
can be defined as pleading the case of another or championing a cause (see
Chapter 3). To advocate is to try to influence outcomes that affect people,
communities, and systems. Additionally, advocacy is a process, not an
outcome, one that includes identifying an issue, collecting information,
identifying who can be influenced to make the decision sought, building
support, and taking action. Advocacy also includes litigation and public
education campaigns. Advocacy can present itself in a variety of ways:

Self-advocacy: advocating for oneself

Individual advocacy: pleading the case of others
Community/public health advocacy: creating awareness of, and
generating support for meeting, the community's health needs
Legislative advocacy: changing or modifying local, state or federal laws

Advocacy is also the process of empowering those less able to present

their views or needs, with the goal of giving them a voice and/or achieving
their objectives. Nurses have long been advocates for their patients, and
advocacy can and does affect the larger systems of care (deChesnay &
Anderson, 2016). Both nurses and communities have a common goal—the
best possible health outcomes for all.
The importance of early nurse advocates such as Lillian Wald, Sojourner
Truth, Margaret Sanger, Clara Barton, Mary Seacole, Susie King Taylor,
Mary Mahoney, and others is that they wielded influence even at a time when
women were not allowed to vote (see Chapter 3). In fact, many women in the
1800s, regardless of socioeconomic status, did not attend school. Women
during these times rarely, if ever, voiced their opinions about issues affecting
their lives, the lives of their children, their families, or their communities; it
was neither expected nor accepted. African American women in the early
20th century were legally forbidden to learn to read and write (Nickitas,
Middaugh, & Aries, 2016). For these women to influence policy during the
19th century is a tribute to their ability to take on the system in which they
lived and to triumph over it.
The early pioneers are seen as feminists, and the entrance of these
women into the political arena opened the way for others, such as Nancy
Pelosi, first-ever female Speaker of the U.S. House of Representatives, and
the four women Supreme Court justices (including one retired). The numbers
of women in elected office continues to grow, and after the 2018 midterm
elections, 24% of members of the senate and 23% of House members were
female. In state legislatures, those numbers were 22.9% and 26.4%,
respectively (Rutgers Center for American Women and Politics, 2018).

1105
Professional Advocacy
One of the chief ways in which nurses have been successful in advocating is
through membership in their professional organizations. The late 19th
century may be seen as the beginning of nurse activism. The Nurses
Associated Alumnae of the United States and Canada and the American
Society of Superintendents of Training Schools of the United States and
Canada were formed in the 1890s (ANA, n.d.a.; National League for
Nursing, 2016). Out of these groups came the ANA and the National League
for Nursing (see Chapter 3). However, in the 1980s, with the stratification of
nursing into various specialties and organizations, representing an assortment
of specialty groups, came the realization that the many nursing groups
needed to coordinate efforts in order to be more successful, per a seminal
article by Cohen et al. (1996). Throughout the next few decades, the nursing
organizations realized, regardless of internal differences and competition,
that to be politically successful, they must join together to work toward their
common political goals. The formation of the following coalitions occurred:

Tri-Council for Nursing—comprising the American Nurses

Association (ANA), the American Association of Colleges of Nursing
(AACN), the National League for Nursing (NLN), and the American
Organization of Nurse Executives (AONE)
American Association of Nurse Practitioners (NPs)—state and
national NP groups initially met for a national forum and eventually to
influence health policy
Nursing Organizations Alliance (The Alliance)— an alliance of
National Federation for Specialty Nursing Organizations and Nursing
Organizations Liaison Forum

These and other coalitions permitted the organizations to lobby for

common nursing issues (e.g., maintenance of federal funding for nursing
education and research) and ultimately the establishment of the National
Institute of Nursing Research within the National Institutes of Health
(Milstead, 2016). Many of the current state nurse practice acts and expanded
responsibilities for NPs are the result of these new coalitions. But more
significantly, the profession worked together to demonstrate that there is a
difference between “self-interest” and “selfishness” (Milstead, 2016).

One of the most significant outcomes of this era was the development of
Nursing's Agenda for Health Care Reform (ANA, 1994), which
exemplified the maturing of nursing as a special interest group and
demonstrated consensus building and collaboration among the more
than 60 nursing and various health care provider organizations.

1106
 Despite nursing's early history of political activism and the fact that
nurses are the largest group of health care providers in the United
States, widespread political involvement has not been fully realized
(Nickitas et al., 2016).
Nursing has the potential to be a major player in Washington when
discussing health care policy. For a recent example of successful
professional advocacy, see Box 13-6.

BOX 13-6 Expanding Practice

Opportunities for Nurse Practitioners as
a Result of Professional Advocacy The
Patient Protection and ACA is estimated
to have decreased the numbers of
uninsured in the United States by 5% to
7% by 2028 from 2010 levels. Thus, an
estimated 15 million more Americans
will have access to primary health care
(Inserro, 2018). The demand for nurse
practitioners (NPs) or advanced practice
nurses (APNs) is increasing; nationally,
it is expected to reach an increase of
30% between 2016 and 2020 (Xue &
Intrator, 2016). NPs are often thought by
patients to provide quality care,
excellent communication with patients,
and clear education about self-
management of chronic conditions (e.g.,
diabetes). Given this increased demand
for services—and specifically those

1107
provided by APNs, there are several
provisions in the ACA that promote
APN practice including the following:
Five years of funds for demonstration projects to expand NP
education programs.
Increased funds for hiring NPs into the National Health Service
Corps.
Increased support for Federally Qualified Health Centers (FQHC)
and Nurse-Managed Health Clinics (NMHCs), as safety-net
providers, to hire APNs to care for their often vulnerable, high-risk
clients.
Medicare beneficiaries with functional limitations and chronic
illnesses are able to receive home-based primary care from NPs
through a 3-year project, Independence at Home Demonstration
(Carthon, Barnes, & Sarik, 2015).

Although these gains have been the hard won result of consistent
lobbying and advocacy efforts on the part of professional nursing
organizations and individuals, the bright future on the horizon for APNs
is at risk because of inconsistent scope of practice laws at the state level
(Poghosyan, Boyd, & Clarke, 2016). In 2015, only 21 states and the
District of Columbia had full autonomy rules for NPs (e.g., NPs could
evaluate/treat patients, order/interpret diagnostic tests, and prescribe
medications). That leaves 29 states with laws for NPs that restrict or
reduce their scope of practice; often, this involves requiring physician
oversight or collaboration (Xue & Intrator, 2016). Some states prohibit
NPs from certifying home health or long-term care and limit their
admitting privileges to hospitals. This practice leads to barriers to
practice and uneven distribution of primary health care providers, with
per capita rates for NPs ranging from 1.7 to 8 per 10,000 people in rural
areas of the country. Most are working in large cities and urban areas
(Xue & Intrator, 2016).
Another important consideration is the fact that NPs often work
with the most vulnerable populations in areas where other health care
providers are scarce, and “their active participation in advocating for
both health and social policies” for their clients is helpful in promoting
health equity in access and quality (Xue & Intrator, 2016, p. 5).
Although NPs are achieving success in the area of policymaking and
expanded practice opportunities, it is still vitally important for them to
advocate and politically support health policies that benefit the clients
they serve.

1108
 1. What are the APN laws in your state?
2. How could allowing for APN full practice authority change how
health care is provided in your community?
Source: Carthon et al. (2015); Inserro (2018); Poghosyan et al. (2016);
Xue and Intrator (2016).

Nurses must take advantage of how the public views the profession. For
more than a decade, nurses have ranked highest in a Gallup poll for honesty
and ethical standards (Gallup, 2018). Clearly, there is favorable impression
of nursing as a profession among the general public. Despite criticism about
special interest and professional organizations “protecting their turf,”
professional nursing organizations demonstrate how a critical mass can be
influential and successful in moving the discussion forward on health care
and the public's perception of nursing. Large professional organizations have
the resources, relationships with policymakers, success at coalition building,
and reputation for the ability to compromise needs to assure viable outcomes.
It is the professional nursing organizations that have elevated nursing
professionalism, given voice to the inequities that affect our society, and
developed the paradigms that influence and affect public health at the
institutional, state, and national level in the 21st century. A united voice on
public policy is more powerful than individual nurses pleading with their
legislators (Taylor, 2016). Being a part of your professional organization
demonstrates your professionalism, promotes your organization's viability,
and demonstrates your social responsibility to advocate for the needs of your
patients.
The pursuit of personal agendas over the common good results in a
piecemeal approach to problems and promotes polarization. Polarization is
the process by which a group is severely split into two or more factions over
a political issue. Polarization can be so intense that people perceive one
another as good or wicked, depending on their ideological opinions. One of
the primary goals of a professional nursing association is to build a collective
voice for nurses. A strong professional association limits polarization by
developing the political skills of its members and ensures that its structure
and processes equitably meet the needs of its constituencies. This is the
essence of politics: people must listen to each other, learn from others'
viewpoints, and compromise to ensure the most positive outcomes from their
endeavors (Nickitas et al., 2016).
Nurses are increasingly becoming shapers of policy on both the local and
federal level; this is occurring because of our experience, perspective, and
expertise in health care (Box 13-7). The realization that improving conditions
for nursing also improves conditions for the communities we serve and the
larger society in which we live and work has enhanced our ability to
organize. This increases our visibility, access to policymakers, and, more

1109
importantly, our capacity to influence the political process (Kostas-Polston et
al., 2015).

BOX 13-7 QSEN: Focus on Quality

Safety Safety: Minimizes risk of harm to patients and providers
through both system effectiveness and individual performance
(p. 128).
(See https://qsen.org/competencies/pre-licensure-ksas/#quality_improvement
for the knowledge, skills, and attitudes associated with this QSEN
competency.) Do not underestimate the power of nurses in action! On May 1,
2018, over 400 nurses from California visited the state capitol to push for
important legislation that could impact them and the patients and populations
they serve. They lobbied in support of A.B. 2874, which would require
hospital systems to give the public 180-day notice before closing facilities or
cutting specific services and would give the state attorney general the
authority to approve or deny hospital closures. As a result, this bill was
amended but became inactive. The nurses also advocated against A.B. 1795
and S.B. 944; these bills would allow paramedics to make clinical decisions
about whether patients should be transported to emergency rooms or taken to
other treatment sites, which the California Nurse Association worried could
threaten patient safety and intrude on the RN scope of practice. Further, if
passed, these policies could increase disparities in health care quality and
access by providing a mechanism for vulnerable populations to be
transported to subpar treatment facilities (National Nurses United, 2018).
Both bills died in the Senate Assembly.

1. Do you know about “lobby days at your local state capitol?” Do

nurses participate?
2. Which nursing organizations or groups have lobbyists working with
your state legislators?

At https://leginfo.legislature.ca.gov/faces/billCompareClient.xhtml?
bill_id=201720180AB2874&showamends=false, look up A.B. 2874 and
analyze how this legislation might improve nursing care and patient
outcomes.
Source: Cronenwett et al. (2007); National Nurses United (2018).

1110
Nursing's Role in Health Care Reform
Since the 1950s, the ANA has advocated for reforms in health care that will
benefit both nurses and their patients. Their involvement in federal health
care reform began in the 1960s with the passage of Medicaid and Medicare.
In the 1970s, the ANA formed a political action committee (PAC). PACs
are organizations that raise money to contribute to political parties or
candidates, with the understanding that those receiving financial and political
support will be sympathetic toward issues of interest to members of the PAC.
In 1991, the ANA released Nursing's Agenda for Health Care Reform: A
Call to Action—a plan so ambitious and forward-looking that Senator
Edward Kennedy referenced this document when introducing his legislation
on health care reform. Even though this legislation failed to pass, the ANA
and other nursing organizations gained wide recognition for their policy
acumen and leadership abilities. During the Clinton-era health care debate,
the ANA continued to play a key role in the policy and political discussions
on health care reform. As research and experience continued to show the
need for health care reform, the ANA remained steadfast in its advocacy and
updated the policy agenda on health care reform and progress toward a more
balanced approach incorporating primary care, community-based care, and
preventive services. The ANA supported the development of a single-payer
system. Understanding the time was ripe for health care reform, the ANA-
PAC identified those legislators supportive of ANA's legislative and
regulatory agenda. They provided financial and political support and
increased their grassroots organizing. RNs nationwide responded and
through multiple activities (e.g., contacting members of Congress, testifying
at hearings, sharing personal stories, participating in high-profile press
conferences, attending rallies and events) lobbied for action. The frontline
nurses also joined ANA's health care reform team, and through these
concentrated efforts and collaborations, health care reform became a reality
in March 2010 (Lewenson, 2015).
Since the enactment of the ACA, ANA has worked to support
implementation and to identify and disseminate the impact of any efforts to
repeal the ACA (ANA, n.d.b.). The strongest efforts to repeal the ACA came
at the end of 2016. The ANA carefully analyzed all proposals, compared
them against the ANA's Principles for Health System Transformation (see
Box 13-8), and made decisions regarding which proposals the organization
would support. As a result of these efforts, in 2017, the ANA was crucial in
stopping the passage of legislation that would repeal aspects of the ACA
important to nursing practice and patient outcomes. Further, in May 2017,
the ANA followed this same process and was vocal in opposition to the
American Health Care Act, which the organization believed would threaten

1111
the health of the public and compromise the quality of health care delivery in
the United States. See Box 13-8.

BOX 13-8 American Nurses

Association's Principles for Health
System Transformation The system
must:
Provide to everyone universal access for essential health care
services including mental health services, preexisting condition
coverage, expansion of safety net through Medicaid, cost-effective
practices, primary care that works in partnership with the patient,
and coordination of care with all team members
Address economics of health care costs through government and
private partnerships, payment systems that include quality and
resource use; address how lifetime caps/coverage
limits/deductibles/copayments may be barriers to care and use an
income-based sliding scale for insurance coverage purchase
Ensure a skilled workforce that provides high-quality health care
services through RN education, increased support for nursing
faculty, and health care work force development and diversity
funding
Source: American Nurses Association (2016a).

Nurses represent the largest number of health care practitioners in

America—more than 3 million—and are poised at the frontline in patient
care to play a major role in the evolving health care system. However, to
change the existing system, the barriers to competent, quality care (e.g.,
nursing shortages, faculty shortages, a lack of proper education and training)
that prevent nursing from taking its rightful place among the cadre of
providers must be addressed. To that end, the Robert Wood Johnson
Foundation (2010) in collaboration with the IOM sponsored a report, The
Future of Nursing: Leading Change, Advancing Health (IOM, 2011). The
Future of Nursing is a seminal document that addressed the need to reform
the health care and public health system of the 21st century and outlined
nursing's pivotal role in this. Four key messages from The Future of Nursing:
Leading Change, Advancing Health (IOM, 2011, p. 4) include the following:
Nurses should:

1. Practice to the full extent of their education and training 2. Achieve

higher levels of education and training that promote seamless

1112
 academic progression 3. Be full partners in redesigning health care 4.
Be part of health care policy and planning using data collection and
an improved information infrastructure to inform decision making

The resulting seven recommendations and indicators of progress as of

August 2019 are as follows:
1. By 2020, increase the number of nurses with a baccalaureate degree to
80%. As of 2018, 56% of nurses have baccalaureate or higher degrees
(Campaign for Action, 2019).
2. By 2020, the number of nurses with a doctorate should be doubled. This
recommendation has been achieved with over 23,800 employed nurses
with doctoral degrees (Campaign for Action, 2019).
3. Allow for advanced practice nurses to practice to the full extent of their
education and training. Nine states have achieved full access to care
provided by APNs since the campaign began, resulting in a total of 22
states with full practice authority for APNs (Campaign for Action,
2019).
4. Provide opportunities for nurses to participate in collaborative
improvement efforts. The number of required clinical courses and/or
activities at top nursing schools that include both RN students and
graduate students of other health professions has increased by 183%
over the last 6 years (Campaign for Action, 2019).
5. Allow leadership opportunities in health care for nurses. As of July
2019, over 6,300 nurses serve on boards across the nation (Campaign
for Action, 2019).
6. Collect and analyze interprofessional health care workforce data. To
date, almost all states collect nursing workforce data related to the
supply of nurses, with smaller but increasing numbers of states
collecting data on nursing education and demand for nursing services
(Campaign for Action, 2019).
7. Prioritize diversity in the nursing workforce. As of 2016, 30% of all
nursing students across levels of education are members of racial and
ethnic minority groups and 14% of nursing students are male
(Campaign for Action, 2019).
Nurses are an important force in health care and should be at the table
with other stakeholders when important decisions are being made. The IOM
report on nursing is a clear hallmark of our growth in the area of health
policy and health reform. A new National Academy of Sciences report on
nursing, scheduled for completion in 2020, will focus on nurses' value added
to health outcomes for all Americans. “Nurses' regular, close proximity to
patients and scientific understanding of care processes … give them a unique
ability to act as partners with other health professionals and to lead in the
improvement and redesign of the health care system and its many practice

1113
environments…” (IOM, 2011, p. S-3). This is a mandate for community
health nurses to be actively involved in advocacy and influencing the future
development of our health care system.

1114
CURRENT US HEALTH POLICY
OPTIONS
What does the current health care system look like for C/PHNs? Earlier in
this chapter, we discussed current health outcomes and the need for an
increased focus on disease prevention and addressing the social determinants
of health. The ACA has changed the policy options for health care on a
national level; concerns persist regarding whether this is the best solution to
ensuring access and controlling costs of care. However, in the past decade,
policy and public health researchers have begun to examine seriously the
health outcomes that have derived from the US health care system as
configured, with access to care largely through employer-based insurance
and a focus on medical treatment. Although the system has spawned
innovations in pharmaceuticals and technological innovations, these services
have often been effective for a small number of people, in acute need and at a
large cost. Thus, the system has developed to be expensive and largely
ineffective for the overall population health, disease prevention, and chronic
disease management needs. The health care system has been very successful
as measured in terms of education of health care professionals,
pharmacological treatments for many illnesses, surgical innovations, and
diagnostic technologies. As discussed earlier, however, these achievements
have not led to overall positive health outcomes for the population as a
whole. The passage of the ACA (Medicaid.gov, n.d.) has led to policy
changes designed to address these concerns (see Chapter 6 for more
information on the ACA).

1115
The ACA and C/PHN Practice
The ACA provided a dramatic change in US policy options. Recognizing that
the US health care system was not addressing all the factors necessary to
improve the health of the public, and that it was costing US taxpayers an
ever-increasing and sustainable proportion of the national budget, the Obama
administration moved to pass health care reform legislation in 2010. The
focus of the ACA, in the minds of the public, was to mandate health
insurance coverage for all US citizens. This would be done through a
required employer minimal health insurance package, a mandate on
employer provision of health insurance or employer contribution to a
marketplace of insurance options for individuals to access, and government
provision of subsidies for low-income people without employer insurance
coverage. Indeed, data indicate that the ACA was initially successful at
insuring those previously uninsured. The percentage of uninsured adults
(ages 19 to 64) dropped from 20% in 2010 to 12% in 2018, but more people
are underinsured (Collins, Bhupal, & Doty, 2019). In the current
administration, however, there have been efforts to repeal the ACA, and
related efforts to curtail ACA expansion have led to projections of numbers
of uninsured beginning to rise again, with projections of 13% of Americans
uninsured by 2028 (Isarra, 2018). See Chapter 6.
Lesser known but equally critical aspects of the ACA include a focus on
health promotion and disease prevention, strengthened requirements for
nonprofit hospitals to demonstrate their community value, and a restructuring
of governmental payment plans to move toward value-based payments.
These aspects are important for C/PHN practice and are not expected to be
impacted dramatically by efforts to repeal or weaken the ACA (Kacic &
Castellucci, 2018).
As part of the ACA efforts to move to a culture of disease prevention, the
ACA mandated formation of a National Prevention Council, composed of
cabinet officials representing the social determinants of health, chaired by the
Surgeon General of the United States. The council developed a National
Prevention Strategy Assocaition of State and Territorial Health Officals
(2011), which addressed core strategic directions and priorities for an
increased focus on public health and wellbeing, including recommendations
for evidence-based interventions in each area (Fig. 13-7).

1116
 FIGURE 13-7 National prevention strategy model. (Reprinted
from National Prevention Strategy. Washington, DC: U.S.
Department of Health and Human Services, Office of the Surgeon
General. Retrieved from
https://www.hhs.gov/sites/default/files/disease-prevention-
wellness-report.pdf)

Subsequent work by the National Prevention Council and the federal

advisory group appointed to advise and guide these efforts included work to
disseminate the interventions and strategies, document successes and lessons
learned, and promote model and exemplary interventions and policies to
promote health and prevent disease across all levels of government (Surgeon
General, n.d.). The federal advisory group, appointed by the president,
included two nurses, who worked to disseminate the NPS to C/PHNs across
the country so that it may be incorporated as part of their practice initiatives
(Surgeon General, n.d.). Successes of the NPS implementation included
efforts in violence prevention in Minnesota; the Healthy Chicago 2.0 health
blueprint adopted by Chicago; and efforts to work with American Indians in
Maine to assess and plan community health improvements (Advisory Group,
2016). Although the NPS is not being actively used in this administration,
much of the strategy has been adopted around the country and appears in
Healthy People 2030.
Additional components of the ACA that have the potential for great
changes in health and health policy at the community level include value-
based purchasing and accountable care organizations (ACOs), along with the

1117
expanded Internal Revenue Service (IRS) requirement for nonprofit hospitals
to conduct regular community health needs assessments and develop
implementation plans based on these data for improving the health of their
communities (Kacic & Castellucci, 2018).

1118
Value-Based Purchasing and Accountable Care
Organizations
The ACA began a movement away from the traditional fee-for-service care
where health providers diagnose and treat individuals and are paid for each
service provided (e.g., office visits, lab fees, prescriptions, follow-up visits)
and that has thought to have led to increasing health care costs (Kacic &
Castellucci, 2018). This style of reimbursement for care has had the problem
of indirectly encouraging additional care, as each service is reimbursed
separately. National health policy has begun to reverse this by mandating no
reimbursement for specific services required because of medical error. See
Chapter 6.

The ACA expands this with a move toward value-based purchasing or

reimbursing a specific amount based on achieving the likely outcome
for clients within specific diagnostic categories.

Instead of fees for office visits, lab fees, and prescriptions, the federal
government is proposing paying for achievable health outcomes in a bundled
manner based on the client's demographics and diagnosis. A diabetic would
not have each service reimbursed, but rather a lump sum reimbursement
would be provided upon the client achieving a level of stability in the disease
(e.g., lab values for hemoglobin A1c within normal limits). This
reimbursement would cover whatever services were required to achieve this
outcome, which might be lab tests and medications, but might also include
C/PHN-provided chronic disease self-management training or clinical
nutrition counseling.

Such a change in reimbursement mechanisms would have a large impact

on health care services, as clinical agencies would need to begin looking
at what services and providers were most effective at achieving the
desired outcomes, with a focus on addressing the social determinants of
health. This would provide an opportunity for C/PHNs to demonstrate
the effectiveness of their practice interventions in improving health
outcomes for individuals and populations (LaPointe, 2019; Swider,
Levin, & Reising, 2017).

When a national sample of C/PHNs was asked about their involvement

with components of the ACA, over 65% responded that they were actively
involved with integration of public and primary health care, and nearly as
many were working in clinical preventive services. Almost 60% noted
activity with patient navigation, care coordination, and establishing
public/private collaborations. Slightly fewer mentioned involvement with

1119
population health strategies and data, along with community health
assessments (Edmonds, Campbell, & Gilder, 2015).

Accountable Care Organizations (ACOs) are another feature of health

care reform that is intended to emphasize quality over quantity.
Physicians and other health care providers are forming groups,
sometimes in conjunction with hospitals, and will be paid based on
patient's treatment outcomes (not the number of visits or tests).
Thus, duplicative tests or procedures should be avoided, as a more
coordinated form of treatment is available.
One goal of ACA is to provide 30% of Medicare services to
alternative payment models, such as ACOs, and away from fee-for-
service models.
In addition to cost savings, quality is also a focus. In 2014,
Medicare ACOs demonstrated $411 million in cost savings, while
27 out of 33 quality measures were improved between 2013 and
2014 (USDHHS, 2016).
Newer types of ACOs not only pay based on quality outcomes but
also penalize for negative outcomes, shifting risk to providers and
away from the government. The number of ACOs is growing, with
923 public and private ACO's identified in 2017 (Muhlstein et al.,
2017). ACO case study examples can be found at the Center for
Medicare and Medicaid Services (CMS) website:
https://innovation.cms.gov/initiatives/ACO/

1120
Policy Competence as an Integral Part of C/PHN
Practice
The US health care system is undergoing significant changes to improve the
health of the public and contain costs. These changes are impacting health
care across the system but are particularly critical for those who work in
communities with the increased emphasis on population health and disease
prevention. The C/PHN can lead the way in addressing the social
determinants of health and focusing efforts on prevention and long-term
health promotion for families and communities. Along with other public
health professionals, C/PHNs need to do this by understanding the policy
process and then determining where their efforts would be most effective in
improving overall population health (Kub, Kulbok, Miner, & Merrill, 2017).
This is a critical time for nursing in general, and C/PHN specifically, as the
health care system focuses attention on what has always been at the core of
C/PHN concern—health where people live, work, play, and pray.

1121
POWER AND EMPOWERMENT
Collaborating with underserved populations to elicit change can be a difficult
task. Citizen participation is never particularly easy in communities that are
excluded from political or economic resources. Sherry Arnstein, in her
classic (1969) treatise A Ladder of Citizen Participation, stated that “citizen
participation is citizen power,” and without access to information about how
the system functions, these populations cannot obtain the resources they need
to make their communities livable and nurturing (p. 217). Arnstein goes on to
point out that those in power often work to prevent those in need from
accessing the process (Fig. 13-8).

FIGURE 13-8 Arnstein's ladder: Eight steps of citizen

participation. (Adapted from Arnstein, S. R. (July 1969). A ladder
of citizen participation. Journal of the American Institute of
Planners, 35(4), 217–224.)

Although Arnstein writes about the anger that disenfranchised

populations feel, she does offer possible solutions that allow each party to
“share power through partnership,” as outlined by engaging in the process
discussed in her treatise (p. 217). See more on this in Chapter 15.

Power can be defined as the ability to act or produce an effect,

possession of control, or authority or influence over others. As public
health professionals, nurses have a commitment to social justice and
working with disadvantaged communities. This means that nurses have
a responsibility to ensure community participation in issues affecting

1122
 them, and they must continually examine the relationship and position
they hold within these communities.
The term community empowerment is defined as the process of
enabling communities to increase control over their lives (WHO, 2019).
Community empowerment, therefore, is more than the
involvement, participation, or engagement of communities. It
implies community ownership and action that explicitly aims at
social and political change. Community empowerment is a process
of renegotiating power in order to gain more control, and power is
a central concept of this process.
Community empowerment necessarily addresses the social,
cultural, political, and economic determinants that underpin health
and seeks to build partnerships with other sectors in finding
solutions (WHO, 2019).

An empowered community is one in which members effectively use

resources (human and fiscal) and collaborate to meet identified needs (Fig.
13-9). Individuals and organizations within empowered communities support
each other, work together for conflict resolution, and increasingly have the
ability to facilitate social change, gaining power over the quality of life in
their community. This demonstrates how empowerment of communities is
linked to empowerment at the individual and organizational level.

FIGURE 13-9 Town hall meetings promote community

participation in public policy. (Photo courtesy of CDC Photo Image
Library.)

How does the C/PHN make sure that preconceived ideas about certain
communities are not forced on the community in order to meet the goals and
objectives of the public health agency? In the past, community health

1123
promotion practice often only met the bottom rung of Arnstein's ladder by
using the rhetoric of community participation, while the professionals
working with the community actually set the agenda. Health promotion may
best be facilitated by the use of empowerment and assisting individuals and
communities in articulating their problems and solutions. This suggests a
change in the relationship between professionals and communities— a
change from the customary hierarchical patient–provider relationship to one
of a partnership. Discovering what is most important to the community and
providing access to that information while supporting leadership from within
the community and encouraging them to overcome bureaucratic hurdles to
action are important parts of community empowerment. Real stories about
clients having problems, such as gaining access to services or resources, not
receiving adequate or timely treatment, or about the need for more school
nurses who are currently spread so thin that they cannot adequately perform
their assigned roles and functions. First-hand knowledge of how our health
care system works (or does not work) can be very persuasive when a nurse
shares personal examples in a way that demonstrates a passion for clients and
communities.
So, how can C/PHNs influence policies that affect the clients and
communities they serve? And, how do we influence policymakers to hear our
concerns and act on them? Using persuasion, through either written or oral
methods, to influence government is known as lobbying. While personal
stories may call attention to your issue, effective lobbying requires more
substance. Seasoned advocates developed ground rules by which to be
effective. Some call them the “ten commandments of lobbying.” However
these steps are named, advocates adhere to the basic ideas inherent in the
following:

Honesty is the best policy. Being known as someone who has integrity
is a lasting virtue. Never mislead a legislator about the importance of an
issue or the position of the opposition as it is difficult to regain
credibility once lost. Do not speak beyond your level of expertise. If you
do not know the answer, say so. If you promise to get the answer, then
do so. Do not promise what you cannot deliver.
Start early. Planning always takes longer than you think it will. Your
interests are not everyone's interests, and convincing others they should
be involved always involves time. If you are planning policy change at
the state or federal level, it is vital to know the legislative process and
the critical time lines.
Know what you want and be prepared. Understand the role politics
plays in getting what you want and how policymakers may respond to
your issue. Targeting your story to the goals, emotions, and interests of
the legislator is important and may result in a positive outcome. It is
crucial to understand the role funding may have on your policy issue.

1124
 KISS (Keep it simple, stupid). Be able to articulate your issues in a
clear and concise manner. Do not confuse possible supporters with
complicated arguments. Key issues should be concise and clear and on
one page, no more than two.
No permanent enemies, no permanent friends. Political affiliation
does not always determine what interests a person has or whether they
are likely to support your issue. It behooves you to speak with everyone.
Respectful disagreement keeps the door open for future agreement and
compromise. Remember, an opponent on one issue may be an ally on
another. Always be polite and professional.
Know your opponents. Understand all sides of the issue prior to
approaching a policymaker. Be prepared to answer questions and
provide data on both sides of the issue.
Make an “ask”: Be clear about what you are asking the legislator for—
to carry legislation or to vote no or yes on specific legislation. Asking
your legislator to vote a certain way is perfectly legitimate, and if you
don't ask, the opposition will. Ask for much more than you think you
can get. When negotiating, this allows you to give up something without
hurting your priorities or your bottom line. In politics, rarely does
anyone get all they want, but priority setting is a key.
There is strength in numbers. The more groups involved, the more
likely you are to be successful. Any opportunity for networking is an
opportunity to enlarge your coalition. Including disparate groups means
you may have accessed conflicting political persuasions. Additionally, it
is useful to have groups who can speak with those who are not viewed
as “friends.” Cross-fertilization of groups is politically expedient but
understands that next time you or they may be in opposition.
Know your legislators and work at the local level. Legislators are
interested in their constituents—these are the people who elected them
to office and who will keep them in office. To be noticed by
policymakers, sharing information with them about their constituents is
the surest way to capture their attention. Information sharing should
occur on issues both in the community where you live and in the one
where you work.
Thank you. Everyone loves to be told, “Job well done.” To maintain
your coalitions, always recognize the work of others. Spreading the
credit is like sowing seeds: the wider the spread, the more bountiful the
crop.

Common methods of making contact with legislators are by e-mail, over

phone, or in person. Often, your first contact will be a staff member. This
person is the gatekeeper and your interaction may determine the level of
communication you have with your legislator. It is important to organize

1125
your thoughts and carefully craft a pitch that ends with an “Ask” or how you
want the legislator to take action (Kostas-Polston et al., 2015, p. 12).

If you plan to make contact in person, prepare a “one-pager,” with your

contact information and credentials listed, along with brief bulleted
points on the subject of interest that includes current statistics and
research (p. 13).
If you meet with a legislator, it is important to remember that they are
not allowed to discuss campaign contributions in their legislative
offices. Finally, it is important for those new to advocacy to understand
that the thing with the most critical influence on policy is money.

Nurses, even with the passage of the recent health care reform
legislation, must become even more actively involved in the process of
influencing policy. How many nurses understand that the nurse practice acts,
or portions thereof, under which they work are developed by legislators or
special interest groups who don't have a background in health care? How
many nurses know who their legislators are at either the state or federal
level? How many nurses have written their legislators about pending health
care legislation or legislation that affects nursing?

1126
Political Action Committees
Financial resources are essential to effective advocacy. One reason why
nurses are less politically active can be tied to a lack of money.
As mentioned earlier, the ANA has a PAC that supports federal
candidates on a nonpartisan basis. Candidates must demonstrate an
interest in and willingness to vote for nursing issues or issues that
nurses support.
To participate in the PAC, you must be a member of the ANA (this
also allows your family to contribute to the PAC). By contributing
to the ANA-PAC, one maximizes his/her contribution by joining
with other nurses. Power in numbers increases our influence with
those candidates we choose to endorse.

During the 2016 election cycle, the ANA-PAC contributed just over
$200,000 to federal candidates who supported nurses and nursing issues.
While this is a large amount of money, it is significantly less than the $1.2
million that the American Medical Association's PAC contributed during the
same time frame (U.S. FEC, n.d.). Because nursing organizations do not
have as much money as other health care groups (e.g., hospitals, physicians,
insurance companies, and health care plans), there is less opportunity to
employ lobbyists and contribute to supportive candidates. This often means
nurses have less influence than other groups.

Another way to influence policy is to make contributions to your

personal legislator. This will keep you on his/her mailing list and may
lead to invitations to local legislative activities. It also lets your
legislator know you are interested in whether he/she remains in office.
Being in regular contact with your legislators provides an avenue for
introducing legislation that impacts nursing or important community
issues, and when you call to ask for a vote “for” or “against” an issue,
the legislator may be more likely to entertain your request.
Lobbyists may work for PACs or independently represent various
special interests or groups. Professional organizations or other special
interest groups (individuals who share a common interest and work
politically to make their goals a reality) may retain paid lobbyists.

Lobbyists are professionals who know the rules governing the state or
federal political process, have or develop relationships with policymakers,
provide guidance for members of the organizations employing them on how
to impact public policy decisions, and work behind the scenes to influence
policy discussions and outcomes. States and the federal government have
laws and regulations that determine the legal actions of lobbyists as well as

1127
the organizations that employ those (Mason et al., 2016; Milstead, 2016).
However, some lobbyists are former legislators or staff members who “take
lucrative jobs representing the very industries” they formerly regulated, and
this “revolving door” lobbying is disconcerting to most citizens as they are
often seen as selling their access to current key legislators (LaPira &
Thomas, 2014, p. 4).

1128
Volunteering
Money is not the only way to build a relationship with your legislator. Being
involved in local and state elections can take many forms. Volunteering your
time can be just as important (Box 13-9). Candidates develop position papers
to tell their constituents where they stand on key campaign concerns. Nurses
have the expertise to assist legislators in developing position papers and
setting policy agendas for health care issues, including the social
determinants of health. Legislators and legislative candidates also need
people to assist in everyday tasks such as phone banking, stuffing mailers,
answering phones, putting up flyers and campaign posters, and walking door
to door to spread support.

BOX 13-9 PERSPECTIVES

A Volunteer's Viewpoint on Campaigning for an

RN
A registered nurse (RN) who had been through what I called the women's
legislative career ladder—School Board, City Council, and the County
Board of Supervisors—was now poised to run for the state legislature.
Because we had had numerous contacts and I believed she would make a
good state legislator and a voice for nursing and health care, I volunteered
to work in her campaign office. I primarily answered the phones on the
evenings I worked, but I met the office staff—many of them were much
younger than me. And, even once, she came in while I was there. I talked
with the staff about some of my experiences as a lobbyist, and they shared
their experiences; many of them were fresh out of college.
She was successful in her run for office, and whenever I needed to meet
with her or her staff, I was shown right in. I was also asked my opinion
about the hiring of certain staff. Her staff knew me by name—many of them
did not work on her campaign, but they were told about me by those
campaign staff who were still around. After 3 years in office, she was
appointed chairperson of a key committee, and I maintained access to her
committee consultants and to her when necessary. We were able to work
together quite successfully, and although we didn't always agree on every

1129
policy issue, I think the weeks I put in volunteering 3 years earlier really
paid off for the clients and the issues I was representing.

Lydia, professional lobbyist

Relationships are critical in policy development and in affecting public

policy. As demonstrated earlier, being a friend can reap huge benefits
when health care policy is on the line. Voting, for instance, is vital—
RNs represent a substantial block of potential voters (Nickitas et al.,
2016).
Joining your local and state professional organizations is imperative to
having the voice of nursing heard at all levels.

You can become more actively involved by writing legislators about the
health care issues that impact the communities, both where you live and
work. It is also vital to understand the importance of critically timing those
communications. Effective communications with legislators should be tied to
times when the issues are being heard in policy committee—thus, you must
know when your issue is scheduled to be discussed in committee. For
example, it is prudent to send letters on your issue—via fax or regular mail—
close to the time of the committee hearing. Holding a press conference or
getting other media coverage when the bill is introduced, or on the day it will
be heard in committee, is quite effective in drawing attention to your issue.
Writing letters to the editor of your local newspaper on health issues and
writing articles for various publications are also effective methods of
persuading others to back your issue.

Other methods for influencing health policy or nursing issues include

applying for positions on boards and commissions; each local area has
advisory committees for their locally elected officials at the city and
county level.
The state board of RNs needs nurses willing to sit on their board or
to serve on various advisory committees and task forces.
At your state capitols, there are usually vacancies on policy
committees, or legislators may be looking for new staff. And, who
better to serve in this capacity than a nurse! Serve your patients and
communities by running for office!

1130
SUMMARY
This chapter briefly reviewed health outcomes in the United States.

Health outcomes for Americans do not compare well with peer

countries, particularly considering the high cost of the US health care
system; this is largely due to system issues and not addressing the
SDOH.
Health policy guides health care and governmental actions related to the
SDOH; C/PHNs can use policy in their practice to improve the health of
the communities with which they work.
Policy competence as it relates to local, state, and federal health policy
—and how nurses are impacted by these policies—is an essential skill
for C/PHNs.
An understanding of how a bill becomes a law helps inform policy
process, implementation, and evaluation.
Frameworks such as the rational and Kingdon provide guidance in
health policy analysis.
Policy analysis as a call for activism can be used to support social
justice in public health, professional advocacy, and the C/PHN's role in
health care reform, PACs, and volunteerism.
Current US health policy includes the ACA within community and
public health practice, value-based purchasing, and accountable care
organizations.

1131
ACTIVE LEARNING EXERCISES
1. Using “Utilize Legal and Regulatory Actions” (1 of the 10 essential
public health services; see Box 2-2 ), describe a legislative bill related
to health at either your state or the federal level and where the bill is
in the legislative process. Identify who is sponsoring the bill, who is
opposing it, and why. Determine the population that will be affected
most by the bill if it passes and in what ways they will be affected.
Discuss what you, as a C/PHN, could do to be involved in this bill
and then develop a political action plan to support or oppose the bill.
E-mail your legislator regarding your position.
2. Who are your state legislators? What are the critical health issues in
your state, and how have your legislators responded to the issues?
How have your state legislators voted on policies to advance the
nursing profession?
3. Attend a meeting of a professional organization, board of directors,
government agency, or council when a health policy or health care
issue is on the agenda. Analyze the positions of the major interest
groups involved and describe to what extent economics comes into
the discussion. Describe who controls the discussion and why.
Compare your findings with classmates.
4. Are nurses the most qualified group to articulate national health care
issues? If so, why? If not, why not?
5. Pick a policy issue and take a position related to political action and
advocacy. What stance does your nursing professional organization
have on this issue?

thePoint: Everything You Need to Make the

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review questions, journal articles, supplemental materials, study aids for
all learning styles, and more!

1132
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practice for nurse practitioners in primary care: A proposed conceptual
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Review. Retrieved from https://www.publichealthlawcenter.org/resources/us-
e-cigarette-regulations-50-state-review
Rapaport, L. (March 13, 2018). U.S. Health spending twice other countries
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spending/u-s-health-spending-twice-other-countries-with-worse-results-
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Rhodes, D. (January 17, 2016). Raising cigarette-buying age to 21 a new
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met-20160117-story.html
Robert Wood Johnson Foundation. (November 30, 2010). Robert Wood
Johnson Foundation launches national campaign to advance health through
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1141
 UNIT 4
The Health of Our Population

1142
1143
CHAPTER 14
Family as Client
"I yearn to enter the 'Promised Land'—a land of ideal health care where family nursing is 'usual
care,' where families are included and welcomed, where family preferences are invited, and where
family illness suffering is softened."

—Janice Bell (2014, p. 8), Family Nurse Theorist

KEY TERMS
Asset-based approach Conceptual framework Developmental framework
Eco-map
Family
Family health Family health nursing Family life cycle Genogram Home
Interactional framework Outcome evaluation Population Referral Resource
directory Roles
Strengthening Structural–functional framework

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Discuss characteristics all families have in common.
2. Identify the stages of the family life cycle and the developmental tasks
of a family.
3. Discuss how a family's culture influences its values, behaviors, and
roles.
4. Describe the functions of a family.
5. Analyze the role of the community health nurse in promoting the health
of the family.
6. Describe the components of the nursing process as they apply to
enhancing family health.
7. Identify the steps in a successful family health intervention.
8. Describe useful activities and actions when intervening on family health
visits.
9. List at least six specific safety measures the community/public health
nurse should take when traveling to a home or making a home visit.
10. Describe the effect of family health on individual health.
11. Describe individual and group characteristics of a healthy family.
12. List the five basic principles the public health nurse should follow when
assessing family health.

1144
13. Discuss the two foci of family health visits: education and health
promotion.
14. Describe the three types of evaluations that are necessary after family
health interventions.

1145
INTRODUCTION
Community health nurses are intimately involved with families. The family
plays a critical role in the health of its members. Health habits such as
preventative care, diet, exercise, and physical activity are developed through
your experiences in a family. Health beliefs, genetic influences, and care of
the ill family member all take place within the family environment. The
community/public health nurse (C/PHN) is in a unique position to influence
and promote family health. Families should be considered at every point of
nursing care.
The definition of family varies by organization, discipline, and
individual. Family theorists suggest that a family consists of two or more
individuals who share a residence or live near one another; possess some
common emotional bond; engage in interrelated social positions, roles, and
tasks; and share cultural ties and a sense of affection and belonging
(Kaakinen, Coehlo, Steele, Tabacco, & Robinson, 2018).
Today's C/PHN needs to understand and work with many types of
families, each of which has unique health needs. For example, a young,
single mother seeks help in caring for her infant. A 67-year-old provides care
for his mother, who was recently discharged from the hospital after a stroke.
A family from Haiti needs instruction on the purchase and preparation of
food for the kidney dialysis diet their father has been given. The
effectiveness of C/PHN depends on knowing how to work with all kinds of
families.
This chapter draws from various theories to strengthen the student's
understanding and appreciation of families as clients. This information will
promote the effectiveness of interventions with families at the primary,
secondary, and tertiary levels of prevention (Box 14-1).

BOX 14-1 Levels of Prevention Pyramid

A Home Visit to an Infant With
Gastroesophageal Reflux SITUATION: A young
single mother with a new infant (Patrick) asks for
help with her baby at a well-baby visit as the
baby is spitting up after feeding. The baby is

1146
 diagnosed with gastroesophageal reflux. The
mother was referred to a PHN for a home visit.
GOAL: Using the three levels of prevention, avoid negative health
conditions, and promptly diagnose, treat, and/or restore the fullest possible
potential.

The family is the basic element of a community and a population. A

family refers to a group of individuals whose behaviors, actions, health
conditions, and interrelationships impact the health of the group and the
individuals (Kaakinen et al., 2018). As discussed in Chapter 1, a community
is a set of people in families that share a common purpose with a sense of
belonging and place (Kaakinen et al., 2018). A population encompasses the
total number of persons in families within communities at a specific
geographic location (Kaakinen et al., 2018). Based on the above definitions,
the family's positive experience when accessing health services improves the
health for the community that leads to a healthier population.
Families need to have equal access to optimal health care, social
services, and community resources in a supportive and healthy environment.
For example, immunization programs exist for infants and children. Pregnant
women can attend childbirth education classes and receive medical care
throughout the entire pregnancy from their health care providers (Mutch,
2016). Growing families can access parenting classes and support groups for

1147
help with developmental crises and in the management of chronic illness
(Lee et al., 2017). Older adults have senior centers for a myriad of social and
recreational activities as well as numerous services and activities offered at
senior discounts (Frost, Beattie, Bhanu, Walters, & Ben-Shlomo, 2019). All
these clients have one point in common—they are members of families.
Clearly, the health of the family influences the health and wellness of the
population.
Within the family, the interactions are unique because a family member
can knowingly or unknowingly influence another. The health of one family
member can influence other members' perspective(s) about health or their
social value system. The emotional state of a family member can be the
deciding factor in another family member's choice for a career or the schools
you attended. The impact can be as mundane as the type of meals eaten. Will
the meal include chicken if the dinner guests include vegetarian parents?
Family members clearly influence each other and the entire family. This
makes for a unique unit of service.
Just as each family is unique, so too are their homes. A public health
nurse may feel comfort in some families' homes and not in others. A home is
a structure or building where families live (e.g., mobile homes, high-rise
inner-city apartments, rural cabins, cardboard boxes, farm labor camps). It
can be daunting for students to enter a home that is a small and cluttered
apartment, a sparsely furnished single room, or a makeshift structure in
disrepair. Each home brings its own set of unique challenges and strengths
that can influence the way the public health nurse perceives and interacts
with the community to promote health, prevent illnesses, and reduce risk.
Public health nurses rely on the nursing process when working with
families, the “core unit of service,” to promote health and wellness, prevent
illness, and improve the overall health of the population. The delivery of care
occurs in various community settings (i.e., homes, work settings, classrooms,
clinics and outpatient departments, neighborhood centers, and homeless
shelters). Although caring for the family, as a unit of service, is an effective
way to treat the population in the communities, practice does not always
match a family nursing theory. The problem, in part, is that health care
services are often tailored to an individual and not a family and/or a
community. Third-party payer and reimbursement policies impose limits to
the kinds of services funded. Public health agencies often organize services
around individuals. The government requires that public health agencies
structure disease statistics or service categories on an individual instead of
aggregated data on a family.
Family-level problem-solving techniques are used to deal with health
issues including health promotion, pregnancy and childbirth, acute life-
threatening illness, chronic illness, substance abuse, domestic violence, and
terminal illness (Beck, Le, Henry-Okafor, & Shah, 2017; Coker, Martin,

1148
Simpson, & Lafortune, 2019; De Grubb, Levine, & Zoorob, 2017; Dyess-
Nugent, 2018). The first step is a detailed family assessment that emphasizes
internal and external influences (Salmond & Echevarria, 2017; Shajani &
Snell, 2019). This creates a database from which a family diagnosis is
generated, an essential step before planning, implementation, and evaluation
of services.
The novice public health nurse must be able to practice within the
nursing process. Moreover, when public health nurses address the health
needs of the core unit of service, the family, the nurses are treating the health
needs of the communities and the population (Association of Public Health
Nurses [APHN], 2016a, 2016b). Public health nurses are legally the leaders
in using the accessible health care services to prevent illnesses and promote
health in families (APHN, 2016a, 2016b; Salmond & Echevarria, 2017).
Family health is the cornerstone for community and population health,
making the family the focus of health care and related services. Therefore,
the health of the family is addressed through the nursing process that involves
assessing, diagnosing, planning, implementing, and evaluating the family.

1149
FAMILY HEALTH AND FAMILY
HEALTH NURSING
Throughout history, the family has been the most basic unit. One of the first
steps for nurses is to explore how a family influences the care that they
provide and how they interact with the family. Most of us were raised in
families and spent a good portion of our lives within families. Our first
experiences with others are influenced by our families of origin. Feetham
(2018) asserts that the way we interact with families actually comes from
how we define family. So we come to our nursing practice with ideas about
families based on our own experiences.

The United States Census Bureau (Pemberton, 2015) views family as

people living together and related by birth, adoption, or marriage.
Kaakinen et al. (2018, p. 5) define family as “two or more individuals
who depend on one another for emotional, physical, and economical
support.”
Kaakinen et al. (2018, p. 5) define family health as a “dynamic
changing state of wellbeing, which includes the biological,
psychological, spiritual, sociological, and culture factors of individual
members and the whole family system.”

Family health is concerned with how well the family functions together
as a unit. It involves not only the health of the members and how they relate
to other members but also how well they relate to and cope with the
community, outside the family. In fact, family health, like individual health,
ranges along a continuum from wellness to illness. A family may be at one
point on that continuum now and at a much different point 6 months from
now. Family health refers to the health status of a given family at a given
point in time (Kaakinen et al., 2018).
Family health nursing is how public health nurses care for individuals
within the family or for the family as the client (family as context) or for the
family as a system (Fig. 14-1). There are multiple ways that community
health nurses can approach families. Some nurses view family nursing as part
of other specialties such as public health nursing, maternal child nursing, or
behavioral health nursing. However, some nurses view family nursing as its
own distinct specialty, rich with its own body of literature and research. Each
of these approaches with families has its own distinct set of beliefs.

1150
 FIGURE 14-1 Community/public health nurses work with
families and individual family members.

Nurses work with individuals within families every day. Most often, the
individual is the recipient of care. While assessing the needs of the
individual, the nurse needs to include the family in the assessment, as the
family is the pivotal provider of care. How does the family assist the
individual family member or hinder his or her progress? What are their
available resources (physically, emotionally, and spiritually)?
Nurses working with families as a system view the family as part of a
larger suprasystem that includes many subsystems. The family becomes
greater than the sum of all of its parts. Any change within the family system
affects all of the family members (Shajani & Snell, 2019).
When visualizing a family as a system, it may help to compare it to a
mobile. Think of all the pieces suspended freely by a string. If you pull
lightly on one piece, all the pieces move, just as a change in one member's
health affects the entire family. Can you think of some examples of this in
your own family?

1151
FAMILY CHARACTERISTICS AND
DYNAMICS
Several observations can be made about families. First, each family is
unique, with its own distinct set of strengths. As a nurse you want to look
first at the family's strengths. When you approach the door of a house to
begin your visit with a family, you cannot be sure of what they will be like.
You will have to gather information about the family in order to provide the
best nursing care possible. Starting with their strengths will assure your
success.
Families share universal characteristics with every other family (Box 14-
2). For instance, families in every culture throughout history have engaged in
similar functions: families have produced children, physically cared for their
members, protected their health, encouraged their education or training,
given emotional support and acceptance, and provided supportive and
nurturing care during illness. These characteristics provide an important key
to understanding each family's uniqueness. No matter how many families a
nurse may visit over the course of a year, each one will have universal
features; it is important for PHNs to know each family's unique set of
characteristics and their effects on family health.

Box 14-2Universal Characteristics of

Family Life
Every family is a small social system.
Families are interdependent.
Families maintain boundaries.
Families exchange energy with their environments.
Families adapt.
Families are goal oriented (providing love, security, and a
sense of belonging).
Every family moves through stages in its life cycle.
Every family has its own cultural values and rules.
Family members share certain values that affect their behavior.
Certain roles are defined for family members.
A family's culture influences its distribution and use of power.
Every family has certain basic functions:
Providing affection

1152
 Providing security
Instilling identity
Promoting affiliation
Providing socialization
Establishing controls
Every family has structure.
Source: Duvall and Miller (1985).

1153
Family Stage of Development
Many of the characteristics and defined developmental stages of individual
growth also apply to families. For example, families change continuously.
Families grow and develop as the individuals within them mature and adapt
to changes. A family's composition, set of roles, and interpersonal
relationships change with time. Families vary with each stage of the family
life cycle. See Box 14-3 for some questions to ask yourself about your own
family.

BOX 14-3 What Do You Think?

Questions for Self-Evaluation
1. What are your first memories of family?
2. What is your definition of family?
3. How would you describe your own family?
4. Who do you now include as family members?

As Duvall and Miller (1985) first pointed out, no two children come to
precisely the same family. Consider the following example of how families
change over time. The Garcia family, a young married couple, begins their
family by getting to know each other, learning more about their new roles,
and developing a satisfying marriage. They have difficulty getting pregnant,
so they decide to adopt a baby. Their baby, Rosa, changes the family and
their roles as parents. Thus new roles are added (father, mother, and
daughter). Within 2 years they become pregnant and Luis is born. This once
again changes the family. Both family size and a reorganization of family
occurred. The children entered school; Mrs. Garcia went back to work, and
soon, Rosa was leaving for college. The Garcia family, like every family, is
moving through a predictable and sequential pattern of stages known as the
family life cycle.
PHNs who are knowledgeable about this cycle can provide anticipatory
guidance to families. For instance, nurses can help prepare the family for
having children. The nurse can help the soon-to-be parents to anticipate the
responsibility and costs of raising her child by helping them calculate child
care needs. The nurse can assist the family in figuring out the monthly costs
of breast-feeding versus buying formula, disposable versus cloth diapers, and
the clothing, equipment, and medical costs of infant care.
To progress through the stages of the life cycle, a family must carry out
its basic functions and the developmental tasks associated with those

1154
functions. Often, how we define family will determine how the family
functions are filled. Unlike developmental tasks, which are specific to each
age level, family developmental tasks are ongoing throughout the life cycle.
The manner and degree to which each function is carried out varies
depending on how well members accomplish individual developmental tasks
and meet the demand of a particular stage (Kaakinen et al., 2018).
Some functions require greater emphasis at certain stages. Socialization,
for example, consumes much of a family's time during the early years of
child development. Duvall and Miller (1985) described these activities as
“stage critical” family developmental tasks that must be completed before
moving onto the next stage. Sample community health nursing actions with
the family at different stages are presented in Table 14-1.

TABLE 14-1 Critical Family Developmental Tasks

Source: Duvall and Miller (1985).

1155
Family Values and Their Effect on Behavior
Every family has its own set of values and rules for operation (McGoldrick,
Garcia-Preto, & Carter, 2016). Like all cultural values, many family values
remain outside the conscious awareness of family members. These values,
often not verbalized, become powerful determinants of what the family
believes, feels, thinks, and does. Family values include those beliefs
transmitted by previous generations, religious influences, immediate social
pressures, and the larger society. Values become an integral part of a family's
life and are difficult to change (Box 14-4).

BOX 14-4 Cultural Values Cultural

values such as the following shape most
decisions and choices in our lives:
Education
Sex roles
Health care
Courtship/marriage
Lifestyle
Childrearing

1156
Family Roles
Roles, the assigned or assumed parts that members play during day-to-day
family living, are bestowed and defined by the family (Kaakinen et al.,
2018). Families distribute among their members all the responsibilities and
tasks necessary to conduct family living.
Family members may play several roles at the same time. This can be
taxing. A single parent often takes on the role of both father and mother but
may distribute responsibilities and tasks more widely. A grandmother or a
child may assume responsibility for some chores and thereby relieve some of
the demands on the single parent. Among families, there is great variation in
expectations for each role and in the degree of flexibility in divisions of
roles. An example may be specific tasks given to girls versus boys within the
family. Girls may be given child care or kitchen responsibilities and boys
given yard tasks.
Many families enjoy the fellowship of organized religious or cultural
groups. This fellowship can be a source of support or comfort, as well as an
additional role function for the family members. Family members can also
participate in roles outside the family. These may involve local or regional
politics, community improvement, volunteerism for nonprofit groups, or
other groups outside the home that the community may offer. These diverse
role relationships should enrich and energize the participants. The
community health nurse may work with families to help them achieve a
balance of activities that promote family health.
Power is the possession of control, authority, or influence over others—
assuming patterns in each family. In some families, power is concentrated
primarily in one member; in other families, it is distributed on a more
egalitarian basis (McGoldrick et al., 2016).
The traditional patriarchal family, in which the father holds absolute
authority over the other members, is rare in American society. However, the
pattern of husband as head of the household and dominant member of the
family is still frequently seen. The dominant power, whether male or female,
holds the majority of the decision-making power, particularly over more
important family matters such as employment, finances, and health care.
With changing societal influences, however, the present trend among
American families is toward egalitarian power distribution.

1157
Family Social Class and Economic Status
As a community health nurse, it is important for your assessment to include
social class of families you are visiting. Social class often shapes a family's
access and choices to work, educational, and health care opportunities
(McGoldrick et al., 2016). Their overall health is often determined by their
class position. The biggest predictor of health is your level of wealth
(Penman-Aguilar et al., 2016). How healthy we are and how long we live are
often related to our social standing. The neighborhoods families choose to
live in, and the schools their children attend, are often determined by social
class. These decisions/choices have lifelong implications and shape the
history of families. See Chapter 23 for more on social determinants of health
and the socioeconomic gradient.
Most people who experience homelessness are single adults. In 2017:

184,661 people in families were homeless.

57,971 families with children were homeless.
This represents one third (33%) of the total homeless population.
16,938 people in families with children who were counted in
unsheltered locations (living on the streets, in cars, or in another place
not meant for human habitation) (National Alliance to End
Homelessness, 2018).

Families who are homeless are not necessarily incomeless. They may
include working parents who just are not making enough money to pay for
housing. On average, a homeless family household consisted of three people.
Homeless families present the C/PHN with unique challenges. Primarily, the
family is in crisis and often not able to provide for their most basic needs.
When families are unable to meet these needs, they are unable to address
other concerns such as medical appointments, healthy eating and exercise,
and other preventative actions that nurses typically recommend.
Children who experience homelessness have higher risks of emotional
and behavioral problems, serious health problems, school mobility, repeating
a grade, and being expelled or dropping out of school and have lower
academic performance (National Alliance to End Homelessness, 2018).
Community health nurses should be aware of this and focus on first
assisting the family in getting their essential needs met. They should also
acknowledge that the behaviors seen in children may be the direct result of
the situation that the family finds itself in. A C/PHN's knowledge of the
resources available in the community is an important first step in providing
the family with the help to deal with the crisis and assisting in the provision
of ongoing shelter, food, health, employment, and schooling needs. See

1158
Chapter 26 for more on homeless populations. You can check your state rates
at https://endhomelessness.org/homelessness-in-america/homelessness-
statistics/state-of-homelessness-2020/

1159
Family Composition
Globally, families—in all varied forms—are the basic social unit (Shajani &
Snell, 2019). The meaning of family among the Hmong of northern Laos
may include hundreds of people who make up a clan. In Mexico, families
remain close, are large, and extend into multiple generations. In Germany
and Japan, families are small and tend to the needs of their elders at home.
In the United States, where families come from many cultural groups,
many variations coexist within communities. Families come in many shapes
and sizes (Fig. 14-2).

FIGURE 14-2 Families exist in many forms.

It is a privilege to gain entry into a family's home. This is a uniquely

private space belonging to the family. The people who are members of this
household interact, care for one another, and bond in ways that may never be
fully understood by anyone outside the family. Therefore, being granted
entrance into this system gives the community health nurse an opportunity to
work with the family that few other professionals experience. Each type of
household requires recognition and acceptance by community health nurses,
who must help families achieve optimal health.

Traditional Versus Contemporary Families

Traditional families are those that are likely most familiar to us:

The nuclear family—husband, wife, and children living together in the

same household. In nuclear families, the workload distribution between
the two adults can vary. Both adults may work outside the home; one

1160
 adult may work outside the home, whereas the other stays at home and
assumes primary responsibilities for the household; or partners may
alternate, constantly renegotiating work and domestic responsibilities.
A nuclear dyad family consists of two adults living together who have
no children or who have grown children living outside the home.
A single adult family is one in which one adult is living alone by choice
or because of separation from a spouse or children or both. Separation
may be the result of divorce, death, or distance from children.

Half of American adults are married today, which is drastically different

than 72% in 1960 (Pew Research Center, 2017). Couples are putting off
marriage as they get their careers started and begin working on their futures.
In 2016, the median age for marriage among men was 29.5 and for women
27.4, which is roughly 7 years more than in 1960 (Pew Research Center,
2017). In 2017, 65% of children under the age of 17 years old lived with
two-parent families which is up slightly from 64% in 2014 (ChildStats.gov,
2019).
Sometimes, in close-knit ethnic communities, families form a kin
network, in which several nuclear families live in the same household or near
one another and share goods and services. They may own and operate a
family business, sharing work and child care responsibilities, income and
expenses, and even meals. Variations of this trend are increasing among all
groups as children postpone leaving home because of economic conditions,
educational plans, or student loans. This is the most popular living
arrangement for young adults today (Vespa, 2017).
The number of young adults who continue to live with their parents is on
the rise. A third of young adults aged 18 to 34 lived with their parents, and
more young adults lived in their parents' home than with a spouse in 2016
(Vespa, 2017).
Families in America today do not look the way they did several years
ago.

The traditional nuclear family has been a fundamental part of our

cultural heritage shared by many Americans and reinforced by religion,
education, and other influential social institutions. The “ideal” family
was historically considered a nuclear family including a mom, dad, and
children. By thinking of this as the ideal family, any variation was often
treated as deviant and abnormal. This view can leave families and
family members, who do not fit this description, feeling isolated and
alone.
Families are changing for a variety of reasons; Americans are putting
off previously expected milestones, families are getting smaller, and life
expectancy is getting longer. There is an increase in single-parent

1161
 adoptions; an increase in lesbian, gay, bisexual, transgender, or queer
(LGBTQ) couples and families; and high divorce and remarriage rates.
The role of women in the family is changing, they are marrying at older
ages, and children are being born outside of marriage. Families should
no longer be defined as “what” they are but rather “who” they are
(Feetham, 2018).
McGoldrick et al. (2016) fosters the importance of putting a positive
spin on the families that make up our world. The nurse is in a unique
position to assess families in a strength-based model rather than viewing
certain families as deviant.

As society struggles with what they consider to be the ideal family, the
media portrays them in various forms, showing that society is beginning to
accept more contemporary definitions of family.

Television shows such as Gilmore Girls, Blackish, Modern Family, and

The Fosters are all examples of the ways that television is changing
along with family structures. The days of Leave it to Beaver type shows
are becoming less common. People want to see characters like
themselves, going through similar experiences, on the shows that they
watch.
Another way that families are impacted by media is through social
media. It can be a positive or negative influence on the family and its
members. In a study done by Valdermorose-San-Emeterio, Sanz-Arazu,
& Ponce-de-Leon-Elizondo (2017), it was discovered that children who
report more digital leisure time as one of their favorite leisurely
practices had less family cohesion. Digital leisure time can be
considered playing video games, social networking, and scanning the
Internet. Since these activities are becoming more commonplace, the
public health nurse should consider these factors when working with
families. See Chapter 10.
One of the positive aspects of social media is its use in promoting health
care resources to families. Nurses can use messaging and other
platforms to reach patients who otherwise may be limited by distance or
transportation issues. Families turn to online resources for many reasons
and health care questions are no exception. With the high usage of
social media, families and its members are likely to use it for health
access and information (Schroeder, 2017). Nurses can play a role in
using them to communicate and teach families with current and
evidence-based information.

Families Experiencing Divorce, Remarriage, and

Blending

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Divorce, remarriage, and blending of families can result in distinct emotional
responses and developmental issues among family members, as shown in
Table 14-2.

TABLE 14-2 Phases of the Divorce–Remarriage–Blending

Cycle and Expected Family Member Responses

Source: McGoldrick et al. (2016).

Divorce
Divorce does not just affect the involved couple; it changes the entire family
structure and each family member's life course. Demographics play a role in
divorce with those who are less educated and earning a lower income.
Approximately 850,000 marriages in the United States end in divorce and
even more parents who are never married break up, which also greatly
impacts the family (Dissing, Dich, Nybo-Andersen, Lund, & Rod, 2017). As
divorce becomes more acceptable, couples are making this choice for a
variety of reasons. These can vary from marital dissatisfaction, infidelity,
finances, and many other factors. Something new to consider in this day and
age is the effect of social media on couples. It is now easier than ever to form
emotional relationships online. Through various online platforms, couples

1163
are able to reconnect with old friends and even make new ones. Social media
boundaries are important for couples to discuss and agree on. These virtual
relationships can become part of a family's daily lives and can lead to
infidelity and even divorce (Abassi & Alghamdi, 2017).
Divorce affects all members of the family in a different way, since each
is at a different stage in life. Each member is going through unique
adjustments and transitions as they cope with their new normal.

For children, it may require coping with a new geographic location and
a new school, as well as adjusting to changes in the mental and physical
health of family members.
In addition to the normal growth and developmental changes, children
from divorced families may face an absent father or mother,
interparental conflict, economic distress, parental adjustment, multiple
life stressors, and short-term crises.
New schools mean that children must find new friends and social
groups, proving themselves once again and trying to gain acceptance in
a completely new social setting. Their previous sense of security and
comfort at home is forever changed. These adjustments take time and
C/PHN can provide support for the children involved (Table 14-2).
The frequency of divorce does appear to be stabilizing in America
today; the number of children living with unmarried parents has
remained unchanged in the 21st century (Kaakinen et al., 2018).

Remarriage and Blending

The United States Census Bureau uses the term “blended families” to
describe families who bring nonbiological children into a new marriage. In
this structure, single parents marry and raise the children from each of the
previous relationships together. If this is the result of divorce or death, this
can be an especially painful transition (Table 14-2).

They may be custodial parents who have the children except during
planned visits with the noncustodial parent, or they may share custody,
so that the children live in the blended arrangement only part time or
possibly live in two separate blended homes.
The family may include children from the couple, in addition to the
children brought into the relationship. Not all divorced adults stay
single; most remarry or cohabitate with another adult, who may or may
not have children. This new couple may have children from their union,
or adopt, creating an even more complex family.
Merged or blended families require considerable adjustment and
relearning of roles, tasks, communication patterns, and relationships.

1164
 Traditional nuclear families have well-established roles and stages that
members go through, but this is not true for blended families, which
leads to the complexity of the family dynamics and structure (Kaakinen
et al., 2018).
We all come to new relationships with our own history from the past.

Since this emerging family pattern is becoming more prominent, it is

very possible that the C/PHN is familiar with this pattern or lives in such a
family. In the blended family, there isn't a definitive and common definition
of who makes up the family among its members (Kaakinen et al., 2018). This
is something for the nurse to keep in mind as the family is assessed. The data
on blended families can be challenging to track since the United States
Census information is done only every 10 years. The American Community
Survey done in 2017 found that 3,927,266 households included stepchildren
(U.S. Census, 2017). Some of the challenges that blended families face are
merging traditions, adjustment to change, sibling rivalry, change in discipline
styles, and managing age differences (Guzzo, Hemez, Anderson, Manning, &
Brown, 2019). This adds to the complexity of the dynamics and health of
families.
Nursing skills that are needed when working with divorced or blended
families include the ability to listen and be empathetic, as well as a
nonjudgmental attitude. The nurse should meet the family where they are at
and provide resources that the family may need. Resources may include
support groups, reading materials, or interventions available in the
community. Communication among all parents and family members should
be encouraged. Peer support groups for children and adolescents and support
from within the schools should be used, if available, or started if they do not
exist. The school nurse could be a rich resource for families also. The
community health nurse can have a significant role in community-wide
planning if services are needed but unavailable.

Single-Parent Families
One of the most common contemporary family structures is the single-parent
family, mostly headed by women. These families are created in several ways.
Sometimes single women choose to adopt or have children without being
married, and some become single parents through divorce. Depending on
how single-parent families come about, there can be loss and grief to deal
with. Family strength and security is important for the family members
regardless of the situation.

In 2016, the birth rate for unmarried women was 42.4 births per 1,000
aged 15 to 44, which is down 2% from 2015 (Martin, Hamilton,
Osterman, Driscoll, & Drake, 2018).

1165
 The percentage of all births to unmarried women was 39.8% in 2016, a
1% decline from 2015 and the lowest level since 2007 (Martin et al.,
2018).

Nonmarital birth rates declined from 2015 to 2016 for women in age
groups under 35, with the rate for teenagers ages 15 to 19 dropping 8% (to
18.5 per 1,000 in 2016).

The rate for females aged 15 to 17 was at an all-time low (8.6).

Conversely, rates rose for all age groups aged 35 and over, reaching
historic peaks for women aged 35 to 39 (35.6) and 40 to 44 (10.0)
(Martin, Hailton, Osterman, & Driscoll, 2019).

This is thought to be the result of two trends; the increased financial

independence of women and the tightening of the job market for men.
Although Kaakinen et al. (2018) mentions that the wage gap between men
and women still exists, women are better able to support themselves than in
the past.
Over time, this form of family has become more accepted by society. It is
important for C/PHNs to view the strengths of single-parent families.
Building on their current strengths can be most helpful in terms of meeting
the challenges that they may face. These challenges will typically result from
one parent being solely responsible for the financial income, caregiving, and
support for the family. The needs of the family will depend on their stage in
the family cycle and experiences that brought them into the single-parent
family. Nurses with their connections in the community can assist these
families through advocacy and collaboration.

Families Headed by an Adolescent Parent or Parents

Statistics indicate that teenagers are increasingly the heads of single-parent
families; some of these teen heads of households become pregnant in junior
high or high school. The birth rate among teens 15 to 19 years old has
continued a steady decline, but teen birth rates in the United States remain
the highest among those in developed countries (Guttmacher Institute, 2015).

The birth rate for women aged 15 to 19 in the United States in 2016 was
20.3 births per 1,000 women, down 9% from 2015 (22.3) and another
record low.
The number of births to teenagers aged 15 to 19 was 209,809 in 2016,
also down 9% from 229,715 in 2015.
The 2016 birth rates for teenagers aged 15 to 17 and 18 to 19 were 8.8
and 37.5 births per 1,000 women, respectively, down 11% and 8% from
2015 to record lows for both groups (Martin et al., 2018).

1166
 Teenagers are still developing physically, mentally, and emotionally and
are not prepared to take on parenthood without help. Consideration should be
given to helping the mother on her life course as well as the baby. The
mother needs support and structure so that she may support her child. Home
visitation programs such as the Nurse Family Partnership are able to provide
this stability for both mom and baby if available in the community.
Specific factors related to teen birth rates are low education and low-
income levels of a teen's family, few opportunities in a teen's community for
positive youth involvement, neighborhood racial segregation, neighborhood
physical disorder (e.g., graffiti, abandoned vehicles, litter, alcohol containers,
cigarette butts, glass on the ground), and neighborhood-level income
inequality, and teens in child welfare systems are at increased risk of teen
pregnancy and birth than other groups. For example, young women living in
foster care are more than twice as likely to become pregnant than those not in
foster care (CDC, 2019). Teenagers also lack availability to contraceptives
and the education to use them properly. They may be afraid to ask for
resources and fear judgment which adds to risk of pregnancy and unsafe sex
practices.
Housing is another significant issue that affects teen mothers. A study
conducted by SmithBattle (2018a), which started in 1988 and continues
today, found that housing is a concern that needs to be addressed when
assessing teen moms. Housing was especially a concern for black moms who
grew up in poverty. Compared to their white counterparts, they lived in
various situations that increased toxic stress associated with discriminatory
housing policies (SmithBattle, 2018a). Children raised without safe and
secure housing struggle in other aspects of their lives. It is also difficult for
teen moms to become productive members of society if they do not have a
home to call their own.
Teen fathers are often left out of the loop for services that communities
provide for the teen mother and infants, and there is a lack of research in the
literature on the experiences and roles of teen fathers (Ngweso, Peterson, &
Quenlivan, 2017). However, it has been established that partner involvement
contributes positively to the outcomes in pregnancy (SmithBattle, Phengnum,
Shagavah, & Okawa, 2019).

A father who is emotionally supportive of the mother and provides child

care and financial support directly and indirectly affects the wellbeing
of his child.
Children with absent fathers are at increased risk for behavioral
difficulties and poor academic performance. Longitudinal research
found lower birth weights and lower cognitive and behavioral scores at
age 2 and poorer health for children of adolescent fathers when
compared with those of adult fathers.

1167
 Ngweso et al. (2017) found that teen fathers feel unprepared and
unincluded in the birth and decision-making process. It would benefit
teen moms, babies, fathers, and the community if we were to involve
teen fathers in the preparation and education of birth and early
parenting.
There are home visiting programs that include the father in the visits
and activities (Nurse Family Partnership, 2019). This encourages a
sense of inclusion and promotes healthy family relationships. Teens
often feel misunderstood; and this is even more true in the case of teen
pregnancy. See Chapter 4 for research demonstrating the effectiveness
of NFP.

The implications for the role of the C/PHN are greatest with the
adolescent parent population. For example, nurses work with young teens
through schools, clinics, or home visiting programs to ensure healthy
pregnancies and teach parenting skills to the parents and grandparents.

Nurses can also ensure that the infant receives immunizations and
primary care health services, reaches age-appropriate milestones, and
can provide family planning information to the new parents.
Teen mothers experience high levels of psychological distress, and one
of the recommendations given by SmithBattle and Freed (2016) is to be
proactive and screen for distress in pregnant and parenting teens.
Teens may have trauma in their backgrounds that may not have been
addressed. They may feel stigmatized and this can prevent them from
reaching out for help. If C/PHNs focus on the teen mothers' strengths
and aspirations to prevent childhood trauma, which they themselves
may have experienced, they will be in a unique position to help these
families (SmithBattle, 2018b).
On a broader scale, C/PHNs should collaborate with other professionals
to make sure that the community has resources for all levels of
prevention, with a focus on primary prevention.

Families Headed by a Cohabitating Couple

Cohabitating couples' ages can range from young adults to elderly couples.
The couples may be heterosexual or LGBTQ; they may or may not share a
sexual relationship. In some instances, these couples have their own biologic
or adopted children. Cohabitation has increased for all race groups of
unmarried mothers in America over the last decade (Pew Research, 2018).
There is a wide class gap in marriage in America. Marriage is more prevalent
and more durable among better educated, higher-income Americans. It
should come as no surprise, then, to find an education gap between married
and cohabiting parents. Married mothers and fathers are over four times more

1168
likely to hold a bachelor's or advanced degree than cohabiting biological
parents (Reeves & Krause, 2017).
Young adults may put off marriage to complete their education, work on
their careers, or simply experiment with different living experiences. Since
many have delayed marriage, it has become more likely that couples will live
together prior to marriage. Living together does not necessarily mean that
marriage is imminent though. Raley (2016) explains that nearly two thirds of
married couples lived together prior to marriage and that couples who
cohabitate are less likely to marry and are more likely to break up within the
first 3 years (Raley, 2016). Elderly couples may choose to cohabitate after
losing a spouse or experiencing loneliness but not wanting to go through a
legal marriage. Similar to the other families mentioned in this chapter,
cohabiting couples have become an accepted family structure in America.

LGBTQ Families
Although the exact number of LGBTQ families is not known, this emerging
family type is increasing. The United States Census estimates close to
900,000 same-sex households. Romero (2017) states that 1.1 million
LGBTQ individuals are married to a same-sex partner. There are over 10.7
million American adults identifying themselves as LGBTQ, and 2 to 3.7
million children report having a LGBTQ parent. Almost one half of LGBTQ
women and about one fifth of LGBTQ men are raising a child. Foster and
adopted children are often being raised by LGBTQ couples, and over 25% of
same-sex couples are raising siblings, grandchildren, or other
related/nonrelated children (Jones, 2015).
Healthy People 2030 addresses lesbian, gay, bisexual, and transgender
Health. This speaks to the importance of understanding the discrimination
and oppression that LGBTQ families have faced. Although much progress
has been made in accepting people with values and beliefs different from
those of the mainstream, LGBTQ still face health-related challenges and
disparities (U.S. Department of Health and Human Services, 2020).
These families have many of the same hopes regarding parenting that
any family may have. In addition, they experience the stress that
accompanies being stigmatized by much of a society.

Lack of acceptance from their families and communities may have

negative implications on their own family.
Out and Equal: Workplace Advocates (2019) reports that one in four of
LGBTQ participants surveyed has experienced workplace
discrimination. Other markers of discrimination (e.g., rejected by
family/friend; been a subject of jokes/slurs; threatened or physically
attacked; poor service at business, hotel, restaurant) have shown

1169
 decreases from the past year to current year; this indicates that some
progress has occurred. Healthy People 2030 addresses reduction in
bullying as an objective for this population (USDHHS, 2020).
Annual family income is lower (39% vs. 38% earning <$30,000; 20%
vs. 34% earning <$75,000) for LGBTQ families than for the overall US
population.

The nurse can become a valued resource for the family. Through
education and anticipatory guidance, the nurse can assist the family to
successfully navigate the developmental stages of their children as well as
the varied issues faced by families. The nurse can work with parents to
anticipate what questions to expect from their children about their family.

Families With Older Adults

Aging is something that begins the day we are born; however, it is not
focused on until a person turns 65 or older or begins to experience declining
health. It is often thought of as something negative rather than a normal
process. Elderly individuals are the fastest-growing segment of the
population and their value is often overlooked. Since Americans are getting
older and families are getting smaller, there is an increase in elderly and a
decrease in adult children to care for them. However, family relationships
remain strong and last longer than ever due to the increase in life expectancy
(Kaakinen et al., 2018).

In 2010, 40 million people in the United States were over the age of 65
years or 11% of the total population. This is projected to double by 2030
(AgingStats.gov, 2015).
Many older adults live independently well into their eighties and
maintain healthy contacts with family and friends.
Others feel isolated because of chronic health problems that limit
mobility, thereby reducing or eliminating the ability to interact or
contribute meaningfully in society. Relationships in later life are
affected by several factors: retirement status, health, mental health, and
caregiving roles (Eliopoulos, 2018).
The way that individual members of the family react to these factors
will affect how the rest of the family copes. This is where the nurse can
help.

The community health nurse needs to understand the complex dynamics

of such situations and offer support and encouragement as family members
work through chronic health problems. Adult children may become
caregivers as their parents become older which is a change in the family
dynamic for nurses to keep in mind. Often, a nurse serves an entire
community of elders in a senior apartment complex, an assisted living center,

1170
or a mobile home community, for whom maintaining wellness is the focus.
Keeping physically active, eating healthy meals, receiving appropriate
medical care and immunizations, and establishing and maintaining social
contacts are some of the tasks elders should focus on to stay healthy well into
old age. The community health nurse can intervene by advocating for the
individual medical and social needs for the elderly.

Foster Families
Many children are removed from their families because of maltreatment due
to abuse, violence, or neglect. When this occurs, children are often placed
with foster families. On September 30, 2016, there were an estimated
437,465 children in foster care, more than a quarter (32%) were in relative
homes, and nearly half (45%) were in nonrelative foster family homes
(childwelfare.gov, 2018).

Foster families take a variety of forms, but all foster families have
formal training to accept unrelated children into their homes on a
temporary basis, while the children's parents receive the help necessary
to reunify the original family.
Although this arrangement is not ideal, most foster families provide safe
and loving homes for these children in transition.
Roughly half (55%) had a case goal of reunification with their parents
or primary caretakers, and a little over half (51%) of the children who
left foster care in 2016 were discharged to be reunited with their parents
or primary caretakers.
Close to half of the children (45% who left foster care in 2016 were in
care for <1 year. (childwelfare.gov, 2018).

Often, foster children have emotional and physical health problems, and
they may never have experienced the positive structure that foster families
provide. Consideration should be given to the loss that typically present in
foster situations. The losses may include biological parents losing their
children, foster parents unable to have biological children, and foster children
losing biological parents (Turney &Wildeman, 2016). These problems,
which can cause stress and grief for everyone involved, are typically ones
that the community health nurse may help to alleviate.

Implications of Family Composition Diversity for

Community/public Health Nurses
The variety of family structures raises three important issues for
consideration:

1171
 First, C/PHNs can no longer hold to a myth that idealizes the traditional
nuclear family. They must be prepared to work with and accept all types
of families. Unless the C/PHN can accept the full array of family
lifestyles and address the special needs of each, it is questionable that
they will be able to fully help the family and may even create additional
difficulties.
Second, the structure of an individual's family may change several times
over a lifetime. A girl may be born into a nuclear family and then
become part of a single-parent family when her parents are divorced. As
she matures, she may become a single adult living alone and then
become a part of a cohabitating couple. Still later, she may marry and
have children in a nuclear family. After the death of her husband as a
senior citizen, she may have a relationship outside of marriage and
choose not to remarry. For the individual, each family form involves
changes in roles, interaction patterns, socialization processes, and links
with external resources. The community health nurse must learn to
address clients' needs throughout these life changes equipping people
with the skills needed to deal with the inevitability of changing
structures.
Finally, each type of family structure creates different issues and
problems that, in turn, influence a family's ability to perform basic
functions. Shajani and Snell (2019) discuss the need for nurses to
identify and develop strengths with families in planning nursing care.
This should be a community health nurse's starting point. What are the
family strengths? How does the family see their strengths? All families
have strengths, although sometimes these are not easily recognized. It is
important for the nurse to identify these with the family's collaboration
(Box 14-5).

BOX 14-5 Questions the Nurse May Ask

the Family 1. What are your strengths as
a family?
2. If you had to tell me your three most favorite things about your
family, what would they be?
3. Name one quality about your mother that you really respect. About
your father? Your partner? Your child?
4. What is your best memory of your family?

The family is the basic unit of a community and a population.

Maintaining the health of family transitions into the health of both the
community and the population. Caring for family impacts the health of the

1172
community, which in turn affects the health of the population (APHN, 2016a,
2016b; Kub, Kulbok, Miner, & Merrill, 2017). This interdependence is
evident even within the family because one family member can positively or
negatively impact other family members and the family unit itself. As a
result, public health nurses must first understand what constitutes a “healthy
family” so that they can use the nursing process with family-level problem-
solving techniques for health prevention and promotion within the family and
subsequently the community and the population.

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Traits Associated With Healthy Family
Functioning
A family is a health aggregate from the interrelationships of the family
members. The health of the family is affected by each family member and all
family members collectively. A healthy family promotes each family
member's growth and resistance to illnesses so that the family's health can
sustain members during times of crisis such as serious illness, emotional
dilemmas, divorce, or death of a family member (Gladding, 2019; Kaakinen,
et al., 2018). Conversely, a family with underdeveloped coping skills or a
limited capacity for problem-solving, self-management, or self-care is often
unable to promote the potential of its members or assist them in times of
need.
Adherence to cultural practices and family standards for family health
can influence each member's health. Many families comply with cultural
norms when deciding about utilizing preventative health care, adhering to
immunization recommendations, completing routine health assessments, or
investing in family planning (Spector, 2017). In turn, these cultural norms
dictate how family members will participate in their health care. This
interlacing can either obstruct or facilitate the health of the family and the
family members.
The description of “normal” family health is challenging given the
heterogeneity and subjectivity of the data related to family health. However,
there are some standards that characterize a healthy family. Major family
strengths have emerged for family functioning and coping with crisis—
family pride, family support, cohesion, adaptability, communication,
religious orientation, and social support (Nichols & Davis, 2019). Specific
topics have been used to characterize a healthy family (Kaakinen, et al.,
2018):

Communicates and listens

Has a balance of interaction among members
Exhibits a sense of shared responsibilities
Teaches a sense of right and wrong
Abounds in rituals and traditions
Respects the privacy of each member
Admits to problems and seeks help

From this information, six signs have persisted about a healthy family—
maintaining a spiritual foundation, making the family a top priority, asking
for and giving respect, communicating and listening, valuing service to
others, and expecting and offering acceptance (Clark-Jones, 2018; Parachin,

1174
1997). While using these signs to guide and understand family-oriented
interventions (Clark-Jones, 2018), six important characteristics have
consistently emerged (Kaakinen et al., 2018):
1. A facilitative process of interaction exists among family members.
2. Individual member development is enhanced.
3. Role relationships are structured effectively.
4. Active attempts are made to cope with problems.
5. There is a healthy home environment and lifestyle.
6. Regular links are established with the broader community.

Healthy Communication Among Family Members

Healthy families communicate in patterns that are regular, varied, and
supportive (Fig. 14-3). Adults talk and engage with adults, children with
children, and adults with children; it is through communications that
families find ways to adapt to changes as they seek family stability
(Denham, Eggenberger, Young, & Krumwiede, 2016).

FIGURE 14-3 Good communication promotes healthy families.

Healthy families discuss problems, confront each other when angry,

share ideas and concerns, and write or call each other when separated. They
communicate through nonverbal means. This level of family communication
sensitizes family members to one another. They watch for cues and verify
messages to ensure understanding, which intensifies the family's recognition
and dealing with conflict. Thus, a communicative family knows to share and
collaborate with each other.
Furthermore, family members use communication to demonstrate
affection and acceptance, to promote identity and fellowship, and to guide

1175
behavior through socialization and social ethics. Importantly, effective
communication patterns are associated with a family that promotes the health
and development of each family member.

Enhancement of Family Members' Development

Healthy families respond to the needs of family members and provide the
freedom and support necessary to promote each member's growth. This
family tolerates differences of opinion or lifestyle because each member has
the right to be an individual, and the family respects this right. A healthy
family encourages freedom and autonomy for each of its members because it
contributes to the family's stability (Kaakinen et al., 2018).
Freedom and autonomy are supported even if the patterns of promoting
family members' development vary from family to family. As a result, family
members will experience increased competence, self-reliance, social skills,
intellectual growth, and overall capacity for self-management among family
members (Kaakinen et al., 2018; Salem et al., 2017; Shajani & Snell, 2019).

Effective Structuring of Family Role Relationships

In healthy families, role relationships are structured to meet the family's
changing needs over time (Kaakinen et al., 2018). In a stable society, families
establish members' roles and tasks to maintain workable patterns throughout
the life of the family. There is high role consistency because family members
experience little to no external pressure or the need to change their role(s).
In a technologically advanced society, most families establish roles for
the changing family needs that are created by external forces. The degree of
role consistency is highly influenced by the permanency of the external
forces on the family members' roles and expected tasks. Finally, changing
life cycle stages require alterations in the structure of relationships. With
each stage, family members change in their developmental needs so that the
family must adapt their roles, tasks, and controls in a healthy family
(Kaakinen et al., 2018; Salem et al., 2017).

Active Coping Effort

Healthy families actively attempt to cope with life's problems and issues.
When faced with a challenge, the family assumes responsibility for coping
and seeks to meet the demands of the situation (Gladding, 2019; Kaakinen et
al., 2018; Nichols & Davis, 2019).
Family members may pursue treatment opportunities for other family
members in order to maintain the health of the family. The collective support
of family members may be essential for a family member to acquire any type

1176
of assistance outside the family. Clearly, the healthy family recognizes the
need for assistance, accepts help, and pursues opportunities to eliminate or
decrease the stressors that affect it (Gladding, 2019; Salem et al., 2017).
Even if most healthy families are dealing with less dramatic, day-to-day
changes, the healthy families remain receptive to innovation, new ideas, and
creative and energetic ways to solve problems. Moreover, healthy families
actively seek and use a variety of resources to solve problems, which may be
internal or external within the family.

Healthy Environment and Lifestyle

Another sign of a healthy family is a healthy home environment and lifestyle.
Healthy families maintain safe and hygienic living conditions for their
members. Steps are taken to minimize the risk of damage to any family
member while maximizing the potential for health within the family.
A healthy family lifestyle encourages family members to find balance or
harmony in their lives so that the family will have sufficient energies for
daily living. A balanced and varied family diet is nutritious and appealing.
Adequate physical activity helps to maintain a healthy weight while
promoting cardiac health. Family members seek out and use health care
services and demonstrate adherence to recommended regimens. The
emotional climate of a healthy family is positive and supportive of growth.
Contributing to this healthful emotional climate is a strong sense of shared
values, often combined with a strong moral ethical orientation. When the
home environment makes family members feel welcomed, they express their
individuality in simple ways (Gladding, 2019).

Regular Links With the Broader Community

Healthy families maintain dynamic ties with the broader community. They
participate regularly in external groups and activities. They use external
resources suited to family needs.
Healthy families also show an interest in current events and attempt to
understand significant social, economic, and political issues. The families are
exposed to a wider range of alternatives and a variety of contacts, which can
increase options for finding resources and strengthen coping skills. Public
health nurses need to assess and encourage family's involvement within the
broader community as it facilitates a relationship between the family and the
community (Kaakinen et al., 2018).

1177
FAMILY HEALTH NURSING:
PREPARING FOR THE HOME
VISIT
Because the nurse encounters most family members in their homes and
neighborhoods, the focus of this section is on the home visit (Fig. 14-4).
However, some nurses encounter families in other settings in the community,
including on the streets, in homeless shelters, and in the homes of relatives or
friends. For more on family health nursing in nonhome community settings,
see Box 14-6. Regardless of the family's location, the family is the client; the
family is the unit of service in public health nursing (Kaakinen et al., 2018).

FIGURE 14-4 Family health assessments are foundational to the

community/public health nurse's work with families.

BOX 14-6 Working With Families in

Nonhome Community Settings There is
a variety of nonhome settings or public
places for visits to accommodate the
family's schedules and routines provided
the family member is comfortable with

1178
 the nonhome setting. A visit may occur
during a lunch break, after work/school,
in a day care or senior center, or public
setting. Be mindful of maintaining a
confidential atmosphere.
Visiting a family member in public places can enhance the family
assessment. The nurse can assess an individual's ability to function
outside the home setting. It decreases the potential of issues in the home
impacting the individual's response(s) to the questions. The family
member may feel comfortable talking about problems and issues related
to the home environment from other family members such as parents.

In the unique setting of the patient's home, the nurse is permitted into the
most intimate of spaces that human beings have. The key to this privilege is
trust. Family members must have a certain amount of trust to let a stranger
and representative of a governmental agency into their home. Family
members believe that you are there to help enhance their ability to function
as a healthy family with internal and external resources. In the same manner,
the nurse must have a certain amount of trust to enter the family's home.
Once the door closes, the nurse enters the client's world where they are the
experts, and the nurse is the guest, a stranger. Nevertheless, you are trusting
that the family welcomes your visit and is ready to work with you for
healthier outcomes.
To be best prepared to enter a client's home, you must have an
understanding of the skills of observation and communication, the
components of the home visit, the various purposes for the home visit, and
how to maintain your own personal safety while making the home visit.
These topics are covered below. For general guidelines on public health
nursing practice when the family is the client, see Box 14-7.

BOX 14-7 Public Health Nursing

Practice Guidelines for Working With
Families The family is the unit of service
in public health nursing (Kaakinen et
al., 2018). The nurse assesses the family

1179
to determine what services are needed to
move the family to a state of health,
which can be determined by using five
guidelines for practice.
Work With the Family Collectively The family
is a group of several persons living together
with a collective personality, collective interests,
and a collective set of needs. The family
functions collectively as a single entity with
common attributes and activities so that all
family members are involved in the nurse–
client interactions (Gladding, 2019; Shajani &
Snell, 2019).
Start at the Family's Present Level of
Functioning The C/PHN begins by conducting a
detailed family assessment to ascertain the
needs and health level of each family member.
The nurse can also recognize patterns of
behaviors to determine collective interests,
concerns, problems, risks, and priorities.
Adapt the Nursing Intervention to the Family's
Stage of Development Every family engages in
the same basic functioning but not the same
approaches to accomplish these functions
within the family's development. A young
family meets the family members' affiliation
needs by establishing mutually satisfying
relationships and meaningful communication
patterns. The bonds of a family in the later

1180
 stages of development change due to some
family members becoming part of another
family unit or family member(s) dying (Box 14-
8). With this assessment, the nurse recognizes
the family's appropriate level of functioning,
determines the problems/risks, and implements
the tailored interventions needed to move the
family to a state of health (Kaakinen et al.,
2018; Shajani & Snell, 2019).
Recognize the Validity of Family Structure
Variations C/PHNs work with families from
communities with varying family structures and
individualized patterns of family functioning.
The nurse must learn to understand and accept
variations in family structure to address the
needs of the families. Two principles guide this
acceptance and understanding (Kaakinen et al.,
2018; Sperry, 2019; Shajani & Snell, 2019):
1. Principle One—Each family is unique in its combination of
structures, composition, roles, and behaviors. This uniqueness is
valid, while family functions effectively and demonstrates the
characteristics of a healthy family.
2. Principle Two—Families are constantly changing throughout the
life cycle, which leads to a family to adapt to its circumstances.

There may be a change in the family structure and the family members'
roles due to internal and external environmental issues from the addition,
loss, or alteration of persons related to the family. It is the C/PHN's
responsibility to help the family to cope with these changes with a
nonjudgmental and acceptance manner about the family structure. A nurse
personally may find it difficult to work with same-sex couples or respect
same-sex marriages because this lifestyle conflicts with the nurse's personal
set of values. As a professional, however, it is the nurse's responsibility to
help promote the collective health of that family because all families are

1181
unique groups, each with its own set of needs that are best served through
unbiased care.

Empower Families Throughout the family visit, the

public health nurse realizes that the ultimate goal
is to assist the family in becoming independent of
services (Kaakinen et al., 2018; Salem et al., 2017;
Sperry, 2019). This positive outcome is
accomplished via the working nurse–family
relationship, which can be guided by four
suggestions:
The current functioning of the family has worked for the family before
meeting you.
Before doing “something” for a family, consider who did this
“something” before you.
Find family strengths even in the most challenging and compromised
family situation.
Think about your ability to manage, cope, or function as well as the
family members if you were in a similar situation.

With an asset-based approach, the nurse collaborates with the family to

discern the family's strengths and positive potentiality embedded in the
family weaknesses so that independence from the agency's services reflects a
positive outcome (Marshall & Easton, 2018). Regrettably, too often, C/PHNs
perceive family weaknesses as needs or problems, which can undermine any
hope of a therapeutic relationship between nurse and family as well as the
use of an asset-based approach. It is the nurse's job to recognize the strengths
in families and to help families recognize them and understand their potential
for self-efficacy (Kaakinen et al., 2018; Shajani & Snell, 2019). The asset-
based approach fosters a positive self-image, promotes self-confidence and
self-efficacy, and often helps a family feel better able to address other
problems as they arise (Marshall & Easton, 2018). Furthermore, C/PHNs
need to ensure that whatever assistance they offer/provide to a family will
promote the family's independence and self-efficacy.
The C/PHN should be able to say, at the least, that the family is
managing as best as possible so that the assessment can explore all aspects of
family functioning, positive and negative. It also emphasizes the positive
outcomes, indicating to the family that they are important to the nurse—
creating a collaborative relationship.

1182
 One helpful communication technique is strengthening, which involves
verbally listing the positive aspects of an otherwise negative situation in a
natural and conversational manner (Gladding, 2019). This strengthening
technique empowers the family through positivism instead of negativity that
may be viewed by the family as condescending or punitive. Strengthening
also facilitates the use of the nurse as a resource and guide (Shajani & Snell,
2019).
Through empowerment, the family can meet the needs of each family
member and the demands made by systems outside the family unit. Of
course, all behaviors must first be assessed in terms of promoting the family
functioning before deemed a strength. Some behaviors that are considered as
strengths are related to basic family functions, family developmental tasks,
and characteristics of family health. Thus, it is the context in which the
behavior exists that makes it a strength, not the behavior alone.

BOX 14-8 STORIES FROM THE

FIELD
Factoring in the Ravina Family's Stage of
Development The Ravinas, a couple in their
early 70s, recently moved to a retirement
complex. They had received nursing visits after
Mrs. Ravina's stroke 3 years earlier but
requested service now because Mr. Ravina was
feeling “poorly” all the time. He thought that
perhaps his diet and lack of activity might be
the cause and hoped the nurse might have some
helpful suggestions. The couple had eagerly
awaited Mr. Ravina's retirement from teaching,
with plans to be lazy, travel, visit all their
children, and do all those things they never had
time to do when they were young. Now, neither
of them seemed to have enough energy or the
capacity to enjoy their new life. The move from
their home of 28 years had been difficult: they

1183
were still trying to find space in the tiny
apartment for their cherished books and
mementos, although they had given many items
away.
Ronald Bell, a C/PHN, recognized that the Ravinas were
experiencing a situational crisis (leaving their home of 28 years) and a
developmental crisis (aging and entering retirement) and may perhaps
have some underlying health problems. Many of the Ravinas'
expectations for this new life stage were unrealistic; they had not
adequately prepared themselves for the adjustments that the loss of their
home and retirement would demand. Through discussion, Ronald was
able to help the Ravina family understand their situation and express
their feelings. He completed physical assessments on the Ravinas and
encouraged regular follow-up with their health care provider. He also
helped them join a support group of retired persons who were
experiencing some of the same difficulties. Because this nurse was able
to help the Ravina family through their crisis in a supportive and
nonjudgmental manner, he found them receptive later to discussing
preparation for the inevitable loss and bereavement that would occur
when one of them died. He was adapting his nursing intervention to this
family's stage of development.

1. What concerns might the C/PHN have in this situation?

2. What strategies might the C/PHN employ for this situation?

1184
Skills Used During the Home Visit
Many skills are needed when assessing, diagnosing, planning, implementing,
and evaluating families in their home at a variety of functional levels. Expert
interviewing skills and effective communication techniques are essential for
effective family intervention (see Chapter 10). It is equally important to
enhance these established techniques with your relational skills (e.g.,
intuition, openness, nurturing, and compassion) (Stastny, Keens, & Alkon,
2016). A trusting relationship is the key to a productive home health visit and
effective use of nursing skills (Healthy Families America, 2019). Through
home visits nurses can assist families in promoting nurturing relationships
leading to stronger family-centered healthy development (Healthy Families
America, 2019). The following paragraphs describe special skills required
when making home visits.

Acute Observational Skills

You will be using your acute observational skills to assess both the family
and the environment, which are equally important for a detailed assessment.
This refers to the ability to take note of every detail (physical and
nonphysical) that is directly and indirectly related to the family, the
environment, the visit, and the entire process. Throughout the visit, the nurse
focuses on the family members' concerns and the purpose of the visit, while
being observant about the neighborhood, travel safety, home environmental
conditions, number of household members, client demeanor, and body
language, as well as other nonverbal cues. All this information contributes to
understanding the family, identifying patterns, and recognizing how to
navigate the neighborhood. Addresses on referrals may be incorrect,
incomplete, or generally dubious. Confirm with the referring agency to
identify any anomalies and environmental conditions of the neighborhood.

Observation of Home and Neighborhood

Environmental Conditions
Conditions in the neighborhood and home environments reveal important
information that can guide diagnosing, planning, and intervention with
families. While traveling to and arriving at the family home, you have been
gathering information about the neighborhood conditions and the physical
appearance of the apartment or house. Observing the home environment
conditions provides an assessment about the resources and barriers
encountered by the family. The external environment may contradict the
family's values, resources, and goals. They may have little control over the
neighborhood or the building in which they live, especially if they are

1185
renting. While these external factors may influence the behavior of the
family, they may not define the behavior.

Observation of Body Language and Other Nonverbal

Cues
You gather data as soon as you knock on the door or ring the doorbell, greet
the people in the doorway, and enter the home (Box 14-9). Observations of
previsit nonverbal cues and body language contribute to your initial opinions
and perceptions about the family. Also, all family members (present or
absent) are doing the same with you (Box 14-10). Thus, you need to be
aware of all family members; acknowledge and greet them. Inquire about
those who are absent. Make this a habit on all visits. Each family member
has opinions and health care needs, even if you only see certain members of
the family on each visit.

BOX 14-9 STORIES FROM THE

FIELD
A Home Visit to James Cutler and Brian Hoag
James Cutler and Brian Hoag have a 6-year
monogamous relationship. A same-sex couple,
they worked with an attorney to privately adopt
a child. The arrangements were completed and
their 2-week-old son, Adrian, arrived in their
home last week. Helen Jeffers, a public health
nurse, receives a referral from the county
hospital where Adrian was born. The request is
for an assessment of the home situation and
parenting skills. At the hospital, the baby tested
positive for cocaine with APGAR scores of 6
and 8 and had some initial difficulty sucking.
Birth weight was 2,900 g. Discharge weight, at 3
days, was 2,850 g. At her first home visit, Helen
finds a neat and orderly two-bedroom
condominium that is well equipped with baby

1186
 supplies. The infant has gained 200 g and is
being well cared for by two fatigued parents
whose previous contact with infants was
limited. James and Brian have many questions
and are anxious learners. Helen plans with the
couple to make weekly home visits to assess
infant growth and development, provide
support, and answer questions. She suggests a
neighborhood parenting class and finding a
reliable babysitter. She also helps James and
Brian develop an infant care work schedule.
After 6 weeks of intervention, Adrian is
thriving. Helen closes the case to home visits,
feeling confident that the parents' goal of
becoming knowledgeable and confident has
been achieved.
1. As the C/PHN, identify the family life cycle and developmental
tasks of this family.
2. How can the C/PHN support this family in health promotion and
education?

BOX 14-10 PERSPECTIVES

A C/PHN Nursing Instructor's Viewpoint on

Home Visits—How Your Knock Helps Families
Open the Door This question may seem trite, but
how do you knock on the door when you visit a
family? Do you use the “I don't want to be here,

1187
and if they don't hear the knock I can quickly and
quietly leave” type of knock that even Superman
can't hear? Or do you knock like, “I'm a bill
collector and you better open this door!” During
this knock, the entire family may be running out
the back door or through a window! The
preferred knock is loud enough to be heard, yet
friendly and nonthreatening. If necessary, practice
“your knock” until you can create this beneficial
combination.
With some families, it is helpful to call toward the door as you knock or
ring the bell with, “Mrs. Smith, this is Jenny from the Health Department—
remember I was coming by today,” or “Ms. Jiminez, it's the student public
health nurse, Terry De Leon, and I brought some pamphlets for you,” or
“Hello, it's James from the neighborhood clinic; we planned to meet today.”
Using such a greeting allows the family to know who is at the door and
choose to open the door if they want. It will get you into more homes than
the “quiet-as-a-mouse” or “bill-collector” knocks.

—Alice K., PHN

Be observant of the family's nonverbal cues such as body language and

demeanor because they provide information that must not be overlooked.
Opening statements such as “You seem anxious today,” or “Did I come at a
bad time? You seem distracted,” will encourage family members to express
what is on their minds, which otherwise might not be indicated or addressed.
Through their facial expressions, hand gestures, subtle glances, eye
movement, and body language, detailed information will be generated to
address both direct and indirect concerns of the family. Overlooking the body
language makes it easy to continue with your agenda instead of the family
member's agenda, although the family is distracted by another, more pressing
issue.

Nonverbal Communication
It is equally important to be aware of your body language that can tell the
family a great deal about how you feel being in their home, dealing with the
family members, and completing the home visit. Suggestive behaviors like
fidgeting with car keys during the entire visit or appearing to be in a hurry or

1188
rushed can be perceived as nervousness, anxious, or not wanting to be in the
current situation. Minimal eye contact or continuously looking at your
paperwork may be viewed as rudeness, unprofessionalism, and
unknowledgeable about the family and/or the purpose of the visit. Your
“fear” can be implied from the refusal to sit on any of the furniture or a
shocked expression from a roach or mouse scampering across the floor. Your
behavior impacts the family's trust in you, subsequent visits, and
interventions.

1189
Components of the Family Health Visit
The components of the family health visits align with the nursing process.
Previsit preparation steps encompass assessment, diagnosing, and planning,
which are necessary for implementation or completion of the actual family
health visit. The documentation and planning for the next visit (or
evaluation) terminates one visit and prepares the nurse for the next action
needed.

Previsit Preparation
Public health nurses identify preliminary family diagnoses and design a plan
for the initial family health visit based on a referral to the agency. A referral
is a request for service from another agency or person. They are the source of
new cases and need timely responses. This request can be a form letter or the
transferal of information from the originating agency to the receiving agency.
Referrals may be formal (from physicians or complementary agencies) or
informal (verbal or telephone referrals from friends or relatives who believe
that someone needs help). Some examples include:

Labor and delivery hospital units request service for low-birth-weight

babies and teen mothers.
Social service agencies request a home assessment for a child being
returned to parents after previous removal.
A homeless shelter might be seeking services for homeless or transient
persons showing signs of uncontrolled diabetes.
A battered woman's shelter needs services to treat emotional issues of a
mother and her children who are running from an abusive husband and
father.
A woman in a city 500 miles away requests that a nurse check on an
elderly relative who lives alone in the community and has recently
exhibited slurred speech and/or has been homebound.

Follow-up visits are based on the family's needs and agency protocol.
Public health nurses must be equipped with the appropriate tools to establish
a physical place to work:

Access to a telephone, the Internet, and other necessary resources

Educational material (pamphlets, brochures, and related Web
information)
Charting tools
Any other supplies required for home visits
Resource directory, which is a list of resources for the broader
community, or a nurse-made directory of resources created over years of

1190
 working with people in the community
A nursing bag or carryall tote (issued by agency or devised by the
nurse) for medical supplies
Specialized supplies depending on the visit (a tote for each type of
visit)
Basic supplies to treat basic needs of a new mother and her infant
or an elderly man with hypertension

Once the nurse is prepared, the family is contacted to schedule a visit.

The referral ideally contains a correct telephone number for the family, a
relative, or a neighbor. The nurse needs to extract as much information as
possible from the referral so that the preparation can be exact and specific for
the health visit. This sets the stage for a detailed assessment, appropriate
family diagnosing, and family-oriented care planning (Arbaje et al., 2018). If
the referral does not contain this information, an unannounced visit is
scheduled. During this visit, it is important to get a contact number for the
family. When calling for the first time, you, the C/PHN, will:
1. Introduce yourself
2. Explain the reason for the call 3. Give the reason why the family was
referred 4. Indicate what the visit consists of 5. Determine when a visit
would be convenient for the family and you 6. Get explicit directions to
where the family is staying (the referral may have a different address, or
the family did not mention that they are staying elsewhere) 7. Repeat
the date and time of the scheduled visit
The nurse's intention(s) may be questioned with some people becoming
defensive or suspicious. A new young mother may wonder, “Why is this
nurse visiting me so close to my time in the hospital? Did I say or do
something wrong with my baby when I was in the hospital?” The C/PHN
will explain that:

The visit is a follow-up one to see if the move from the hospital to home
is okay.
The visit is an opportunity for her to ask questions that she might have
about her new baby since her return home. It is also a chance to learn
more about handling her baby in the home if needed.
The visit is a service provided by the agency to all mothers.
The visit is paid for by taxes or donations, or by the client's health
maintenance organization (if applicable). There is no direct cost to her
or the family.

Following logical steps in the previsit preparation enhances the nurse's

confidence in her or his ability to intuitively recognize patterns and/or trends
from the referral information for preliminary diagnoses to guide preliminary
care planning.

1191
Making the Visit
It is recommended to call the family to remind them of the scheduled
meeting and your arrival time prior to the scheduled visit. State the purpose
of the visit and the anticipated length of time needed. Once you arrive, the
following guidelines for initial contact should be used (Kaakinen et al.,
2018):
1. Engage the family in a manner to build a supportive and trusting
relationship (Box 14-11).
a. Introduce yourself to the family.
b. Explain the value of the nursing services provided by the agency.
c. Spend the first few minutes of the visit establishing cordiality and
getting acquainted (a mutual discovery or “feeling out” time).
d. Become acquainted with all family and household members if you
are making a home visit.
e. Encourage each person to speak for himself.

BOX 14-11 Developing a Trusting

Relationship with the Stevenson Family
The public health nurse, David Dow,
made an initial home visit after referral
by an outpatient physician who was
concerned about possible child abuse.
The physician suspected abuse after
seeing bruises on the arm of a baby boy
(Eugene) who was in the emergency
room for treatment of a laceration on
the forehead. Alice Stevenson, the
mother, claimed that the laceration
resulted from Eugene falling off a table
when she was changing him. She also
explained that the bruise happened
when Phillip (Eugene's older brother)

1192
was playing too rough. David began the
visit by stating that he was simply
following up on the emergency room
visit and wanted to see how Eugene was
progressing. David made no mention of
child abuse. He simply observed Alice
and the children closely to learn more
about the family's background and used
the strengthening technique to create a
trusting relationship interaction. Due to
David's supportive demeanor, Alice
agreed to further visits, and at one of the
visits, Alice confessed that her ring cut
Eugene's forehead when she slapped
him. “I could not get him to stop crying,
no matter what I did,” she whimpered.
“I just could not endure it any longer.”
She also confessed that the bruises
happened when she, not Phillip, grabbed
Eugene roughly to stop him from pulling
and touching things he should not.
David learned that Alice's husband
abandoned her while she was still
pregnant with Eugene. David realized
that Alice would be particularly
vulnerable to any criticism, so he

1193
 concentrated on her strengths such as
managing the home, dressing the
children, and reading to little Eugene.
During subsequent visits, Alice and
David were able to discuss her feelings
frankly and work toward improving the
health of the Stevenson family. Alice
started counseling and attended a
support group for single parents
counseling.
2. Use acute observational skills.
a. Use your “sixth sense” or intuition as a guide regarding family
responses, questions they ask, and your personal safety (trust your
feelings).
b. Be sensitive to verbal and nonverbal cues.
c. Be accepting and listen carefully.
d. Be cognizant of possible internal and external stressors and effect
on mental status of family.
e. Be aware of your own personality—balance talking and listening
—and be aware of your nonverbal behaviors.
3. Help the family focus on issues and move toward the desired goals.
a. Be adaptable and flexible (you may be planning a prenatal visit,
but the woman delivered her baby the day after you made the
appointment, and now there is a newborn).
b. Be aware that most clients are not extremely ill and have higher
levels of wellness than are generally seen in acute care settings.
c. Be prepared to develop a sustained continuity of care by actively
collaborating with the family in addressing their issues.
4. Near the end of the visit, review the important points and emphasize
the family strengths.
5. Plan with the family for the next visit.

The length of the visit varies depending on its purpose and can influence
the C/PHN–family relationship.

Less than a 20-minute visit

1194
 Not enough time for a thorough assessment, but ideal for
Dropping off supplies
Relaying information about a referral
Stopping by at the family's request, for instance

More than a 60-minute visit

Avoid; not a productive way to provide nursing services.

Any lengthy assessments should be conducted over two visits.
Disruptive to the family with the potential for unwanted outcomes.
Families have routines that are important to them.
The family may feel that nothing of value occurred during a
visit.
The family may not continue to make themselves available for
future visits. This becomes a balancing act for the family and
the nurse, and you may want to work at picking up on
nonverbal cues.
May reflect the nurse's hesitation in trusting the family to
understand and/or follow the instructions and feedback.
Limits the family's ability to seek out community resources for
community-based health care.

Remember, the outcome of better health for family members must be

demonstrated in order to support and validate the value, as well as justify the
cost of public health nursing services.

Concluding and Documenting the Visit

The current home visit concludes after planning for the follow-up visit with
the family. You will say goodbye and pack up any paperwork, materials, and
supplies used for this visit in your car. Before leaving this community, you
need to get ready for the next home visit on your schedule. By arriving
prepared at the next home, you demonstrate respect for the family's time,
efficiency, and professionalism (Arbaje et al., 2018).
Documentation or charting of each home visit used to be typically
completed as soon as the nurse returned to the agency. Today, it is
recommended that charting happens immediately at the end of the home visit
(not upon arrival at the next one) on an agency-provided device (laptop,
smartphone, or tablet) linked to electronic charting forms and records
(Arbaje et al., 2018). For the most part, most agencies expect the charting to
be completed as soon as practically possible in that workday.
Agencies use a variety of forms that assist the nurse to document fully
and succinctly. Some forms use a checklist format that contains code
numbers, letters, or checkmarks on developmental or disease-specific care

1195
plans. A four-paged postpartum visit and newborn assessment may consist of
two narrative forms to chart the expectations for the mother and baby plus
two forms for the head-to-toe assessment of the newborn. There is a place to
document parent teaching within the expected parameters and for listing
other professionals' involvement with the family. Other forms may focus on
chronic illness common in the agency's clientele (e.g., alcoholism, chronic
obstructive pulmonary disease, communicable diseases diabetes, HIV/AIDS,
hypertension).

1196
Focus of the Family Health Visit
The focus of family health visits depends on the agency's mission and
resources or services and the needs of the families. Some agencies provide
education, recreational activities, and support groups for families of persons
with Alzheimer's disease, asthma, or diabetes. Other agencies provide
services to address issues related to immigration, poverty, and/or
homelessness (Beck et al., 2017; de Grubb et al., 2017; Lee et al., 2017). In
general, family health visits are designed to educate, provide anticipatory
guidance, and focus on health promotion or prevention.

Family Education and Anticipatory Guidance

Local health departments distribute their services based on the broader
community's needs. The health department may contract with health care
providers to treat a community with a high rate of teen pregnancies and high-
risk infants through home or clinic visits to all teens and women with high-
risk pregnancies and their newborns after delivery (Tachibana et al., 2019).
The treatment involves teaching prenatal, postpartum, and newborn care and
providing anticipatory guidance to promote regular health care provider
visits for the infant, immunizations, and safety awareness. The health
department may address the needs of another community with a significant
number of older adults or migrant workers who need to learn how to manage
a chronic illness, enhance their nutrition, and practice safety measures to
prevent injuries and falls (Coker et al., 2019; Frost et al., 2019).

Family Promotion and Illness Prevention

Family members can be taught health promotion activities for healthy living
even within the limitations of chronic illnesses. These activities may include
screening for hypertension and elevated cholesterol, performing a physical
assessment, teaching about nutrition and safety, and promoting
immunization.
Immunizations protect the health of all individuals and the larger
community. Although such services are not brought into the home, it remains
the C/PHN's responsibility to provide information about immunizations,
teach the importance of following an immunization schedule, and follow up
with the family during home visits. A focus on population health shifts care
to the needs of the community and strengthens the focus on aggregate health
promotion strategies that optimize personal health (APHN, 2016a, 2016b).
Adding social determinants of health also contributes to the ultimate goal of
creating “social, physical, and economic environments that promote attaining

1197
the full potential for health and wellbeing for all” (USDHHS, 2020, para. 4;
see Box 14-12).

BOX 14-12 HEALTHY PEOPLE 2030

Selected Goals and Objectives Related to Family
Health

1198
Reprinted from U.S. Department of Health & Human Services (USDHHS). (2020). Healthy People
2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

C/PHNs provide health promotion services during a family health visit in

any setting. During prenatal classes, the C/PHN teaches couples about the
expected changes during pregnancy and provides anticipatory guidance for
safe infant care and postpartum care (Mutch, 2016). The C/PHN screens
older adults for hypertension or elevated cholesterol at the senior center,
educates family members attending Alcoholics Anonymous, or provides
mental and health assessments for homeless persons in shelters.

1199
Personal Safety During the Home Visit
Being streetwise is essential when interacting and traveling throughout
communities. Continuation of personal safety must be considered while
maintaining respect for the families, a trusting relationship, and
professionalism.

Traveling to and in the Neighborhood

When leaving your “base of operation,” make sure you have all the necessary
supplies, materials, and paperwork for the scheduled home visits. To ensure
safety and promote coordination with your agency, always inform your
agency about your planned itinerary and all contact information (your mobile
phone number and telephone numbers of families scheduled to visit) so that
the agency can promptly reach you (Arbaje et al., 2018). Traveling safely in
a community can mean different things to different people.
Traveling in an agency or private car requires

A full gas tank

Addresses for families you are visiting, city/county map, or GPS
A cell phone

Using public transportation requires

Change/bus card or smartphone app for each bus trip

A current bus schedule
Knowledge of the exit at the bus stop closest to your family's home
Knowledge of the bus stop for the return trip to agency or to the next
home visit
A cell phone

You should always call ahead to the family and give them an estimated
time of your arrival. Be “streetwise” when walking in neighborhoods. A
C/PHN understands the value of safety measures used by expert nurses,
following these measures for personal safety, and not challenging them.
Another focus of concern is the perceived risk to self when making a home
visit. Feeling and being safe can relate to the nurse's perception of a situation,
views on risk-taking, awareness of the traveling conditions (e.g., the time
and/or the setting), and coping process. What one person sees as a risk,
another sees as a challenge or an opportunity, and another may see nothing.
We each perceive risks differently based on knowledge, experience, and
personality.

1200
Arriving at the Home
Make sure you are at the right house. Do not go into the home until you are
assured that the family you are intending to visit does live there and is home.
You are scheduled to visit 16-year-old Jennifer and her 5-day-old infant,
Marcus. A 50-year-old man answers the door when you knock. Give your
name and ask if Jennifer can come to the door because you are here to see
her. Do not enter the house even if he invites you in to wait for Jennifer.
Smile and let him know that you are comfortable waiting for Jennifer at the
door. Remain outside the house and go inside only after you talk to Jennifer
at the door. This precaution ensures that the family members you want to
visit are in the house and that this is the right address.

Dealing With Challenging Situations

Due to the nature of the home setting, you may encounter unexpected and
challenging situations, including family conflict, family members under the
influence, and the presence of strangers.

Friction Between Family Members

During a home visit, two or more family members may begin to argue or
physically fight. You should immediately terminate the visit and inform the
family what will take place regarding the home visit. Follow these steps:
1. Inform the family that the visit is now terminated.
2. Calmly let the family know that such distraction takes away from the
purpose of the visit.
3. Inform the family that you will return at another convenient time.
4. Calmly and quickly remove yourself from the home.
When two or more family members are physically fighting, never
intervene, try to stop the fight, serve as a referee, or assist an adult family
member. You may be the next victim. Once you are out of the house, call
911, if necessary, from your cell phone. Once you are safe, rely on your acute
observation skills to recall the altercation. This data may provide significant
information about the family's structure, process, and health. Depending on
your assessment and processing of the information, it may be appropriate to
discuss the altercation and the friction in the family at a later visit.

Family Members Under the Influence

If the focus of the visit is on two family members, but a third member's
behavior suggests the use of drugs or alcohol, use your judgment as to the
best action to take. It is important for you to assess the situation and proceed
accordingly within the parameters of guidelines provided by your agency or
your school. If the intoxicated or high person goes to another room and

1201
remains quiet/calm, it might be appropriate to continue the visit. You might
want to discuss your observations with the two family members. If the
intoxicated or high person remains in another room but interrupts the visit by
being abusive or distractive, it is best to terminate the visit. Let the two
family members know that you want to reschedule when the intoxicated or
high family member is not under the influence or is not present. Never put
yourself in the middle of a situation that could deteriorate rapidly and
compromise your safety.

The Presence of Strangers

In some families, it is common to have extended family members, neighbors,
and friends present in the home. This may be the norm for the family but not
for the nurse because it is a different setting from her or his experience. The
nurse may have to weave your way past five teenage boys sitting on the front
stoop in order to enter the home and step over three men sleeping on the
living room floor in the small apartment of a teenage mother and her infant.
Children may be riding their tricycles inside the house during a teaching visit
to two young parents who do not seem fazed by the commotion. These
situations may not be indicative of danger, but they can make you feel
vulnerable and uncomfortable, while distracting you from the purpose of the
visit. Always rely on your observation skills; inquire about the people you
observe in the periphery of the home visit; ask about their relationship to the
family and if they should be included in the visit. The family may suggest
that you ignore these people or say they are transient family members. It may
be important to learn who they are, if they have unmet health care needs, or
if their presence influences the health of the family you are visiting.

1202
APPLYING THE NURSING
PROCESS TO FAMILY HEALTH
The nursing process (assessing, diagnosing, planning, implementing, and
evaluating nursing care) includes steps used to deliver care to families and
aggregates in community health settings. These steps are, interestingly, the
same ones used to care for clients in acute care settings and in the extensive
clinic system. The difference in implementing this process in family health
nursing is the context (the home), the client focus (the family), and the
consideration of external variables not typically encountered in other
contexts. In public health nursing, addressing the health needs of the core
unit of service (in this case, the family) should always transition to
addressing the health needs of the community and the population. The
context and application of each step are tailored to the needs of the
population by focusing on the core unit of service (APHN, 2016a, 2016b).
The nursing process commences on the first visit when the public health
nurse performs an initial assessment (Box 14-13). Subsequent visits entail
the nurse and the family working collectively to reach the targeted goals.

BOX 14-13 C/PHN Use of the Nursing

Process
Family Health
Family assessment refers to a detailed collection of information
from the C/PHN's observations about the family and external
environment that includes verbal cues, nonverbal cues, and what is
observed as well as what is not observed (certain barriers to health
care may be invisible, camouflaged as another issue, or
understated).
During the family diagnosis process, the C/PHN recognizes
patterns, behaviors, constraints of health (positive and negative),
and/or seen/unseen routines from the collected information during
the assessment (Swartz, 2018). This step involves identifying
issues, risks, concerns, and problems that can negatively and
positively alter the health of the family. During the family planning
of care step, targeted outcomes and goals are identified based on
the patterns of unhealthy/healthy behavior and relationships.

1203
 A plan of care is created. It includes interventions, strategies, and
interactions, which involves family resources and external services
to promote the health of the family.
Implementation of family care plan involves the C/PHN
collaborating with the family, community resources, and external
services to organize and complete the plan of care. The family is
educated about the resources and how to use them to address the
health problems and promote the family health. It is equally
important to include seen/unseen cultural and social issues in
completing the interventions and strategies.

Finally, the evaluation step is where the entire nursing process is

reviewed to determine if (1) the targeted outcomes and goals were
achieved, (2) the process was a positive experience for the family, (3)
new and current relationships with internal and external resources will
maintain and strengthen the efforts for the family health, and (4) the
family feels comfortable in participating in their care. With this
understanding of the nursing process, the novice public health nurse is
ready to prepare to work with families in the community (Swartz,
2018).

1204
Preliminary Considerations
Before implementing the nursing process, the nurse must establish (1) a
conceptual framework, (2) a clearly defined set of data collection categories,
and (3) a method of measuring a family's functional level.

Conceptual Frameworks
A conceptual framework is a set of concepts integrated into a meaningful
explanation (Hosseini Shokouh et al., 2017). Three conceptual frameworks
are used in public health nursing: the interactional, structural–functional, and
developmental (Hill & Hansen, 1960; Raingruber, 2017; Shajani & Snell,
2019).
Theories structured on the interactional framework focuses on the
family's internal environment, their relationships. The family is a unit of
interacting personalities with emphasis on communication, roles, conflict,
coping patterns, and decision-making processes (Raingruber, 2017; Shajani
& Snell, 2019).
The structural–functional framework creates a structure that focuses
on the family's internal and external environments. The family is a social
system with a specific structure that exists in an external environment
defined by interactions with other social systems (e.g., other families, church,
work, and the health care system). The family structure is used to process,
analyze, and understand how the family functions in the external
environment (Raingruber, 2017; Shajani & Snell, 2019).
The theories based on the developmental framework incorporate
elements from both interactional and structural–functional frameworks. For a
life cycle perspective, one examines the changing roles and tasks as family
members progress through life cycle stages within the environment. Internal
relationships elucidate the development of the family. External
environmental influences highlight how the family is structured, functions as
a social system, and interacts with other social systems. This framework
gives context to the family development within the environment (2018;
Raingruber, 2017; Shajani & Snell, 2019).
Even though these three core frameworks are the basis for theories and
conceptual models used by C/PHNs, these frameworks are the foundations
for various methods of family assessment. Their concepts have been
combined to design family assessments, diagnosing process, and intervention
models.

Data Collection Categories

1205
The conceptual framework gives the nurse a format to group the data about
the family into specific categories in order to organize the collected data.
This data may be useful for assessing, diagnosing, care planning, and serving
as a guide for subsequent visits in which to obtain additional information.
For an example of a data collection tool that lists 12 assessment categories in
which data are grouped for three data sets (family strengths and self-care
capabilities, family stresses and problems, and family resources), see
(Edelman & Kudzma, 2017).

Methods of Measuring a Family's Functioning

Family function includes the relationships, interactions, and structural
properties within the family system in which communication, conflict,
cohesion, adaptability, and organization are assessed. The C/PHN will
evaluate the strengths, resources, and protective factors of a family including
any underlying behaviors that might create unsafe conditions.

1206
Family Health Assessment
A thorough family health assessment relies on the public health nurse's
commitment to understand the family, to determine the value of the referred
information, and to process any prior opinions about the family in order to
promote family health. See Box 14-14 for guidelines that can help the
C/PHN conduct a detailed family assessment and organize data. See Box 14-
15 for an application-oriented exercise in conducting a family assessment.

BOX 14-14 STORIES FROM THE

FIELD
Assessing the Beck Family's Nutritional Status
A public health nurse had an initial contact
with Mr. and Mrs. Beck and their youngest
child at the well-baby clinic. The 9-month-old
child was over the 95th percentile for weight
and at the 40th percentile for height. The nurse
also noted that both parents were obese. The
nurse asked about the family's eating patterns,
the baby in particular, and suggested a home
visit to determine whether the Becks were
interested in family nursing. The nurse
explained the purpose of home visits (to assess
all family members, coping patterns, eating
patterns, and food purchasing choices) and the
importance of including all family members
and asked for a time that would be good for the
family as a whole. The nurse explained that
each person should be involved and committed
to the agreed-upon goals and that, like a team
of oarsmen, the family has to pull together to
accomplish the purpose of the visits. To help the

1207
Beck family improve its nutritional status, the
nurse might suggest a session of brainstorming
to uncover many causes of poor nutrition. More
brainstorming might also lead to more solutions
and plans for action. On each visit, the nurse
views the Becks as a group so that group
responses and actions would be expected.
Evaluation of outcomes will be based on what
the family did collectively. The Becks were
interested, and a home visit date was made.
1. What developmental stages appear to have been achieved?
2. What is your plan of action for this family over the next three
visits?
3. What are the goals for this family (immediate, midrange, and
long-term)?

BOX 14-15 STORIES FROM THE

FIELD
A Family Assessment for Lorenzo You are a
C/PHN assigned to a small surburb in Chicago.
Your new client is Lorenzo, a 103-year-old
White American male. He is being released
from the geriatric ICU of Uptown Hospital
after being treated for severe pneumonia, three
episodes of delirium, and 2-degree bedsores. He
resides in his own house in the center of
Othertrackside. The local hospital is the only
medical facility with a geriatric unit in a 75-
mile radius that will accept Medicare clients.
His respiratory complications started 4 weeks ago. He experienced
SOB and pain with breathing after working in his garden 3+ hours at
43°F temperature while it was raining. The frequency and severity of

1208
 the respiratory problems resulted in Lorenzo significantly decreasing his
activities while increasing his time in the bed. When he was rushed to
the hospital, due to severe chest pains and arrhythmia, his neighbor
Adam, a 97-year-old African American male, expressed to the admitted
nurse, “Please fix him Ms. Nurse. He has just been lying in bed staring
at the ceiling for a while now. Even at bedtime, it was like sleeping next
to a dead person; he didn't even roll around or sit up. He even didn't
speak to his sister and brother when they made their occasional visit or
any of the neighbors who stopped by to check on us.” The nurse later
discovered that Lorenzo and Adam are in a 50+ year intimate
relationship.
Your job is to facilitate Lorenzo's return to his home from Uptown
Hospital, assist him in regaining his preillness level of activity, and
address issues affecting his mental health. The teaching over your
scheduled visits will include but not limited to the following:

Signs and symptoms warranting follow-up

Medication and administration
Nutrition and fluid consumption
Bladder, bowel, skin, and mental health care
ADLs and IADLs
Physical activity/endurance
Safety/injury prevention
Altered significant other/family/neighbor processes
Community resources

Consider the following questions:

1. How will you empower the family to avoid Lorenzo's isolation

(self-imposed and socially constructed), risky behavior, and
potential for noncompliance with his treatment?
2. How would you prioritize Lorenzo's issues, both medical and
psychosocial?
3. As the public health nurse, what interventions can you utilize to
achieve the indicated goals without offending, embarrassing,
alienating, and/or “outing” the core family system?

Assessment Methods
Assessment methods generate information about selected aspects of family
structure and function, while matching the purpose for assessment. An
informal approach consists of the nurse's acute observational skills and
occasional questioning to confirm the observations and determine the next
direction to take. A formal approach entails the use of specific questions and

1209
assessment tools to assess each family member in terms of health data,
family history, physical data, family's development, or potential health
problems not detected by family members.
The genogram (Fig. 14-5) diagrams the family's genealogy,
relationships, and complex family patterns. The PHN can formulate
hypotheses about a family over a significant period of time and across
generations (de Souza, Bellato, de Araujo, & de Almeida, 2016). Completing
the genogram with the family encourages family expression, which can
reveal family behavior and problems. The genogram has been useful in
linking health outcomes to preventive strategies based on potential health
risks and guiding clinical and public health interventions (Centers for
Disease Control and Prevention [CDC], 2018).

FIGURE 14-5 A genogram.

The eco-map (Fig. 14-6) shows the connections between a family and
the other systems in the ecologic environment. It visually depicts dynamic
family–environment interactions (de Souza et al., 2016). A central circle
represents the family or family member with smaller peripheral circles
indicative of people and systems significantly relating to the central circle.

1210
Connecting lines between the central circle and smaller ones depict the
strength of relationships.

FIGURE 14-6 An eco-map of a family's relationship to its

environment.

For consistency and ease of documentation, public health nursing

agencies usually develop their own tools, often in the form of questionnaires,
checklists, flow sheets, or interview guides (Chapman et al., 2017; Pontin et
al., 2019) to fit organizational needs (for examples of family assessment
tools, visit ). One type of family assessment tool uses questions
based on characteristics of healthy families and follows a checklist format
that is useful to observe family growth or decline over a span of time. The
novice C/PHN can use this tool to gather data and to document how the
nurse's rapport develops with the family and the PHN's comfort level.
Another type of family assessment tool has an open-ended format that
allows the nurse to create an informative document while limiting subjective
observations. A self-care assessment guide examines a family member's
ability to provide self-care by measuring the family's stressors and self-care
practices. This tool is used adjunctively, especially with families from
various cultural groups. Videotaping is a method used to assess family
interactions for structured observations and analyses of life-changing events.
Using it with other tools enhances the breadth of data collection.

Guidelines for Family Health Assessment

1211
There are five guidelines to use since a family health assessment results in a
voluminous amount of data. These guidelines emphasize the family as the
core service unit and will strengthen your ability to work collaboratively with
the family—promoting a trusting relationship.

Focus on the Family as a Total Unit

The family is a single core unit of service, and it is the family's aggregated
behavior that is being assessed (APHN, 2016a, 2016b; Shajani & Snell,
2019). The C/PHN ensures that the information is typical of the entire family.
Getting families to share their stories can be a health promotion tool by
creating meaning for individuals and the family. The story can tell nurses
what is important to the family to help develop interventions. Nurses can
begin by asking the family who are you from rather than where are you
from? Practice telling and listening to family stories with someone
(Driessnack, 2017).
When assessing the communication patterns of two family members, the
nurse is also thinking about how other family members communicate among
themselves and with the two being assessed. After analyzing the data, the
nurse may decide that the family, as a whole, communicates well and
supportively even if one family member does not. The nurse documents this
deviation and considers it in the care planning.

Ask Goal-Directed Questions

Goal-directed questions are the cornerstone of a detailed assessment (Sperry,
2019; Shajani & Snell, 2019). They facilitate the C/PHN in determining a
family's level of health, making family diagnoses, and crafting a care plan.
These relevant questions yield relevant and comprehensive data that goes
beyond the family dynamics at the moment (Sperry, 2019). Examples of
goal-directed questions include the following:

Does this family recognize when a change needs to be made?

How does the family react when a change is forced on the family?
If a problem arises from the change, such as the baby having diarrhea or
constantly crying, will the family be responsible for dealing with the
problem?
Is there a family member who knows how to solve the problem, and will
this person be willing to accept outside assistance?

Thus, you watch everyone closely for signs of the family's response(s) to
change and the ability to problem-solve any problems resulting from the
change. Another more open-ended format or approach is to use assessment
categories to stimulate questions to explore family support systems for a
specific category.

1212
Collect Data Over Time
You want to take your time to accumulate observations, make notes, identify
both major and minor issues, and observe the interactions of all family
members (Sperry, 2019; Shajani & Snell, 2019).
Timeliness also helps to develop a trusting and supportive relationship
with the family since assessment can occur during any family activity such as
mealtime. The family needs to feel comfortable with you, the observing
nurse. Even if the C/PHN feels welcomed and comfortable at the initial home
visit, it may take the family several visits to reciprocate that level of comfort.

Combine Quantitative With Qualitative Data

Both qualitative and quantitative data are collected when appraising a
family's health and are used to create a database for planning care. Asking if
family members engage in some type of behaviors is qualitative, and asking
how often the family engages in the behaviors is quantitative.
One type of assessment tool evaluates a family's ability to enhance
individuality by rating the family's behavior on a scale of 0 (never) to 4
(most of the time), which provides a way to compare the family's
development over several home visits. The difference between the present
and previous scores assists the C/PHN in executing the intervention(s). For
this reason, it is useful to conduct periodic assessments when a case is
reopened or every 3 to 6 months if it is kept open for an extended period.

Exercise Professional Judgment

The content of a family assessment is driven by the nurse's professional
judgment with the assessment tools guiding the nurse's observations and
quantifying the nurse's decisions (McDowell & Boyd, 2018; Sperry, 2019).
The nurse may observe that a family makes good use of a community
agency, but the decision that using this external resource contributes to the
family's health results from a professional judgment. An assessment tool is
only a tool, and its value should never be interpreted as an absolute and
irrevocable statement about a family's health status.
As a professional, the C/PHN knows that the completion of an
assessment tool should occur at the end of the home visit(s). The C/PHN may
review the assessment tool before entering a family's home or keep it in a
folder for easy reference or note during the visit. However, the assessment
tool is not completed in the presence of the family. Even with an eco-map or
genogram, the C/PHN uses professional judgment to determine when the
family is ready.

1213
Family Health Diagnosis
The family diagnosing process moves the data from assessment to care
planning, implementation, and evaluation. This process is an expected
standard of practice for public health nurses (APHN, 2016a, 2016b). The
C/PHN uses observational skills and clinical reasoning to understand the
patterns in the data.
Specifically, the C/PHN identifies patterns of behavior, barriers
preventing the family from being healthy, and internal relationships with the
external environment (APHN, 2016a, 2016b). Next, the nurse prioritizes the
information while taking the best action(s) for the desired outcome or goal
(Kaakinen et al., 2018). The diagnosing process can occur as follows
(Kaakinen, et al., 2018):
1. Identify the family health problems.
a. Determine what family members are directly and indirectly related to
the problem.
b. Determine what factors from the external environment are related to
the problem.
c. Describe the problem as it impacts the identified family members
and external environment.
d. Indicate the risks that are associated with the problem(s).
e. Prioritize the problems along with their risks with an emphasis on the
problems that are overlapping and/or have overlapping risks.
2. Indicate the factors from the family (family unit and family members)
and the external environment that are associated with the health
problems.
3. Determine the measurements (quantitative and qualitative data) that
confirm or verify the health problems.
The diagnosing process is an ongoing one with two major goals: improve
the family health and give them the tools for health promotion. It should be
completed several times, especially with a lot of assessment data so that the
nurse can craft a plan of care to move the family toward a state of health.

1214
Family Health Planning and Implementation
A formal care plan occurs after identifying the main concerns, problems, and
risks. The nurse and the family collaborate to identify the problem(s), to
suggest interventions, and to discuss the plan of action (Fiese, Celano,
Deater-Deckard, Jouriles, & Whisman, 2018; Stastny et al., 2016; Shajani &
Snell, 2019).
If there is no agreement, the data should be reviewed and discussed with
family members to reach a mutual understanding about the best interventions
and how to put them into action. The family needs to believe in the plan of
action or the nurse will be limited in her or his efforts to prevent identified
problems and/or risks while promoting the family's health (Shajani & Snell,
2019). Once family members are ready to learn ways to improve their health
status, then the nurse determines the best teaching approach to use and tailors
interventions to the specific family needs and functional capability (Sperry,
2019; Shajani & Snell, 2019). If the family's level of functioning does not
enable them to use anticipatory guidance and teaching, then the nurse can
serve as a counselor.
Planning for subsequent visits assures that the nurse is totally prepared
for the next encounter with the family, assuring a successful family visit.
This planning ensures that the family transitions toward a healthy outcome in
the visit. Planning commences during the first home visit as the nurse
collects data so that subsequent visits can be individualized and tailored to
meet the family's needs, especially since this information is not available
from a paper referral. Consequently, planning for the next visit will affect the
nurse's continued success with the family.
Implementation includes making referrals and contacting appropriate
resources.

Making Referrals
The nurse makes a referral so that the family can have access to services that
might be beyond the agency's resources. The referral reflects the nurse's
knowledge of resources within the community, which includes the eligibility
requirements and availability of services, provided by official, voluntary,
religious, and neighborhood organizations (Kaakinen et al., 2018; McDowell
& Boyd, 2018). The nurse must also be aware of any updates or changes to
the information about these organizations. Therefore, C/PHNs need to
network with colleagues on a regular basis in order to remain up-to-date with
community services for family referrals (APHN, 2016a, 2016b; Kaakinen et
al., 2018).

1215
Contacting Resources
Public health nurses know how to access key personnel in agencies, which
can eliminate some of the red tapes involved in obtaining services, while
giving family members pointers on procuring needed services. When
C/PHNs seek informal services for families, the nurse establishes a
relationship with the agency's staff that can help nurses secure services for
the family over time. This rapport can also be used to connect with other
agencies, which increases the nurse's database of services.

1216
Family Health Evaluation
Evaluation represents the final step in the nursing process and involves
appraising the work with the family and preparing for the next visit. A formal
evaluation concludes with the documenting of the outcomes, which
facilitates the nurse in making appropriate referrals and contacting key
resources to meet the needs of family.
The components of the evaluation are the structure–process, the
outcome, and the nurse's self-evaluation. Each one contributes to determining
what made the visit a success and what made it less than successful by
evaluating if the outcomes were achieved and if they can be advanced to the
next level of family health. The nurse must be prepared to determine if a
change is needed in the structure–process, the nurse's level of preparedness,
or the nurse's behavior in order to promote health in the family, the
community, and eventually the population.

Structure–Process Evaluation
The structure–process evaluation should be completed first as it refers to the
organization of the visit and how it proceeded (see Chapter 12). The nurse
identifies where the organization or the flow of the assessment needs to be
changed or modified in order to avoid distractions in the next visit.
Specifically, the nurse will analyze the available resources, number of
persons present, timing of home visit(s), environmental factors, or
materials/supplies used as well as the use of observational skills, people's
attitudes, and reliance on standards of assessment and analysis. Every aspect
must be used in the evaluation in order to effectively and thoroughly modify
subsequent visits.

Outcome Evaluation
The outcome evaluation facilitates the nurse in deciding if the anticipated
outcomes were achieved and what made them possible. This outcome
evaluation, a formal appraisal process, happens with documentation of the
home visits. The effectiveness of any achieved outcomes is determined with
standards and/or agency-driven criteria.
The standards are the Nursing Outcomes Classification (NOC) System,
the Nursing Intervention Classification (NIC) System, and the Omaha
System (see Chapter 15). The agency-driven criteria may be the successful
achievement of the indicated expectations for each client category or visit
type. Evaluating the outcomes with the agency-driven criteria may be more
exact if the effectiveness is demonstrated by small changes over time in the

1217
family dynamics as noted on a visit-by-visit basis instead of cumulatively as
represented in the standards. Therefore, the nurse must use professional
judgment to determine the success or failure of the family to achieve certain
outcomes at the conclusion of agency services, with the family included in
the decision process.

Self-Evaluation
The self-evaluation encompasses the nurse appraising the ability to facilitate
the desired outcome during the home visit(s), the level of being prepared, the
thoroughness in data collection, the degree of preparedness for subsequent
home visits, and the pros and cons of completed home visits. In other words,
this self-evaluation affords the community/public health nurse the
opportunity to recognize her or his strengths and failings with internal
measures to improve practice (Edelman & Kudzma, 2017).
In some agencies, routine peer evaluations are conducted to recognize
strengths and/or weaknesses not indicated in a self-evaluation. The peer
evaluation can be completed by an agency staff nurse who makes a family
visit with the community/public health nurse and provides feedback based on
her or his observations. This might be helpful when working with a family
that has not made progress toward the desired outcomes or to a family you
have not been able to reach (Sperry, 2019). Peer consultation can also assist
the C/PHN in becoming better prepared or more focused in order to improve
the interaction(s) with families from different cultures or in difficult
situations (Spector, 2017).

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SUMMARY
Because today the family is recognized as an important unit of service,
an effective C/PHN must understand family theory and characteristics.
Family health and individual health strongly influence each other, and
family health affects community health.
Although every family on the globe is unique in terms of its needs and
strengths, each family is at the same time alike because of certain shared
universal characteristics: every family is a small social system, has its
own cultural values and rules, has structure, has certain basic functions,
and moves through stages in its life cycle.
The C/PHN needs to understand the different needs of various family
patterns. Whereas the single adolescent parent needs the community
health nurse's knowledge of family developmental theory, more
complex interaction patterns and living arrangements are created by
divorce, remarriage, the blending of families, and the unique
relationships these arrangements create. Gay and lesbian families with
children may also have special needs, calling for a sensitive
understanding of society's reaction to their family.
The essential starting point in the community health nurse's work is to
accept the family's definition of who their family is and listen to the
family's ideas. The nurse and the family become partners in providing
health care, with the nurse beginning the work assessing the family's
strengths, which will begin to build a positive relationship between the
nurse and the family. The family unit remains the focus of service in
public health nursing because each family member strongly influences
the other, which affects the community health.
Healthy families demonstrate six important characteristics. The
characteristics of a healthy family provide one assessment framework
that public health nurses can use.
Making family health visits is a unique role for nurses and is one of the
activities common to most public health nurses.
The nurse's preparation for the visit facilitates (1) an orderly and
organized flow for the visit and (2) the nurse becoming acquainted with
the family, which is indispensable for the comprehensive execution of
the nursing process and development of a trusting relationship.
For a comprehensive assessment, C/PHNs employ acute observational
skills, good verbal and nonverbal communication, assessment skills, and
intuition to guide them safely in the community and with the families
they visit.

1219
The family is a total unit or single entity, and the nurse must consciously
recall this point through the home visits and every stage of the nursing
process, especially during assessment.
To systematically assess a family's health, the nurse needs a conceptual
framework, categories for data collection, and a measure of the family's
level of functioning.
The main broad categories of a family health visit are previsit
preparation, conduct of the visit, postvisit documentation, and
preparation or planning for the next visit. Each step contributes to the
success of the subsequent one.
There are specific precautions for safety that a nurse must follow if
using a personal or agency car or public transportation or walking to
visit families. Safety must be considered in a family's home even if it
means terminating the visit and rescheduling.
The nurse empowers the family by establishing a verbal or written
contract with the family so that the family members (1) understand their
personal roles and responsibilities in the relationship and (2) feel
confidence in making independent decisions about their own health.
The C/PHN makes referrals to other agencies on behalf of the family in
order to provide all the services that a family needs; therefore, the
C/PHN needs to know how and where to locate official and voluntary
services within their community.

1220
ACTIVE LEARNING EXERCISES
1. Analyze two families you know well (other than your own) and
answer the following questions:
If the major breadwinner in this family was unable to work or lost his
or her job, how would the family most likely respond immediately
and in the long term?
What are the strengths of the family?
How could a nurse most effectively intervene in this situation?
2. Talk with members of a blended family, and discuss with each
member his or her relationships with stepchildren, stepparents, or
siblings. What strengths can they identify in their family? How has
this helped them adapt to their blended family?
3. Listen to two to three stories on Story Corp https://storycorps.org/.
What did you learn? Are there themes that you recognize among the
stories?
4. Construct an eco-map of your family and ask a peer to do the same,
which can be completed face-to-face or online (i.e., Google Docs).
Compare the eco-maps. Assess the balance between your family and
the resources in its environment. How does your eco-map compare
with that of your peer? What changes are needed in each family
system? Are you able to influence the changes that are needed?
5. Using “Build a Diverse and Skilled Workforce” (1 of the 10 essential
public health services; see Box 2-2 ), watch one of the two YouTube
videos, A Day in the Life of a Public Health Nurse
(https://www.youtube.com/watch?v=n8FvhaMvcDQ) or A Day in the
Life-Mary (Public Health Nursing) https://www.youtube.com/watch?
v=fGj5wncmuX0, with one or two classmates. Evaluate the public
health nurse in terms of structure–process and outcomes as well as a
peer evaluation of the PHN. With your classmates, discuss the PHN's
strengths and weaknesses, and identify what actions you would
emulate, change, or leave as is. Identify five instances in the video
that made you feel uncomfortable, discuss with your classmates why
these occurrences affected you, and discuss ways to process these
feelings.

thePoint: Everything You Need to Make the

Grade!

1221
 Visit http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, study aids for
all learning styles, and more!

1222
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CHAPTER 15
Community as Client
“The health of the public is another shared value. Not only does each individual have an interest
in staying healthy, but all of us together share an interest in having a healthy population.”

—Dan E. Beauchamp & Bonnie Steinbock, New Ethics for the Public's
Health

KEY TERMS
Assets assessment Community as client Community development
Community diagnosis Community-oriented, population-focused care
Community subsystem assessment Conceptual model Descriptive
epidemiologic study Key informants Outcome criteria Partnerships Priority
setting Problem-oriented assessment Social determinants of health
Windshield survey

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Discuss three essential characteristics of nursing service when a
community is the client.
2. Describe the contributions of two models of nursing practice to
community/public health nursing practice.
3. Describe the characteristics of a healthy community.
4. Describe the meaning of community as client.
5. Articulate three specific considerations of each of the three dimensions
of the community as client.
6. Discuss methods of community health assessment.
7. Delineate five sources of community data.
8. Describe the role of the community health nurse as a catalyst for
community development.

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INTRODUCTION
When you open the door of a senior center where you will be promoting
cardiovascular fitness, advocating for exercise equipment, and suggesting
changes in the on-site meal program, how might theories of public health
nursing contribute to your success? When you approach your city council
about the need to increase staffing for public health services, what models of
public health nursing practice might support your argument? What are
theories, models, and principles, and what is their relevance to day-to-day
public health nursing practice? These are the key issues explored in the first
three sections of this chapter.
The remainder of the chapter explores the definition of a healthy
community, dimensions of the community as client, and application of the
nursing process to the community as client. Included in this discussion are
the types of community needs assessment, methods of collecting and sources
of community data, data analysis and diagnosis, and making, implementing,
and evaluating plans for community health promotion.

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WHEN THE CLIENT IS A
COMMUNITY: CHARACTERISTICS
OF COMMUNITY/PUBLIC HEALTH
NURSING PRACTICE
Nursing exists to address people's health care needs, and nurses fulfill this
purpose through their work in various specialty areas. Specialties are
characterized by the unit of care for which the specialty is responsible and by
the goal of the specialty. Each specialty requires a particular area of
knowledge and a set of skills for excellence in practice.
Public health nursing is a specialty in which the unit of care is a specific
community or aggregate, and the nurse has responsibility to promote group
health. The goal of this specialty is health improvement of the community.
Some of the skills required for excellence in public health nursing practice
include epidemiology, research, teaching, community organizing, and
managing programs and outcomes related to interpersonal relational care.
Public health nursing is characterized by community-oriented,
population-focused care and is based on interpersonal relationships. In the
following sections, each of these characteristics is examined in more depth.
A community is a collection of people interacting with one another
because of geography, common interests, characteristics, or goals. These
interactions include social institutions, such as schools, government agencies,
and social services. The concept of community as client refers to a group or
population of people as the focus of nursing service (Anderson & McFarlane,
2019).
As described in Chapters 1 and 2, understanding the concept of the
community as client is a prerequisite for effective service at every level of
community nursing practice. Population-focused practice distinguishes
community health nursing from other nursing specialties (American Nurses
Association [ANA], 2018; American Public Health Association, Public
Health Nursing Section, 2013).
Community orientation is a process that is actively shaped by the unique
experiences, knowledge, concerns, values, beliefs, and culture of a given
community. For example, when an outbreak of hepatitis occurs, the public
health nurse (PHN) does more than simply treat infection in individuals. The
nurse also

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 Uses disease investigation skills to locate possible sources of infection
(see Chapter 7)
Determines how the community's knowledge, values, beliefs, and prior
experiences with infectious disease may influence its interpretation of
the disease, response to the outbreak, and treatment preferences
Uses knowledge and suggestions gathered from the community to
develop, in collaboration with other health professionals, a community-
specific program to prevent future outbreaks

A community-oriented nurse who provides education about sexually

transmitted diseases to a group of students at a Catholic university includes
consideration of community values regarding sexual behavior. Similarly, a
community-oriented nurse who provides nutritional counseling to a
community of Hispanic older adults considers the meaning of food in their
culture, the types of food most commonly consumed, and the cooking
methods most commonly used.
A population refers to all people occupying an area, such as a city,
county, or state. Parts of populations may be subpopulations or aggregates.
Smokers and refugees are two subpopulations. The nurse's place of
employment commonly limits the population that the nurse serves. For
example, a nurse who works for a county health department is limited
professionally to caring for the population residing in that county.
A population focus requires that a nurse use population-based knowledge
and skills such as epidemiology, community assessment, and community
organizing as bases for interventions. For example, a population-focused
nurse employed by an autoworkers' union may study all cases of repetitive
use injury occurring in the auto industry in the United States in the past 5
years, develop a program for reducing repetitive use injury, and lobby
industry executives for adoption of the program.
Community-oriented, population-focused care employs population-based
knowledge and skills and is shaped by the characteristics and needs of a
given aggregate, community, or population. C/PHNs provide community-
oriented, population-focused care when they count and interview homeless
people sleeping in a park and, based on these data, help develop a program to
provide food, clothing, shelter, health care, and job training for this
population.

1233
THEORIES AND MODELS FOR
COMMUNITY/PUBLIC HEALTH
NURSING PRACTICE
Nursing is a theory-and evidence-based profession. “Theory-guided,
evidence-informed practice is the hallmark of any professional discipline”
(Smith, 2019, p. 3). As a nursing specialty, community/public health nursing
is not only guided by theories and evidence that pertain to the nursing
profession, but also theories and evidence that have been specifically
developed and tested for the specialty. Borrowed and shared theories are also
major parts of the practice of community and public health nursing.
Examples of shared theories are health behavior, learning theory, and
diffusion of innovations.
In the classical definition, a theory is “a set of interrelated constructs,
definitions, and propositions that present a systematic view of phenomena by
specifying relations among variables, with the purpose of explaining and
predicting the phenomena” (Kerlinger, 1973, p. 9). A theory is based either
explicitly or philosophically on a conceptual model (also referred to as a
conceptual framework, a conceptual system, or a paradigm). A conceptual
model, as originally defined, is a set of concepts and the propositions that
integrate them into a meaningful configuration (Lippitt, 1973). These
concepts are presented in a framework format used to explain the
relationships among variables. A conceptual model cannot be used directly in
research or clinical practice. Linking a conceptual model with one or more
theories to form the conceptual-theoretical systems of knowledge is needed
for action (Fawcett, 2017).
Having been exposed to nursing theories throughout your nursing
program, you will recall that nursing theories are usually classified as grand
theories, middle-range theories, and situation-specific theories (Smith &
Liehr, 2018).
Grand theories are frameworks composed of concepts and relational
statements that explain abstract phenomena (Smith, 2019). These theories
have a high level of abstraction and are not directly applicable to nursing
practice. An example of a grand theory is Rogers' Model of the Science of
Unitary Human Beings. This model emphasized that the individual and
environment should be viewed as one unit; that is, focusing on the individual
without examining her or his environment or examining parts of a
community, such as its health care or housing, does not provide an adequate

1234
picture of its totality in relation to the person (Johnson & Webber, 2015).
Rogers also incorporated developmental theory into her model by describing
the development of “unitary” persons or systems according to three
principles: (1) life proceeds in one direction along a rhythmic spiral, (2)
energy fields follow a certain wave pattern and organization, and (3) human
and environmental energy fields interact simultaneously and mutually,
leading to completeness and unity (Rogers, 1990).
Middle-range theories have more limited scope and are less abstract than
grand theories. These theories are intended to be used for practice as well as
research. An example of a middle-range theory is self-care of chronic illness
(Riegel, Jaarsman, & Stromberg, 2012). The core elements of this theory are
self-care maintenance, self-care monitoring, and self-care management. Self-
care management is a process of recognizing changes in signs and symptoms,
making decisions about self-care actions, and evaluating outcomes of that
action. Several factors influence whether a patient is successful in
performing self-care, such as confidence, motivation, and support from
others. Community/public health nurses provide care to many individuals
who use self-care to manage their chronic illnesses. This theory would be
helpful to care for these individuals.
Situation-specific theories focus on specific nursing phenomena that
reflect clinical practice and are limited to specific populations or to particular
fields of practice. “They are theories that are more clinically specific, that
reflect a particular context, and that may include blueprints for action” (Im &
Meleis, 1999, p. 13). An example of a situation-specific theory is depression
in Black single mothers (Atkins, 2016). The investigator hypothesized and
tested a model of the relationships of perceived stress, perceived racism, and
self-esteem to depression. Although further study is needed, this model of
situation-specific theory of depression can be used to improve care to single
Black mothers (Atkins, 2016).
Betty Neuman's Systems Model provides a comprehensive holistic and
system-based approach to nursing that contains an element of flexibility (Fig.
15-1). The theory focuses on the patient's response to actual or potential
environmental stressors and the use of primary, secondary, and tertiary
nursing prevention intervention for retention, attainment, and maintenance of
patient system wellness. Table 15-1 shows an example of applying Neuman's
model to the prevention of cardiovascular disease (CVD) in an ethnic
minority population (Neuman, 1980).

1235
 FIGURE 15-1 Neuman's health care systems model. (Adapted
with permission from Neuman, B., & Fawcett, J. (2011). The
Neuman systems model (5th ed., Fig. 1-3, p. 13). Upper Saddle
River, NJ: Pearson. Original diagram copyright © 1970 by Betty
Neuman.)

TABLE 15-1 Applying Neuman's Model to Prevention of

Cardiovascular Disease (CVD) in an Ethnic Minority

1236
Population

Source: Angosta, A.D., Ceria-Ulep, C.D., & Tse, A.M. (2014). Care delivery for Filipino Americans
Using the Neuman Systems Model. Nursing Science Quarterly, 27(2), 142-148.

1237
Salmon's Construct for Public Health Nursing
Although not a theory, Salmon proposed a model to specifically guide
community health nursing practice. Salmon (1982, 1993) described public
health as an organized societal effort to protect, promote, and restore the
health of people and public health nursing as focused on achieving and
maintaining public health.
The model describes three practice priorities:

Prevention of disease and poor health

Protection against disease and external agents
Promotion of health

The three general categories of nursing intervention are:

Education that is directed toward voluntary change in the attitudes and

behavior of the subjects
Engineering that is directed at managing risk-related variables
Enforcement that is directed at mandatory regulation to achieve better
health

The scope of practice spans individual, family, community, and global

care. Interventions target determinants in four categories: human/biologic,
environmental, medical/technologic/organizational, and social.
Using Salmon's approach, a C/PHN attempting, for example, to reduce
the transmission of tuberculosis, would use education, engineering, and
enforcement in working with the population of affected individuals and
families. Strategies could include collaboration with the client community on
a variety of interventions, from mandating isolation precautions to providing
education about medications and connecting the client and his or her family
to social support, in an effort to prevent further disease in the community and
to promote global health.

1238
Minnesota Wheel: The Public Health Interventions
Model
The Minnesota Department of Health, Division of Community Health
Services, Public Health Nursing Section, developed a model that depicts
public health interventions and applications for public health practice. In the
form of a wheel (Fig. 15-2), the model contains 17 different interventions for
population-based interventions within three levels of public health practice:
community-focused practice, systems-focused practice, and individual-
focused practice (Minnesota Department of Health, 2019).

FIGURE 15-2 The Minnesota wheel. (Reprinted with permission

from Minnesota Department of Health, Division of Community
Health Services, Public Health Nursing Section. Retrieved from
https://www.health.state.mn.us/communities/practice/research/phnc
ouncil/docs/PHInterventions.pdf)

The Wheel can be applied in a variety of activities, including public

health practice, nursing education, and management. Keller and colleagues
emphasized that the “use of the Wheel has empowered nurses to explain in a
better way how their practice contributes to the improvement of population
health” (Keller, Strohschein, Lia-Hoagberg, & Schoffer, 2004, p. 454). The
wheel is useful for C/PHNs because it visually depicts the comprehensive list
of interventions nurses must consider in the scope of practice. Schaffer,

1239
Anderson, and Rising (2016) described how school nurses used the model
interventions in their day-to-day work.

1240
Public Health Nursing Practice Model
The Los Angeles County Public Health Nursing (LAC PHN) Practice Model
was developed in response to an identified need for a model that could blend
public health nursing practice and the principles of public health, which
could be applicable to both the generalist nurse and nurses working in
specific programs (Smith & Bazini-Barakat, 2003). The LAC PHN Practice
Model (Public Health Nursing, Los Angeles County Department of Health
Services [PHN, LAC-DHS], 2013) integrates foundational nursing and
public health guiding documents, including the Public Health Nursing
Standards of Practice, the 10 essential public health services, the Healthy
People health indicators, and the Public Health Nursing Practice Model (Fig.
15-3). The LAC PHN Practice Model provides a “conceptual framework that
assists in clarifying the role of the C/PHN and presents a guide for public
health practice applicable to all public health disciplines” (Smith & Bazini-
Barakat, 2003, p. 42).

FIGURE 15-3 Public health nursing practice model. (Reprinted

from the Los Angeles County Department of Public Health, Public
Health Nursing. Retrieved from
http://publichealth.lacounty.gov/phn/docs/PracticeModelfinal2.pdf)

The principles of population-based practice are included in the LAC

PHN Practice Model (PHN, LAC-DHS, 2013; Smith & Bazini-Barakat,
2003). C/PHNs integrate assessment, policy development, and assurance into
their work. The three levels of population-based practice—individuals and
families, community, and systems—are addressed, with the nursing process
applied throughout the model. The 17 interventions, as first presented in the

1241
Minnesota Public Health Nursing Model described above, are also
incorporated into the LAC PHN Practice Model. This model promotes the
concepts of an interdisciplinary public health team working together with an
emphasis on primary prevention. The model also recognizes the importance
of active participation of the individual, family, and community (PHN, LAC-
DHS, 2013; Smith & Bazini-Barakat, 2003).

1242
Omaha System
The Omaha System (Fig. 15-4) is a multidisciplinary standardized interface
that incorporates documentation of nursing assessment and interventions
(Thompson, Monsen, Wanamaker, Augustyniak, & Thompson, 2012). It is a
comprehensive system, with the following components (Martin, 2005):

FIGURE 15-4 Omaha system model of the problem-solving

process. (Reprinted with permission from Martin, K. S. (2005).
The Omaha System: A key to practice, documentation, and
information management (2nd ed.). Omaha, NE: Health
Connections Press.)

The problem classification scheme is a holistic, comprehensive method

for identifying clients' health-related concerns. Included are domains,
problems, modifiers, and signs/symptoms. Problems can be identified at
the individual, family, or community level.
The intervention scheme provides a framework for documenting plans
and interventions in the client record in the areas of health teaching,
guidance, and counseling; treatments and procedures; case management;
and surveillance.
The problem rating scale for outcomes consists of a Likert-type scale
that is a systematic and recurring method to document the progress of
clients in the record and in case conferences during their time of service
in the agency. It is used in conjunction with any problem in the problem

1243
 classification scheme. Central to problem rating is quantifying outcomes
in three dimensions: knowledge (what the client knows), behavior (what
the client does), and status (how the client is).

The model is applicable to individuals, families, and communities and

provides a mechanism to evaluate both individual and group change over
time. With ongoing pressure for public health program funding, outcome
data are vital and can be captured through the application of the Omaha
System.

1244
PRINCIPLES OF
COMMUNITY/PUBLIC HEALTH
NURSING
Public health nursing is “…evidence-based and focuses on promotion of the
health of entire populations and prevention of disease, injury, and premature
death” (ANA, 2013, p. 3). The key elements of this practice include (ANA,
2018)

Population-level focus on issues including health inequities and the

needs of special vulnerable populations
A comprehensive and systematic assessment with particular attention to
the determinants of health
A focus on primary prevention
Implementation of interventions of primary, secondary, and tertiary
levels of prevention

The ANA recognizes that C/PHNs function as part of an interdisciplinary

team from various organizations and agencies and collaborate with members
of the communities they serve and recommends a baccalaureate education for
entry-level C/PHNs. The Public Health Intervention Wheel and the 10
Essential Public Health Services serve as guides to the C/PHN's activities
(ANA, 2018).
Principles are universals to help achieve the most beneficial outcomes.
The goals of public health nursing, to promote and protect the health of
communities, are facilitated by adhering to eight principles identified by the
ANA (2018) for public health nursing practice. These principles are
summarized in Box 15-1 and discussed in depth below (ANA, 2018).

BOX 15-1 Principles of Public Health

Nursing
1. Focus on the Community. The client or unit of care is the
population.
2. Give Priority to Community Needs. The primary obligation is to
achieve the greatest good for the greatest number of people or the
population as a whole.

1245
 3. Work in Partnership With the People. The processes used by
public health nurses (C/PHNs) include working with the client as
an equal partner.
4. Focus on Primary Prevention. Primary prevention is the priority
in selecting appropriate activities.
5. Promote a Healthful Environment. Public health nursing focuses
on strategies that create healthy environmental, social, and
economic conditions in which populations may thrive.
6. Target All Who Might Benefit. A C/PHN is obligated to actively
identify and reach out to all who might benefit from a specific
activity or service.
7. Promote Optimum Allocation of Resources. Optimal use of
available resources to ensure the best overall improvement in the
health of the population is a key element of the practice.
8. Collaborate With Others in the Community. Collaboration with
a variety of other professions, populations, organizations, and other
stakeholder groups is the most effective way to promote and
protect the health of the people.

Adapted from American Nurses Association (2018, pp. 8–9).

1246
Principle 1: Focus on the Community
The first principle reminds us that the ultimate responsibility of public health
nursing is to direct services to the population as a whole. Even though
C/PHNs may intervene to address individual, family, or group needs, the
entire community is the client (Ervin & Kulbok, 2018).

1247
Principle 2: Give Priority to Community Needs
The second principle deals with the ethical obligation of the C/PHN to give
priority to the needs and preferences of the whole community over those of
one individual. This means that the nurse must consider interventions that
will lead to the greatest good for the most people (Rushton & Broome,
2015).

1248
Principle 3: Work in Partnership With the People
The third principle requires the C/PHN to work in partnership with the
community. The nurse and the community members (or groups) each bring
their own values, beliefs, and expertise to the partnership (Anderson &
McFarlane, 2019). Policy development and assurance are more likely to be
accepted and applied if there is mutual consideration of and respect for these
elements. Developed policies need to be communicated in language that
reflects an understanding of the community

1249
Principle 4: Focus on Primary Prevention
The fourth principle of public health nursing underscores the importance of
primary prevention in promoting the health of people. Public health nursing
has an obligation to prevent health problems and injuries and to promote a
higher level of wellness (Anderson & McFarlane, 2019).

1250
Principle 5: Promote a Healthful Environment
The fifth principle highlights the importance of ensuring that people live in
conditions conducive to health. C/PHNs, along with other public health
professionals, understand the effects of social determinants of health and
work to improve those (O'Brien, 2019).

1251
Principle 6: Target All Who Might Benefit
The sixth principle involves outreach strategies to meet the obligation to
serve all people who might benefit from an intervention. This tenet requires
that the nurse examine policies or programs to determine whether they are
accessible and acceptable to the entire population in need and advocate for
change if necessary (Ervin & Kulbok, 2018).

1252
Principle 7: Promote Optimum Allocation of
Resources
The seventh principle addresses resource allocation decisions. In most
communities, the available resources are not sufficient to meet all needs of
all people. The nurse must ensure that the community is using limited
resources in ways that lead to the greatest improvement in health (Swider,
Berkowitz, Valentine-Maher, Zenk, & Bekemeier, 2017). To promote
optimum allocation of resources, the nurse must

Know the latest research on the effectiveness of various programs in

addressing needs
Collect information about the short-and long-term costs of programs
Evaluate existing programs and policies for ways to improve or
discontinue them
Communicate this information to community decision makers, so that
they can make resource allocation decisions that are most likely to
improve the community's health

C/PHNs should continue to work on all levels to promote greater funding

for public health programs and more effective allocation of resources.

1253
Principle 8: Collaborate With Others in the
Community
The eighth principle underscores the importance of collaboration with other
nurses, health care providers, social workers, educators, spiritual leaders,
business leaders, and government officials within the community. This
interdisciplinary collaboration is essential to execute effective programs and
improve health outcomes. Programs that are planned and implemented in
isolation can lead to fragmentation, gaps, and overlaps in health services
(Ervin & Kulbok, 2018).

1254
WHAT IS A HEALTHY
COMMUNITY?
Just as health for an individual is relative and will change, all communities
exist in a relative state of health. A community's health can be viewed within
the context of health being more than just the absence of disease and
including things that promote the maintenance of a high quality of life and
productivity. A key vision for healthy communities is presented in Healthy
People 2030 the national agenda for health and well-being published by the
U.S. Department of Health and Human Services (USDHHS, 2020). See
Chapter 1. The five overarching goals for the health of the nation are to:

Attain healthy, thriving lives and well-being free of preventable disease,

disability, injury, and premature death.
Eliminate health disparities, achieve health equity, and attain health
literacy to improve the health and well-being of all.
Create social, physical, and economic environments that promote
attaining the full potential for health and well-being for all.
Promote healthy development, healthy behaviors, and well-being across
all life stages.
Engage leadership, key constituents, and the public across multiple
sectors to take action and design policies that improve the health and
well-being of all (USDHHS, 2020).

Healthy People 2030 objectives and targets provide guidelines for

communities to follow to promote the health of their members. By
encouraging collaboration across communities, empowering individuals to
make better choices, and measuring progress toward set benchmarks,
Healthy People 2030 can be used as a road map for achieving longer and
healthier lives for all Americans.
The National Prevention Strategy (NPS), largely based on Healthy
People priorities, was developed in 2011 to further national health
improvement efforts. The NPS aims to guide national efforts in the most
effective and achievable means for improving health and well-being. The
strategy prioritizes prevention by integrating recommendations and actions
across multiple settings to improve health and save lives. To realize this
vision and achieve this goal, the strategy identifies four strategic directions
and seven targeted priorities (Association of State and Territorial Health
Officials, 2019).

1255
 The strategic directions provide a strong foundation for all of our
nation's prevention efforts and include core recommendations necessary to
build a prevention-oriented society. They include

Healthy and safe community environments: Create, sustain, and

recognize communities that promote health and wellness through
prevention.
Clinical and community preventive services: Ensure that prevention-
focused health care and community prevention efforts are available,
integrated, and mutually reinforcing.
Empowered people: Support people in making healthy choices.
Elimination of health disparities: Eliminate disparities, improving the
quality of life for all Americans.

Within this framework, the priorities provide evidence-based

recommendations that are most likely to reduce the burden of the leading
causes of preventable death and major illness and include

Tobacco-free living
Preventing drug abuse and excessive alcohol use
Healthy eating
Active living
Injury-and violence-free living
Reproductive and sexual health
Mental and emotional well-being

The NPS serves as a road map for community health nurses collaborating
with stakeholders and community partners, to address priority areas such as
healthy eating, active living, and tobacco control through the prioritization of
prevention and integration of recommendations and actions across multiple
settings. By working on shared priorities, community health nurses can serve
as a valuable partner in identifying community health needs and connecting
communities with available resources. Nurses can also serve as community
educators, empowering people with information to make healthy choices
while working to create environments where healthy choices are more
accessible and affordable, which is the ultimate intent of the strategy
(Lushniak, Alley, Ulin, & Graffunder, 2015).

1256
DIMENSIONS OF THE
COMMUNITY AS CLIENT
The health of a community can be characterized through a number of
perspectives. Donabedian's classic theory of structure, process, and outcomes
provides unique insight into the health status of the community (Donabedian,
2005).

Status/people is the most common measure of the health of a

community. It typically comprises morbidity and mortality data
identifying the physical, emotional, and social determinants of health.
Structure of a community refers to its services and resources.
Community associations, groups, and organizations provide a means for
accessing needed services. Adequacy and appropriateness of health
services can be determined by examining patterns of use, number and
types of health and social services, and quality measures. These
measures provide key information and correlate to health status.
Process reflects the community's ability to function effectively. It
includes processes within the community and between the community
and the state or national levels to maintain health and improve
outcomes.

These characteristics are discussed in more detail later in this chapter

under the discussion on “Planning to Meet the Health Needs of the
Community.” See Chapter 1 for more information on healthy communities.
Addressing community health by examining the process, in addition to
the structure and status dimensions, provides a broader view into the
complexities of community health and community actions for change. It is a
key not only to examine health outcomes but also to consider how the
interactions between processes and structure impact health outcomes (Public
Health Accreditation Board, 2019). These are detailed in Tables 15-2 and 15-
3.

TABLE 15-2 Community Profile Inventory: Location

Perspective

1257
TABLE 15-3 Community Profile Inventory: Population
Perspective

1258
1259
Location
The health of a community is affected by location, because placement of
health services, geographic features, climate, plants, animals, and the human-
made environment are intrinsic to geographic location. The location of a
community places it in an environment that offers resources and also poses
threats.
The healthy community is one that makes wise use of its resources and is
prepared to meet threats and dangers. In assessing the health of any
community, it is necessary to collect information not only about variables
specific to location but also about relationships between the community and
its location. Do groups cooperate to identify threats? Do health agencies
cooperate to prepare for an emergency such as a flood, tornado, or
earthquake? Does the community make certain that its members are given
available information about resources and dangers?
Table 15-2 describes the location perspective of the Community Profile
Inventory, including the six location variables: community boundaries,
location of health services, geographic features, climate, flora and fauna, and
the human-made environment.

Community Boundaries
To talk about the community in any sense, one must first describe its
boundaries. Measurement of health within a community must be preceded by
definition of geographic and informal boundaries around the target
population. Nurses need to be clear, for example, that a target community of
older adults includes a description of age and location (e.g., all persons 65
years and older in a given city or county). Some communities are distinctly
separate, such as an isolated rural town, whereas others are closely situated to
one another, such as the suburbs of a large metropolis. Therefore, it is
important for the nurse to know the nature of each location and clearly define
its boundaries.

Location of Health Services

If the members of a town must travel 200 miles to the nearest clinic or dental
office, the health of the community will be affected. When assessing a
community, the community health nurse needs to identify the major health
centers and know where they are located. For example, an alcoholism
treatment center for indigent alcoholics was located 30 miles outside of one
city. This location presented transportation problems and profoundly affected
the length of time they remained at the center and the willingness of clients
to voluntarily seek treatment there. If a well-baby clinic is located on the

1260
edge of a high-crime district, parents may be deterred from using it. It is
often helpful to plot the major health institutions, both inside and outside the
community, on a map that shows their proximity and relationship to the
community as a whole.

Geographic Features
Communities have been constructed in every conceivable physical
environment, and environment certainly can affect the health of a community
(see Chapter 9). A healthy community is one that takes into consideration the
geography of its location, identifies possible problems and likely resources,
and responds in an adaptive fashion. For example, Anchorage, Alaska, and
San Francisco, California, are both located on a geologic fault line and are
subject to major earthquakes. In such places, the health of the community is
determined, in part, by its preparedness for an earthquake and its ability to
cope and respond quickly when such a crisis occurs.

Climate
Winter weather patterns are expected to become more variable as average
global temperatures continually increase. Research findings indicate that
there is a relationship between temperature variability and health outcomes,
including cardiovascular, respiratory, cerebrovascular events, and all-cause
morbidity and mortality. Populations most vulnerable to global changes are
older adults, residents of rural areas, children living in poor countries, and
those with preexisting medical conditions (World Health Organization,
2019a, 2019b, 2019c).

Flora and Fauna

Plant and animal populations in a community are often determined by
location. The way a community responds to these populations, whether wild
or domesticated, can affect the health of the community.
Public health officials note chronic environmental factors as a possible
cause for increased asthma cases: pollution from high-traffic areas,
secondhand smoke in homes, and poor living conditions characterized by
dust mites, mold, industrial air pollution, mouse and cockroach droppings,
and animal dander.
C/PHNs need to know about the major sources of danger from plants and
animals affecting the community under study. Are there community agencies
that provide educational information about these dangers? Does the populace
understand their significance? Are emergency services, such as a poison
control center, available to community members?

1261
The Built Environment
Every community is located in the midst of an environment created and
transformed by human ingenuity. People build houses and factories, dump
wastes into streams or vacant lots, fill the air with gases, and build dams to
control streams. All of these human alterations of the environment have
important implications for community health. A C/PHN might improve the
health of a community by working with community members, legislators,
and stakeholders to improve the design of the built environment to promote
health and well-being.

1262
Population Characteristics
When one considers the community as the client, examining the health status
of the total population in a given community is a critical component. Table
15-3 presents the population perspective section of the Community Profile
Inventory.

Size
Knowing a community's size provides community health nurses with
important information for planning. For example, when conducting
emergency preparedness planning, knowledge of the population size will
ensure that an adequate number of resources can be made available in the
event of an emergency. See Chapter 27 for issues related to rural and urban
population health.

Density
In some communities, thousands of people are crowded into high-rise
apartment buildings. In others, such as farm communities, people live great
distances from one another. Population density, or the number of people
residing within a square mile area, is used to describe how many people live
within a community. Living in high-density, crowded communities affects
individual and community health by increasing community members'
exposure to pollution and an urbanized diet (The Healthy City, 2018). A low-
density community, however, may also pose problems. When people are
spread out, provision of health care services can become difficult.
A healthy community takes into consideration the density of its
population. It organizes to meet the differing needs created by its density
levels (e.g., it recognizes differences in density between the inner city and
the suburbs and allocates services accordingly). See Chapter 27 for more on
health risks specific to rural and urban areas.

Composition/Demographics
Communities differ in the types of people who live within their boundaries.
Age, sex, educational level, occupation, and many other demographic
variables affect health concerns (CDC, 2019a). Understanding a community's
composition is an important early step in determining its level of health. For
example, when planning a cost-free vaccination program, knowledge of
community demographics allows nurses to identify those who are eligible
and those who would benefit most from the program.

1263
Rate of Growth or Decline
Community populations change over time. Some grow rapidly. As people
leave to find new employment or better living conditions, consumption of
goods and services drops. Community morale may suffer, and community
leadership may decline. Even a stable community can have problems (e.g.,
members may resist needed change because they notice little fluctuation in
their population; commercial and residential properties may be abandoned or
left vacant). This trend is widely observed across the country, as the United
States has progressed from being a manufacturing society to a postindustrial
and technologically focused one.

Cultural Characteristics
A healthy community is aware of the diversity and the needs of the cultural
subgroups (McElfish et al., 2017). See Chapter 5 for more about transcultural
nursing in the community.

Social Class and Educational Level

Social determinants of health impact a wide range of health, functioning,
and quality of life outcomes (Fig. 15-5; National Academies of Sciences,
Engineering, and Medicine, 2019; USDHH, 2020). They reflect social
factors and the physical conditions in the environment in which people are
born, live, learn, play, work, and age. They are shaped by the distribution of
money, power, and resources at global, national, and local levels and
contribute to health inequities among different groups of people based on
social and economic class, gender, and ethnicity. For these reasons, social
determinants of health are an underlying cause of today's major societal
health dilemmas (National Academies of Science, Engineering, and
Medicine, 2019). See Chapter 23.

1264
 FIGURE 15-5 Health impact pyramid. (Reprinted from CDC.
(2018). Health Impact in 5 years. Retrieved from
https://www.cdc.gov/policy/hst/hi5/)

It is generally known that different groups have different health

problems, as well as a variety of resources for coping with illness and diverse
ways of using health services. A healthy community recognizes these
differences and creates health care services to meet these varied needs.

Mobility
Americans are a mobile population. Outcomes from the 2017 American
Community Survey indicate that approximately 40 million people moved
annually within their region, 3.8 million moved between regions, and nearly
another 2 million moved to the United States from abroad between 2013 and
2017. Oftentimes these fluctuations are linked to social and economic factors
(U.S. Census Bureau, 2019). If the population turnover is extensive,
continuity of services may suffer. Leadership for improving the health of the
community may change so frequently that concerted action becomes
difficult. High turnover may necessitate special attention to health education
about local conditions.
Population groups may arrive and depart in seasonal swings; fluctuations
in the number of migrant farm workers, tourists, or college students can
affect a community. Immigrants and refugees may represent a significant
population subgroup in many areas of a country, and public health officials
must recognize their unique health needs and barriers (Philbin, Flake,
Hatzenbuehler, & Hirsch, 2018). A healthy community neither ignores nor

1265
overreacts to this kind of mobility. Rather, its members work collaboratively
to recognize and address their unique needs and barriers to health.

1266
Social System
In addition to location and population, every community has a third feature—
a social system. The various parts of a community's social system that
interact and influence the health of a community are called social system
variables. These variables include health, family, economy, education,
religion, welfare, politics, recreation, law, and communication (Fig. 15-6).
Whether assessing a community's health, developing new services for the
mentally ill within the community, or promoting the health of older adults,
the community health nurse needs to understand the community as a social
system. A community health nurse working in a tiny village in Alaska needs
to understand and work with the social system of that village no less than a
nurse practicing in New York City. When a group of organizations are linked
and have similar functions, such as all those providing social services, they
form a community system or subsystem. The various community systems
have a profound influence on one another. Because this interaction among
parts determines the health of the whole, it is the total social system that
concerns community health nurses. Table 15-4 guides the nurse in assessing
a community's social system variables.

FIGURE 15-6 The community as a social system. Each of the 10

major systems of a community includes a number of subsystems
that are made up of organizations. Members of the community
occupy roles in these organizations.

1267
TABLE 15-4 Community Profile Inventory: Social System
Perspective

1268
THE NURSING PROCESS APPLIED
TO THE COMMUNITY AS CLIENT
Consisting of a systematic, purposeful set of interpersonal actions, the
nursing process provides a structure for change that remains a viable tool
employed by the community health nurse. This chapter examines the use of
the nursing process as applied at the aggregate or community level. Five
components—assessment, diagnosis, planning, implementation, and
evaluation—give direction to the dynamics for solving problems, managing
nursing actions, and improving the health of communities and community
health nursing practice. Three characteristics support the use of the nursing
process in community health nursing.

First, the nursing process is a problem-solving process that addresses

community health problems at every aggregate level with the goals of
preventing illness and promoting public health.
Second, it is a management process that requires situational analysis,
decision-making, planning, organization, direction, and control of
services, as well as outcome evaluation. As a management tool, the
nursing process addresses all aggregate levels.
Third, it is a process for implementing changes that improve the
function of various health-related systems and the ways that people
behave within those systems.

The nursing process provides a framework or structure on which C/PHN

actions are based (ANA, 2013). Application of the process varies with each
situation, but the nature of the process remains the same. Certain
characteristics of that process are important for community health nurses to
emphasize in their practices. The Quad Council of Public Health Nursing
Organizations (which is now the Council of Public Health Nursing
Organizations), building on the work of the Council on Linkages Between
Academia and Public Health Practice, developed a list of core competencies
for C/PHNs. These competencies have helped clarify the role of the
community health nurse within the context of community as client (see the
appendix and http://www.quadcouncilphn.org/wp-
content/uploads/2018/05/QCC-C-PHN-COMPETENCIES-
Approved_2018.05.04_Final-002.pdf; Quad Council, 2018).

1269
Deliberative
The nursing process, like the research process in evidence-based practice, is
deliberative—purposefully, rationally, and carefully thought out. It requires
the use of sound judgment that is based on adequate information. C/PHNs
often practice in situations that demand the ability to think independently and
make difficult decisions. Furthermore, thoughtful, deliberative problem
solving is a necessary skill for working with the community health team to
address the needs and problems of aggregates in the community. The nursing
process is a decision-making tool to facilitate these determinations (ANA,
2018).

1270
Adaptable
The dynamic nature of the nursing process enables the community health
nurse to adapt it appropriately to each situation and apply it to meeting
aggregate health needs. Furthermore, its flexibility is a reminder to the nurse
that each client group and each community situation is unique. The nursing
process must be applied specifically to the individual situation and group of
people. Based on assessment and sound planning, the nurse adapts services
to meet the identified needs of each community client group.

1271
Cyclical
The nursing process is cyclical and in constant progression. Steps are
repeated over and over in the nurse–aggregate client relationship. The nurse
engages in continual interaction, data collection, analysis, intervention, and
evaluation. As interactions between nurse and client group continue, various
steps in the process overlap with one another and are used simultaneously.
The cyclic nature of the nursing process enables the nurse to engage in a
constant information feedback loop: the information gathered and lessons
learned at each step of the process promote greater understanding of the
group being served, the most effective way to provide quality services, and
the best methods of raising this group's level of health.

1272
Client Focused
The nursing process is used for and with clients. Community health nurses
use the nursing process for the express purpose of addressing the health of
populations. They are helping aggregate clients, directly or indirectly, to
achieve and maintain health. Clients as total systems—whether groups,
populations, or communities—are the targets of the C/PHN's nursing process
(ANA, 2018).

1273
Interactive
The nurse and clients are engaged in a process of ongoing interpersonal
communication. Giving and receiving accurate information is necessary to
promote understanding between nurse and clients and to foster effective use
of the nursing process. Furthermore, because of the movement toward
informed use of health care, demands for clients' rights and the concept of
self-care have gained emphasis. Client groups and community health nurses
have increasingly joined forces to assume responsibility for promoting
community health. The nurse–aggregate client relationship can and should be
a partnership, a shared experience by professionals (nurses and others) and
client groups (Tucker, Arthur, Roncoroni, Wall, & Sanchez, 2015).

1274
Need Oriented
A long association with problem solving has tended to limit the focus of the
nursing process to the correction of existing problems. Although problem
solving is certainly an appropriate use of the nursing process, the community
health nurse can also use the nursing process to anticipate client needs and
prevent problems. The nurse should think of nursing diagnoses as ranging
from health problem identification to primary prevention and health
promotion opportunities. This focus is needed if the goals of community
health—to protect, promote, and restore the people's health—are to be
realized.

1275
Interacting With the Community
All steps of the nursing process depend on interaction, reciprocal exchange,
and influence among people. Although nurse–client interaction is often an
implied or assumed element in the process, it is an essential first
consideration for community health nursing. This type of engagement was
observed during the Flint water crisis, where C/PHNs established
relationships with community members and were thereby able to identify and
directly aid in addressing their needs. These relationships also facilitated
communication between community members and service providers (see
Chapter 10 for more details). Listening to a group of older people, teaching a
class of expectant mothers, lobbying in the legislature for the poor, working
with parents to set up a dental screening program for children—all of these
involve relationships, and relationships require interaction. Mutual give and
take between nurse, clients, and community stakeholders—whether a family,
a group of mothers on a Native American reservation, or representatives
from resource agencies within the community—is an expected and much
needed skill that should be integrated throughout the nursing process.

Need for Communication

C/PHNs can serve as effective liaisons—facilitating communication between
stakeholders and clients to ensure that health needs are both identified and
adequately addressed.

Interaction and Effective Communication

Through open and honest sharing, the nurse (and others on the health team)
can begin to develop trust and establish lines of effective communication.
For instance, the nurse explains the nurse's role and purpose for being there.
The nurse encourages the group members to talk about themselves. The
nurse and group members together discuss their relationship and clarify the
desired nature of that alliance. Does the group want help to identify and work
on its health needs? Would its members like this nurse to continue regular
contacts? What will their respective roles be? Effective communication, as a
part of interaction, is essential to develop understanding and facilitate a free
exchange of information between nurse and client.

Interaction Is Reciprocal
Sharing of information, ideas, feelings, concerns, and self goes both ways.
The community health nurse (and other collaborating health professionals)
represents one system and the client group represents the other. Health care
professionals tend to prioritize based on their own perspective and many

1276
times neglect to take the clients' wishes into account. Whether the client is a
parent group, a homeless population, or an entire community, this exchange
involves a two-way sharing between the nurse and client group. The key
elements of interaction are mutuality and cooperation.
Consider the following example: After several weeks of meeting with a
community member focus group to discuss disease management and physical
activity, a C/PHN noticed that community violence was a recurring theme
during group discussions. Community residents described conditions in the
neighborhood as unsafe and many indicted that they were afraid to adopt the
nurse's recommendations to increase physical activity because of ongoing
violence near their homes. The nurse initially felt unprepared to address this
issue but, after consulting with other support agencies within the community,
realized that resources were available. After meeting and coordinating with
community members and support agencies, the nurse was able to develop a
feasible and safe physical activity plan for residents. Engagement with
community members and communication were the first step in reapplying the
nursing process and allowed goals for the group to be accomplished.

Interaction Paves the Way for a Helping Relationship

As nurse and client interact, each learns about the other. A test period occurs
before trust can be fully established (Summach, 2011). For a female school
nurse working with middle school students about health education and
human sexuality, establishing interaction was more difficult at the time of the
initial contact with the boys than with the girls. They had been reluctant to
talk and felt embarrassed to discuss personal subjects with an adult they did
not know. Nonetheless, their interests in bodybuilding and personal
appearance were strong enough to bring them to these optional sessions.
Interaction began with a friendly exchange on nonthreatening topics and
gradually deepened, as the boys seemed ready to discuss personal subjects.
Eventually, it was relatively simple to talk about a new “problem” (and start
the nursing process over again), because a helping relationship had already
been developed. The nurse had a track record. The boys trusted, respected,
and liked the nurse, so they were happy to interact around a newly stated
need.

Aggregate Application
As noted in earlier chapters, community health practice focuses largely on
the health of population groups; therefore, interaction goes beyond the one-
on-one with individual patients. The challenge that the community health
nurse faces is a one-to-aggregate approach. A group of parents concerned
about teenage alcohol abuse, people with physical disabilities needing access
ramps, and a neighborhood's older adult population frightened by muggings

1277
and thefts are all aggregates or clients with different concerns and opinions.
As defined in Chapter 1, an aggregate refers to a mass or grouping of distinct
individuals who are considered as a whole and who are loosely associated
with one another. Each person in an aggregate is influenced by the thoughts
and behavior of other group members. Nursing interaction with an aggregate
client demands an understanding of group behavior, group dynamics, and
group-level decision-making. It requires interpersonal communication skills
applied at the group level. Interaction is more complex and challenging with
an aggregate than with an individual but also can be rewarding. Once
community health nurses acquire an understanding of aggregate behavior,
they can capitalize on the potential of group influence to make a far-reaching
impact on the health of the total community. Chapter 10 more closely
examines communication and interaction with groups.

1278
Forming Partnerships and Building Coalitions
Community-level nursing practice also requires teamwork. The job of
planning for the health of an entire community or a community subsystem
requires that the nurse collaborate with other professionals. Usually, the
nurse is part of an organized team, separate from the agency that employs the
nurse. The team is brought together with the goal of improving the health of
the community. Each group member brings expertise and a particular view of
the problem. These interprofessional work groups are often formed as either
partnerships or coalitions (Wyer, Umscheid, Wright, Silva, & Lang, 2015).
The Maryland Collaborative is an example of a collaborative practice
approach to reduce college drinking and related problems (Arria & Jernigan,
2018). A priority for the Maryland Department of Health and Hygiene was to
reduce excessive drinking among college students. A collaboration was
formed with the state health department, the Chancellor of the UC System,
and other university presidents in the state to address excessive drinking on
college campuses through the lens of individual, interpersonal networks, and
organizational and environmental factors. Using assessment techniques, hot
spot areas on campuses were identified, and campus teams worked with local
community members to develop strategies to reduce excessive drinking and
related problems. An evidence-based and community partnership approach
can address serious health issues at the individual and community, level
thereby providing a “…positive academic and social experience for students,
quality of life for the campus community, and viability of the surrounding
neighborhoods” (Arria & Jernigan, 2018, p. 311).
Partnerships are agreements between people (and agencies) that support
a joint purpose. A partnership can be large (e.g., a multinational corporation
and several high schools; a city government and the county jail system), or it
can be a more modest endeavor (e.g., a group of older adult citizens and a
preschool program; a Girl Scout troop and a community recycling program).
To enhance the outcomes of a program for the homeless while improving
the health needs of homeless individuals and families, the Shelter Nurse
Program and public health nursing service, along with community members,
worked in partnership to develop a plan to demonstrate population outcomes
formalizing goals and objectives for the agency (Minnich & Shirley, 2017).
By collaborating on this project, the partnership identified program needs,
developed goals and objectives, and created a comprehensive evaluation plan
to meet the needs of the local homeless population. Working together to
develop areas for improvement to meet the needs of homeless clients, both
the agency and the shelter nurses learned the value of a program
development model and the importance of front-line workers' participation in
the process (Minnich & Shirley, 2017).

1279
 Community-wide partnerships require more planning and coordination
than do small partnerships. For example, because of increased student
enrollment, a college may need two additional temporary and part-time
faculty members who can teach the C/PHN course. The county public health
department is interested in more new graduate nurses coming to work in the
agency. The nursing program and the health department form a partnership
and design a plan to solve both problems. The health department selects two
staff nurses who have master's degrees and are qualified to teach
undergraduate clinical courses in C/PHN one day a week for two semesters.
The benefits for everyone are numerous. The nursing program solves a
temporary staffing problem; the nurses from the health department share
their expertise with students, enhancing their practice and the students'
learning experience; and the health department successfully introduces a pool
of students, who may be potential staff members, to the agency and the
services that it provides for the community.
A coalition is an alliance of individuals or groups that work together to
influence the outcomes of a specific problem. Coalitions are an effective
means to achieve a collaborative and coordinated approach to solving
community problems. Steps to coalition building include (CDC, 2015b)

Defining goals and objectives

Conducting a community assessment
Identifying key players or leaders
Identifying potential coalition members

Staying in touch with the coalition members, running effective meetings,

and keeping every participant involved are means of keeping the coalition
active.
Sound public health practice depends on pooling resources—including
people—in ways that will best serve the public. In planning for a
community's health, the community (represented by appropriate individuals
and agencies) must be involved. Community health nurses cannot lose sight
of the need for client involvement at all levels and in all stages of community
health practice (Box 15-2).

BOX 15-2 PERSPECTIVES

1280
A Public Health Nurse's Viewpoint on Addressing
Adolescent Pregnancy I am a public health nurse
and my health department serves a community
with a large proportion of adolescents and young
adults aged 18 to 24. After reviewing data from a
recent community health status assessment,
members of our community council observed a
significant increase in the number of unplanned
pregnancies among members of this age group.
We proceeded to convene a group of community
stakeholders with the intention of partnering with
them to identify and implement solutions to
address these issues. Several meetings were held,
and key members of the community were invited
to participate, including a local church pastor,
youth group leaders, and administrators
representing nonprofit organizations targeting
this same issue. Further analysis of this issue, the
group agreed to develop a plan to address
unplanned pregnancy and to also target resources
toward secondary prevention in order to support
those who had experienced unplanned
pregnancies and were now raising their children
as single parents.
An assessment of community resources was conducted to identify
available programs and resources. We searched the literature for best
practices on this topic and collaborated with program planners to develop
an implementation plan for our target population. The group engaged local
leaders to request funding for areas where gaps in services were identified.
After 2 months of planning, community resources were identified and
coordination was conducted to begin marketing and outreach efforts.
Referral mechanisms in local clinics were used to link potential clients to
our program, and we received several word-of-mouth recommendations for

1281
participants. The program consists of birth control education, counseling,
participation in group informational sessions, and the assignment of a
primary care manager in our community-based clinic.
A 6-and 9-month outcome evaluation is planned to monitor the effect of
our program. Anecdotal feedback has been resoundingly positive. The
commitment of our partners is evident as our efforts have been embraced
and supported by a wide range of leaders and community members. This
commitment appears to have yielded a great response from program
participants. Participants have remarked about the quality of services
received, and many have commented on the quality of care they received in
our program.

Tara, public health nurse

1282
TYPES OF COMMUNITY NEEDS
ASSESSMENT
Assessment is the key initial step of the nursing process; it involves
collecting and evaluating information about a community's health status to
discover existing or potential needs and assets as a basis for planning future
action (Anderson & McFarlane, 2019). Assessments are also a critical
requirement for public health department accreditation (Public Health
Accreditation Board, 2019).
Several models or frameworks can be used for assessment. Three such
models are

Mobilizing for Action through Planning and Partnerships

Protocol for Assessing Community Excellence in Environmental Health
Planned Approach to Community Health

These models have been developed through partnership with the Centers
for Disease Control and Prevention (CDC) to improve community
assessment in relation to healthy people goals (CDC, 2015a) and to assist
communities in assessing health promotion and chronic disease prevention
programs. The Healthy People Web site also provides planning tools and
toolkits to assist local communities (see internet resources on ).
These are all valuable resources that provide specific guidelines focusing on
local-level strategies to improve the health of communities.
Assessment involves two major activities:

Collection of pertinent data

Analysis and interpretation of data

These actions overlap and are repeated constantly throughout the

assessment phase of the nursing process. While assessing a community's
ability to enhance its health, the nurse may simultaneously collect data on
community lifestyle behaviors and interpret previously collected data on
morbidity and mortality.
Community health assessment is the process of determining the real or
perceived needs of a defined community. In some situations, an extensive
community study may be the first priority; in others, all that is needed is a
study of one system or even one organization. At other times, community
health nurses may need to perform a cursory examination or windshield

1283
survey to familiarize them with an entire community without going into any
depth (Anderson & McFarlane, 2019).

1284
Familiarization or Windshield Survey
A familiarization assessment is a common starting place in evaluation of a
community. Familiarization assessment involves studying data already
available on a community and then gathering a certain amount of firsthand
data in order to gain a working knowledge of the community. Such an
approach may use a windshield survey—an activity often used by nursing
students in public health courses and by new staff members in community
health agencies. Nurses drive (or walk) around the community of interest;
find health, social, and governmental services; obtain literature; introduce
themselves and explain that they are working in the area; and generally
become familiar with the community and its residents. This type of
assessment is needed whenever the community health nurse works with
families, groups, organizations, or populations.
The windshield survey provides knowledge of the context in which these
aggregates live and may enable the nurse to better connect clients with
community resources (Box 15-3). See an example in Box 15-4.

BOX 15-3 Community Familiarization

(Windshield) Survey A windshield
survey is often done to help you become
familiar with a new community or
public health service area.
Walking/driving around neighborhoods
and interacting with community
members can provide a context for
further community assessment. You
might begin at the local Chamber of
Commerce or government building to
determine history, current statistics, and
demographics and to access maps and
further resources for data you might use

1285
for a more formal community health
assessment.
Physical
Look at the age and conditions of the buildings, the density
(apartments, houses on large lots) and materials used (bricks,
plywood), and the zoning and maintenance of yards/empty lots.
What clues does that give you about the community as a whole?
How similar are the houses (are some neighborhoods very rich,
others very poor)? Are there abandoned vehicles, piles of excess
trash, large numbers of stray animals/for sale signs, or vacant
houses?
Are there open spaces (parks, agricultural areas, public/private
areas like golf courses) and are they being used; by whom?
Are there boundaries separating the community (e.g., natural
boundaries like rivers, economic boundaries,
commercial/residential boundaries)?
What about air/water quality, signs of pollution?

Economic
Does the area look like it is a thriving community?
Are there areas where homeless gather? Soup kitchens?
Is there adequate shopping (e.g., grocery stores, shopping centers)?
Does it appear that food stamps are accepted/welcomed?
Are there businesses, industries, manufacturing, and adequate
places for employment? What is the unemployment rate?

Services
Are there schools (how many, in what condition)? School nurses?
What are the main concerns or problems with the educational
system here (e.g., dropout rates)?
Are there libraries? Do they provide additional services (e.g.,
internet)? Are they well used?
Are there recreational facilities (e.g., gyms, playgrounds, soccer
fields, baseball diamonds)? Are these being used and by whom?
How many churches do you see? What denominations?
Is there adequate health care? Does the community have a
hospital? Are there adequate health care services (e.g., physicians,
clinics, nurses, mental health/substance abuse facilities, PH
department services, nursing homes, traditional health care

1286
 providers)? Is it a medically underserved area or a health
professions shortage area?
What types of social services are available (e.g., welfare/social
workers, shelters, mental health counseling)? Do you see one main
location for social services (e.g., government center) or are they
dispersed around the community?
What types of public/private transportation are available? Are
highways and roads crowded with traffic? Accident rate? Are there
bike paths/trails and adequate sidewalks? How is transportation
access for the disabled?
Does the community “feel” safe to you? Is there adequate fire and
police protection? What is the crime rate? What are the most
common types of crimes?
Are there signs of political activity (e.g., posters, notices of
meetings, predominant party affiliations)? Do people feel that they
can be involved in decisions made by their local government?

Social
Are there common “hangouts” (e.g., teen gathering spots, chess
playing for older adults)? What about local newspapers, radio, and
TV (e.g., satellite dishes)?
Who do you see on the streets? Are there indications of
homogeneity or diversity of ethnicities, languages spoken, SES
(socioeconomic status), and occupations? How are people dressed?
How do people feel about living in this community? What
problems or concerns do they express? What strengths do they
note? How “healthy” is their community?
What are your impressions of this community?
Source: Anderson and McFarlane (2019).

BOX 15-4 STORIES FROM THE

FIELD: WORKING WITH THE
COMMUNITY ON A SAFETY
ASSESSMENT CONSIDER THE
FOLLOWING EXAMPLE: AFTER
SEVERAL WEEKS OF MEETING
WITH A COMMUNITY-MEMBER

1287
FOCUS GROUP TO DISCUSS
DISEASE MANAGEMENT AND
PHYSICAL ACTIVITY, A PUBLIC
HEALTH NURSE (C/PHN) NOTICED
THAT COMMUNITY VIOLENCE
WAS A RECURRING THEME
DURING GROUP DISCUSSIONS.
COMMUNITY RESIDENTS
DESCRIBED CONDITIONS IN THE
NEIGHBORHOOD AS UNSAFE AND
MANY INDICTED THAT THEY
WERE AFRAID TO ADOPT THE
NURSE'S RECOMMENDATIONS TO
INCREASE PHYSICAL ACTIVITY
DUE BECAUSE OF ONGOING
VIOLENCE NEAR THEIR HOMES.
THE NURSE INITIALLY FELT
UNPREPARED TO ADDRESS THIS
ISSUE BUT AFTER CONSULTING
WITH OTHER SUPPORT AGENCIES
WITHIN THE COMMUNITY, SHE
REALIZED THAT RESOURCES
WERE AVAILABLE. AFTER
MEETING AND COORDINATING
WITH COMMUNITY MEMBERS
AND SUPPORT AGENCIES, SHE

1288
WAS ABLE TO DEVELOP A
FEASIBLE AND SAFE PHYSICAL
ACTIVITY PLAN FOR RESIDENTS.
ENGAGEMENT WITH COMMUNITY
MEMBERS AND COMMUNICATION
WERE THE FIRST STEP IN
REAPPLYING THE NURSING
PROCESS AND ALLOWED GOALS
FOR THE GROUP TO BE
ACCOMPLISHED.
1. What should the C/PHN know about location, population, and
social system to be better prepared to work with this group?
2. How can the C/PHN use the nursing process to direct the plan of
care with this community?

1289
Problem-Oriented Assessment
A second type of community assessment, problem-oriented assessment,
begins with a single problem and assesses the community in terms of that
problem. Instead of working to gather information about the larger
community, the nurse would identify resources, programs, and support
networks of potential benefit to the family. Steps taken to complete this
assessment would include collecting data on local prevalence and incidence,
interviewing officials to obtain information on processes and policies, and
identifying local programs and services.
The problem-oriented assessment can be used when familiarization is not
sufficient, and a comprehensive assessment is not feasible. This type of
assessment is responsive to a particular need and should also seek to describe
contextual issues associated with the need. The data collected can support
community efforts to address specific problems. Data should address the
magnitude of the problem to be studied (e.g., prevalence, incidence), the
precursors of the problem, and information about population characteristics
(e.g., community resources, strengths, and weaknesses), along with the
attitudes and behaviors of the population being studied ( Kirst-Ashman,
2014).

1290
Community Subsystem Assessment
In community subsystem assessment, the C/PHN focuses on a single
dimension of community life. For example, the nurse might decide to survey
churches and religious organizations to discover their roles in the community.
What kinds of needs do the leaders in these organizations believe exist?
What services do these organizations offer? To what extent are services
coordinated within the religious system and between it and other systems in
the community?
In one situation, churches and other cultural leaders were instrumental in
providing information to address the local public health department's
concerns. A small county health department worked with the nearby
university C/PHN clinical instructor and the instructor's students to
determine why two specific racial/ethnic groups did not use free women's
health clinics. Students from the university conducted focus groups with
local clergy and representatives from the racial groups to better understand
the group's health seeking behaviors. Health department officials reviewed
transcripts from the focus groups and discovered that most members of the
groups were unaware of the services provided through the county health
department. The students then conducted additional interviews with families
within the groups and found that, as part of their cultural practice, husbands
generally accompany their wives when getting prenatal care or family
planning services. They also learned that members of the group felt more
comfortable with health care personnel of their own race and that there was a
provider from their ethnic group practicing in a neighboring county. As a
result of these subsystem engagements, health department staff were able to
tailor their service offerings to better meet the needs to these groups and a
partnership for health was established with local clergy and group members.
Community subsystem assessment can be a useful way for a team to
conduct a more thorough community assessment. If five members of a
nursing agency divide up the 10 systems in the community and each person
does an assessment of two systems, they could then share their findings to
create a more comprehensive picture of the community and its needs.

1291
Comprehensive Assessment
Comprehensive assessment seeks to discover all relevant community health
information. It begins with a review of existing studies and all the data
presently available on the community. A survey compiles all the
demographic information on the population, such as its size, density, and
composition.
Key informants are interviewed in every major system—education,
health, religious, economic, and others. Key informants are experts in one
particular area of the community, or they may know the community as a
whole. Examples of key informants would be a school nurse, a religious
leader, key cultural leaders, the local police chief or fire captain, a mail
carrier, or a local city council person. Then, more detailed surveys and
intensive interviews are performed to yield information on organizations and
the various roles in each organization.
A comprehensive assessment describes the systems of a community and
also how power is distributed throughout the system, how decisions are
made, and how change occurs (Anderson & McFarlane, 2019).
Because comprehensive assessment is an expensive, time-consuming
process, it is not often undertaken. Performing a more focused study, based
on prior knowledge of needs, is often a better and less costly strategy.
Nevertheless, knowing how to conduct a comprehensive assessment is an
important skill when designing smaller more focused assessments (Box 15-
5).

BOX 15-5 PERSPECTIVES

A Public Health Nursing Student Viewpoint on

Addressing Adolescent Pregnancy After
completing my Med-Surg courses, I was excited to
begin my Community Health rotation. I looked
forward to stepping outside of the clinical
environment to engage community members but I

1292
absolutely I dreaded the thought of having to
complete the perfunctory comprehensive
community health assessment. To my delight, the
assessment process had recently been revamped
and, instead of repeating the task of collecting the
same data that the previous classes had collected,
my class was able select from a list of community
health projects for which data were needed. These
projects were directly related to grants currently
being written by staff and state-directed program
evaluations that the department was working on.
The fact that these were real-time projects made
the assignment feel less like a task and more like a
meaningful opportunity to contribute to the health
of community members served by the department.
My class voted to collect data for a grant-funded
project to address teen pregnancy, and we set
about creating our own survey tools drawing from
standardized assessment products. We were
excited about our work and tackled the project
bunch of detectives chasing down leads! We
divided into subgroups, gathered data, problem-
solved and worked together to achieve our goals.
We also worked with other agencies and NGOs,
and spoke with local health care providers and
members of the community. Toward the end of
our project, we collaborated with the program
director for a teen pregnancy program to
distribute questionnaires to local teens so that we
could gather information on sexual activity and
attitudes. At that time, the conservative county

1293
that we worked in had the highest rate of teen
pregnancies in the state and many parents
opposed Sex Ed. However, we were able to gather
information and statistics on teen pregnancies in
this county and compared it with state and
national data. After investigating best practices
for teen pregnancy prevention programs, we
formed into smaller work groups, some met with
school officials, high school students, teachers, and
parents to educate them about this project. In the
end, everyone in my class felt that by working on
this project, they made a meaningful contribution
to the community and the health department and
the university heartily agreed!
Mikinsey, nursing student

1294
Community Assets Assessment
Assets mapping focuses on the strengths and capacities of a community
rather than its problems (Jakes, Hardison-Moody, Bowen, & Blevins, 2015)
and evaluates variables such as the needs that exist, the goals to be achieved,
and the resources available for carrying out the study.
Although it is difficult to determine the type of assessment needed in
advance, understanding the various types of community assessment in
advance helps to facilitate your decision. Based on a classic model developed
by McKnight and Kretzmann in the 1980s (Kretzman & McKnight, 1993),
the assets assessment provides a framework for conducting a complete
functional community assessment and serves as a guide to the community for
the nurse, as well as the foundation for community development.
The previously mentioned methods are needs oriented and deficit based
—in other words, they are pathology models, in which the assessment is
performed in response to needs, barriers, weaknesses, problems, or perceived
scarcity in the community. This may result in a fragmented approach to
solutions for the community's problems rather than an approach focused on
the community's possibilities, strengths, and assets. The assets assessment
also provides the community the ability to “identify a variety and richness of
skills, talents, knowledge, and experience of people” and “provides a base
upon which to build new approaches and enterprises” (p. 4).
Assets assessment begins with what is present in the community (Jakes
et al., 2015). The capacities and skills of community members are identified,
with a focus on creating or rebuilding relationships among local residents,
associations, and institutions to multiply power and effectiveness. This
approach requires that the assessor look for the positive or see the glass as
half full. The nurse can then become a partner in community intervention
efforts, rather than merely a provider of services. Assets assessment includes
three levels (Kramer, Seedat, Lazarus, & Suffla, 2011):
1. Specific skills, talents, interests, and experiences of individual
community members such as individual businesses, cultural groups, and
professionals living in the community.
2. Local citizen associations, organizations, and institutions controlled
largely by the community such as libraries, social service agencies,
voluntary agencies, schools, and police.
3. Local institutions originating outside the community controlled largely
outside the community such as welfare and public capital expenditures
(p. 14).
The key, however, is linking these assets together to enhance the
community from within. The community health nurse's role is to assist with

1295
those linkages.

1296
METHODS FOR COLLECTING
COMMUNITY DATA
The health status of the community may be assessed using a variety of
methods. Regardless of the assessment method used, data must be collected.
The Community Health Assessment and Group Evaluation (CHANGE) Tool
(https://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/to
ols/change/downloads.htm) is an example of a current process to prioritize
community needs for community-based improvements (CDC, 2019d). The
tool assists C/PHNs and community members through the community
change process (commitment, assessment, planning, implementation, and
evaluation). Once a CHANGE team is assembled, data must be gathered to
fully assess the community's need. Data collection in community health
requires the exercise of sound professional judgment, effective
communication techniques, and special investigative skills. Four important
methods are discussed here: surveys, descriptive epidemiologic studies,
community forums or town meetings, and focus groups.

1297
Surveys
A survey is an assessment method in which a series of questions is used to
collect data for analysis of a specific group or area. Surveys are commonly
used to provide a broad range of data that will be helpful when used with
other sources or if other sources are not available.
To plan and conduct community health surveys, the goal should be to
determine the variables (selected environmental, socioeconomic, and
behavioral conditions or needs) that affect a community's ability to control
disease and promote wellness. The nurse may choose to conduct a survey to
determine such things as health care use patterns and needs, immunization
levels, demographic characteristics, or health beliefs and practices.
The survey method involves self-report, or response to predetermined
questions, and can include questionnaires, telephone, or in person interviews
(Polit & Beck, 2017).
Survey findings can be combined with other health data in order to better
understand the health status of the community and the determinants of health.
These data include reports of health risks and outcomes by zip code
(Agarwal, Menon, & Jaber, 2015; Wang, Ponce, Wang, Opsomer, & Yu,
2015) and CDC Environmental Health Tracking Network reports of local
environmental health exposures (Charleston, Wilson, Edwards, David, &
Dewitt, 2015). Consideration of these data along with survey results allows
for a more comprehensive understanding of the community's health status
and the conditions impacting health.

1298
Descriptive Epidemiologic Studies
A second assessment method is a descriptive epidemiologic study, which
examines the amount and distribution of a disease or health condition in a
population by person (Who is affected?), by place (Where does the condition
occur?), and by time (When do the cases occur?). In addition to their value in
assessing the health status of a population, descriptive epidemiologic
studies are useful for suggesting which individuals are at greatest risk and
where and when the condition might occur. They have also long been known
to be useful for health planning purposes and for suggesting hypotheses
concerning disease etiology (Merrill, 2017). Their design and use are detailed
in Chapter 7.

1299
Geographic Information System Analysis
In Chapter 10, the concept of GIS was introduced as a health information
technology. GIS technology is an integration of research methods and
analytic techniques from both medical geography and spatial epidemiology.
It has been well documented as a tool that can collect, organize, and display
public health data, and it is widely used in assessment and research of health
disparities, resource availability, and health-related behaviors (WHO, 2019a).
Harvard's T.H. Chan School of Public Health offers a Web site
designated to the use of GIS in public health, including particular research
studies. For instance, one line of research examines effects of air pollution on
MI rates within the community of Worchester and spatial mapping of
incidence and levels of pollution. Researchers are also working on
developing a predictive model for pollution's effect on death rates in Eastern
Massachusetts. A prospective study of normative aging began with data
collected from healthy cohort of 2,500 individuals in the 1970s; and GIS data
on exposure are used to estimate cumulative exposure to pollution and its
association with COPD, MI, and death (Harvard University, 2019). The
WHO has been using GIS for leprosy elimination (WHO, 2019a).

1300
Community Forums and Social Media
The community forum or town hall meeting is a qualitative assessment
method designed to obtain community opinions. It takes place in the
neighborhood of the people involved, perhaps in a school gymnasium or an
auditorium. The participants are selected to participate by invitation from the
group organizing the forum.
Members come from within the community and represent all segments of
the community that are involved with the issue. For instance, if a community
is contemplating building a swimming pool, the people invited to the
community forum might include potential users of the pool (residents of the
community who do not have pools and special groups such as the Girl
Scouts, elders, and disabled citizens), community planners, health and safety
personnel, and other key people with vested interests. They are asked to give
their views on the pool: Where should it be located? Who will use it? How
will the cost of building and maintaining it be assumed? What are the
drawbacks to having the pool? Any other pertinent issues the participants
may raise are included. This method is relatively inexpensive, and results are
quickly obtained.
A drawback of this method is that only the most vocal community
members, or those with the greatest vested interests in the issue, may be
heard. This format does not provide a representative voice to others in the
community who also may be affected by the proposed decision.
Town halls are used to elicit public opinion on a variety of issues,
including health care concerns, political views, and feelings about issues in
the public eye, such as school safety.
Frequently, local news may stream important city government or school
board meetings. Other methods of opinion gathering include e-mailing to
support a particular view, Web-based survey sites, and text messaging a Yes
or No vote on an issue. Social media sites, like Facebook and Twitter, are
also popular forums for opinion sharing. Digital media is often used to elicit
grassroots opinions from local community members. See more ideas on the
use of social media in Chapter 10.

1301
Focus Groups
Focus groups are similar to the community forum or town hall meeting in
that it is designed to obtain grassroots opinion with a small group of
participants, usually 5 to 15 people.
The members chosen for the group are homogeneous with respect to
specific demographic variables. For example, a focus group may consist of
female community health nurses, young women in their first pregnancy, or
retired businessmen. Leadership and facilitation skills are used in
conjunction with the small group process to promote a supportive
atmosphere and to accomplish set goals. The interviewer guides the
discussion according to a predetermined set of questions or topics. A focus
group can be organized to be representative of an aggregate, to capture
community interest groups, or to sample for diversity among different
population groups. Whatever the purpose, however, some people may be
uncomfortable expressing their views in a group situation.
The choice of assessment method varies depending on the reasons for
data collection, the goals and objectives of the study, and the available
resources. It also varies according to the theoretical framework or
philosophical approach through which the nurse views the community. In
other words, the community health nurse's theoretical basis for approaching
community assessment influences the purposes for conducting the
assessment and the selection of methodology. For example, Neuman's health
care systems model forms the basis for the “community-as-partner”
assessment model developed by (Anderson & McFarlane, 2019). Additional
resources on methodologies for assessing community health (e.g., list of
internet resources) are available on .

1302
SOURCES OF COMMUNITY DATA
The community health nurse can look in many places for data to enhance and
complete a community assessment. Data sources can be primary or
secondary, and they can be from international, national, state, or local
sources. Web sites for many primary and secondary data sources are included
in internet resources on .

1303
Primary and Secondary Sources
C/PHNs make use of many sources in data collection. Community members,
including formal leaders, informal leaders, and community members, can
frequently offer the most accurate insights and comprehensive information.
Information gathered by talking to people provides primary data, because
the data are obtained directly from the community. Specific examples are
health team members, client records, community health (vital) statistics,
census bureau data, reference books, research reports, HEDIS measures, and
community health nurses.
Secondary sources of data include people who know the community well
and the records such people create in the performance of their jobs. Because
secondary data may not totally describe the community and do not
necessarily reflect community self-perceptions, they may need augmentation
or further validation through focus groups, surveys, and other primary data
collection methods.

1304
International Sources
International data are collected by several agencies, including the World
Health Organization (WHO) and its six regional offices and health
organizations, such as the Pan-American Health Organization. The WHO
publishes health statistics by country and information about specific diseases
and health measures in their annual Global Health Observatory. Information
from these official sources can give the nurse in the local community
information about immigrant and refugee populations he serves. More
information on international health agencies can be found in Chapter 16.

1305
National Sources
C/PHNs can access a wealth of official and nonofficial sources of national
data (see Chapter 6 for more information). Official sources develop
documents based on data compiled by the government. The following are the
major official agencies: USDHHS. This is the main agency from which data
can be retrieved, and the National Center for Health Statistics (NCHS) at the
Centers for Disease Control and Prevention (CDC) was specifically
established under its auspices for the collection and dissemination of health-
related data. This agency is the nation's principal health statistics agency,
compiling data from many sources. These data provide information for many
functions, including health status for various populations and subgroups,
identification of disparities, monitoring trends, identifying health problems,
and supporting research.
USDHHS also developed Healthy People 2030 (USDHHS, 2020),
designed to focus America's attention on the major national health problems,
including realistic goals for national, state, and local agencies to work toward
over one decade. Other data sources are also available through the CDC
(2019b).
U.S. Census Bureau. This agency undertakes a major survey of
American families every 10 years, gathering data on health, socioeconomic,
and environmental conditions. This information is available on the Web or on
a CD-ROM, allowing numerous variables to be viewed in combination, for
easier development of a community profile (U.S. Census Bureau, 2019).
National Institutes of Health (NIH). This system focuses on improving
the health of the nation. An emphasis is placed on discovery of new cures or
treatments and preventing disease. Employees of these agencies prevent,
diagnose, and treat diseases and conduct research and disseminate research
findings (NIH, 2019).
Nongovernmental organizations (NGOs) have data sources generated
from research they conduct that focuses on the population, disease, or
condition they were developed to serve. Each agency collects data at the
national level; however, the more accessible arm for services functions at
state, county, and local levels. Examples of these agencies are the American
Cancer Society (ACS), American Heart Association (AHA), the American
Association of Retired Persons (AARP), Mothers Against Drunk Drivers
(MADD), and Students Against Drunk Drivers (SADD). The Public Health
Foundation (2020) offers information on many areas of interest to C/PHNs:
teams toolbox, critical thinking tools, population heath driver diagrams, and
other quality improvement tools for public health. The Kaiser Family
Foundation and the RAND Corporation have a variety of fact sheets and
compilations of data from various sources. The Gallup Poll provides national

1306
survey information on various topics, including health. Information from
such national sources allows community health assessment teams to compare
local data with national and state statistics and trends—a very valuable
function. The Robert Wood Johnson Foundation's (2019) County Health
Rankings and Roadmaps is based on a model of population health that
emphasizes the many factors that, if improved, can help make communities
healthier places to live, learn, work, and play. Proprietary data sources
include the American Hospital Association, the American Medical
Association, or various health insurance companies. See Chapter 6 for a list
of data collection systems.

1307
State and Local Sources
For nurses, the most significant state source of assessment data comes from
the state health department. This official agency is responsible for collecting
state vital statistics and morbidity data.
The Behavioral Health Surveillance System (BRFSS) is the world's
largest telephone health survey that monitors health risk at the state level
(CDC, 2019c). Supported by the CDC, the information is used at various
levels to identify risk and prevent disease. As a resource to local health
departments, the state health department provides invaluable support
services, and it is the main source of health-related data on the state level.
Nonofficial agencies have state chapters or headquarters and compile
their information at the state level. Local nonofficial agency chapters have
documents of compiled state and national data on the population, disease, or
condition they address.
State and county budgets or public health agency Web sites may also
provide helpful information. All states collect vital statistics (e.g., births,
deaths), and many collect information on hospitalization and morbidities
related to infectious diseases, cancer, or cardiovascular disease. State
departments of education may have school-based data on immunizations and
overall school health. Information on traffic accidents, mental health, and
environmental hazards is often available at the state level. States may also
organize their statistics by county level, making it easier to compare your
county's data with others.
Many sources of information may be obtained at the local level. Some
key sources are the local visitor's bureau, city chamber of commerce, city
planner's office, health department, hospitals, social service agencies, county
extension office, school districts, universities or colleges, libraries, clergy,
business and service organizations, and community leaders and key
informants. Some of these sources compile their own statistics, but all have
views of the community particular to their discipline, interest, or knowledge
base. Some agencies at the local level develop city or county directories.
These are updated periodically and are valuable resources for community
health assessment teams and community health nurses. More detailed
information on national, state, and local health agencies, and information
available from them, can be found in Chapter 6.

1308
DATA ANALYSIS AND DIAGNOSIS
This stage of assessment requires analysis of the information gathered, so
that inferences or conclusions may be made about its meaning. Such
inferences must be validated to determine their accuracy, after which a
nursing diagnosis can be formed.

1309
The Analysis Process
First, the data must be validated: Are they accurate, complete, representative
of the population, and current? Several validation procedures may be used
(Northwest Center for Public Health Practice, n.d.):

Data can be rechecked by the community assessment team.

Data can be rechecked by others.
Subjective and objective data can be compared.
Community members can consider the findings and verify them.

Validated data are then separated into categories such as physical, social,
and environmental data. In many instances, data spreadsheets are used to
provide a structure for data organization. Next, each category is examined to
determine its significance. At this point, there may be a need to search for
additional information to clarify the meaning of the data. Only then can
inferences be made and a tentative conclusion about the meaning of the data
be reached (Anderson & McFarlane, 2019).
Big data have increasingly become a go-to source for clinical and
community health professionals seeking to learn more about the health status
of communities. Defined as large volumes of data that is amassed, managed,
and analyzed from multiple sources, big data provide the level of detail
necessary predict and understand public health risks and to develop
interventions for specific groups within a larger population. These data are
used in disease surveillance, predicting health risk, targeting interventions,
and understanding disease (Zhu et al., 2019). It can be found in clinical
information systems (i.e., electronic health records), public payer data claims
(i.e., Medicare), and research databases.
Some computer programs are designed to analyze community assessment
data. For large, complex, or ongoing community assessment plans, this may
be the best method. For smaller, one-time assessments, the paper-and-pencil
method may be sufficient and less unwieldy. Some communities may hire an
outside professional assessment service. These teams often use the latest
technology when analyzing data. Not all communities can afford such a
service, and if key leaders become familiar with assessment, analysis, and
diagnostic processes, an investment in a computer program may be
worthwhile. Regardless of the analysis method used, data interpretation
remains a critical phase of the process.
In data interpretation, the ever-present danger exists of making
inaccurate assumptions and diagnoses. The importance of validation cannot
be overemphasized. Before making a diagnosis, all assumptions must be
validated: Are they sound? Community members should participate actively

1310
in validation efforts by clarifying perceptions, explaining the circumstances
surrounding the situation, and acting as sounding boards for testing
assumptions. Other resources, such as the health team members and
community leaders, are used to explore and confirm inferences. Data
collection, data interpretation, and nursing diagnosis are sequential activities,
with validation serving as the bridges between them. When performed
thoroughly, these steps lead to accurate diagnoses.

1311
Community Diagnosis Formation
The next step of the nursing process, after analysis, is the development of the
community diagnosis. Community diagnosis stems from analysis of
assessment data.
The diagnosis “describes a situation” and “implies a reason” or etiology
focusing on a specific community (Anderson & McFarlane, 2019).
Various taxonomies and classification systems are used in nursing to
describe specific nursing problems, and each one has its limitations when
dealing with community-level diagnoses. The North American Nursing
Diagnosis Association (NANDA) is much more oriented to nursing
diagnoses of individuals and families than to community-level problems.
Nursing Outcomes Classification (NOC) is also generally individual
oriented. The Omaha System, originally designed by the Omaha Visiting
Nurse Association and described earlier in this chapter, is again primarily
used in nursing diagnoses of individuals, families, and small groups, and
some community health applications have been developed (Omaha System,
2017).
An example of a research study that used the Omaha System was one in
which researchers evaluated the following behaviors of Syrian refugees
living in urban areas of Turkey (Ardic, Esion, Koc, Bayraktar, & Sunal,
2018):

In the environmental domain: income, sanitation, and residence

In the psychosocial domain: communication with community resources,
social contact, interpersonal relationships, mental health, neglect, and
caretaking/parenting
In the physiological domain (communicable/infectious conditions)
Health-related behaviors (nutrition, personal care, substance use, health
care supervision, and medication regimen)

A sociodemographic questionnaire provided individual and housing

characteristics, and the Omaha System-Problem Classification List was used
to identify issues and plan for intervention based on the specified nurse-
identified domains and behaviors of concern. Due to language issues and
limited time with an interpreter, there was no detailed evaluation of
outcomes. However, The Omaha System components can be used by the
local health departments to support the diagnosis and planning of further
initiatives for the refugee population (Ardic et al., 2018).
This chapter discusses nursing diagnosis as characterized by Neufeld and
Harrison (1996), based on the classic work of Mundinger and Jauron (1975).

1312
These authors proposed the use of nursing diagnoses in the community by
substituting the term client, family, group, or aggregate for the word patient.
Neufeld and Harrison (1996) described a nursing diagnosis as the
statement of a [client's] response which nursing intervention can help to
change in the direction of health and which also identifies essential factors
related to the unhealthful response.
Nursing diagnosis was used by Neufeld and Harrison as the foundation
for development of wellness diagnosis (Neufeld & Harrison, 1996): “…the
statement of a client's [or community's] healthful response which nursing
intervention can support or strengthen. It should also identify the essential
factors related to the healthful response.”
In 1996, Stolte developed a manual dedicated solely to nursing wellness
diagnosis which were later incorporated with community diagnosis by
Carpenito (2017) in her well-known handbook of nursing diagnosis
application.
By substituting the term community for client, family, group, or
aggregate, the nursing or wellness diagnosis can be applied to the community
as a whole. These diagnoses identify the conclusion the nurse draws from
interpretation of collected data and describe a community's healthy or
unhealthy responses that can be influenced or changed by nursing
interventions. These findings allow the nurse to collaborate with community
and health team members to affect positive changes in outcomes.
In community health, nurses do not limit their focus to problems; they
consider the community as a total system and look for evidence of all kinds
of responses that may influence the community's level of wellness.
Responses encompass the whole health–illness continuum, from specific
deficits, such as a lack of senior centers or day care programs, to
opportunities for maximizing a community's health, such as promoting
farmer's markets for better access to fresh fruits and vegetables or improving
the safety of the roadways. The statement of community response—the
diagnosis—can focus on a wide range of topics.

1313
Community Diagnoses
Data have been gathered from a variety of sources and have been validated
by several means. The data have been recorded, tabulated, analyzed, and
synthesized, so that patterns and trends can be seen. The use of charts,
graphs, and tables assists in visualizing the synthesized data. The community
assessment team should present their findings to peers and colleagues and
use their expertise to assist in the formulation of the community diagnoses.
Inferences are drawn from the data, and these statements refer to actual
or potential problems. Additional statements involve etiology, by stating that
this condition is related to certain conditions or problems. There may be a
number of these statements, involving several subsystems, for every one
diagnosis. Signs and symptoms of the diagnosis relate to the magnitude or
duration of the problem, usually documented “as manifested by” (Anderson
& McFarlane, 2019).
Continuing with the nursing process format, nursing diagnoses for the
community are developed. Community diagnoses refer to nursing diagnoses
about a community's ineffective coping ability and potential for enhanced
coping. The statements about the community should include the strengths of
the community and possible sources for community solutions, as well as the
community's weaknesses or problem areas.
Community-level diagnoses can be developed (Carpenito, 2017). These
diagnoses are used as tools as the community begins to plan, intervene, and
evaluate outcomes. Diagnostic categories for individuals (e.g., knowledge
deficit of senior services, high risk for injury or falls) can often be applied at
the community level.
Community-level nursing diagnoses should portray a community focus,
include the community response, and identify any related factors that have
potential for change through community health nursing. These may also
include wellness diagnoses, which indicate maintenance or potential change
responses (due to growth and development), when no deficit is present.
Community nursing diagnoses must also include statements that are
narrow enough to guide interventions, have logical linkages between
community responses and related factors, and include factors within the
domain of community health nursing intervention.
Examples of wellness and deficit community nursing diagnoses and
several diagnoses for a specific community follow:
1. Wellness nursing diagnosis for an assisted living community of elders.
The senior residents of an assisted living center (community focus) have
the potential for achieving optimal functioning related to (host factors)
their expressed interest in exercise, diet, and meaningful activities and

1314
 to (environmental factors) their access to exercise opportunities,
nutritional information, and social outlets.
2. Deficit community nursing diagnosis for a rural farmworker community.
The inhabitants of (name of the town) in (name of the state) are at risk
for illness and injury related to (host factors) exposure to pesticides,
lack of motivation to add or use safety devices on farm machinery, lack
of safety knowledge, choice to take unnecessary risks (environmental
factors), lack of family income to purchase newer equipment, and long
hours of work that lead to stress and exhaustion.
3. Community diagnoses for Anytown, Kansas. Anytown, Kansas, is
experiencing an increase in crime, a problem compounded by the small
size of the police force and an influx of many new community
members. The community has worked together constructively in the
past, communicates well, and has strong recreational outlets for
community members. The community:

Has expressed vulnerability and feels overwhelmed related to threats to

community safety
Has failed to meet its own expectations related to inadequate law
enforcement services
Has expressed difficulty in meeting the demands of change related to an
influx of new community members
Has a successful history of coping with a previous crisis of teenage
pregnancy
Has positive communication among community members
Has a well-developed program for recreation and relaxation

Such diagnoses can guide communities toward maximizing or improving

their health as they plan, implement, and evaluate changes to be measured by
established outcome criteria. Broad goals can form the basis for planning
interventions. From these goals, more specific activities, interventions, and
targeted programs can be designed. Measurable objectives can be written and
evaluated (Anderson & McFarlane, 2019). Outcome criteria are measurable
standards that community members use to measure success as they work
toward improving the health of their community. Outcome-based or
evidence-based nursing practice applies to aggregates in the community as
well as to patients in acute care settings.
Nursing diagnoses change over time because they reflect changes in the
health status of the community; therefore, diagnoses need to be periodically
reevaluated and redefined. The changing diagnosis can be a useful means of
moving a community toward improved health because it gives community
members a clear standard against which to measure progress.

1315
PLANNING TO MEET THE
HEALTH NEEDS OF THE
COMMUNITY
Planning is the logical decision-making process used to design an orderly,
detailed series of actions for accomplishing specific goals and objectives.
Planning for community health is based on assessment of the community and
the nursing diagnoses formulated, but assessment and diagnosis alone do not
prescribe the specific actions necessary to meet clients' needs (Anderson &
McFarlane, 2019; Minnesota Department of Health, n.d.a). See Chapter 12
for more on program planning.
Knowing that a group of mothers at the well-child clinic need emotional
support does not tell the nurse what further action is indicated. A diagnosis of
culture shock (adjustment deficit to a contrasting culture) for a family newly
arrived from Cuba does not reveal what action to take. The nurse must
systematically develop an appropriate plan (Box 15-6). See Chapter 12 for
more on planning, implementing, and evaluating community health.

BOX 15-6 Levels of Prevention Pyramid

The Problem of Child Abuse SITUATION:
Desire to reduce the incidence of child abuse in a
given community by 50% within 2 years.
GOAL: Using the three levels of prevention, avoid or promptly diagnose
and treat negative health conditions, and restore the fullest possible
potential.

1316
1317
Tools to Assist With Planning
A wide variety of tools are available to enhance community health
improvement planning; these include activity descriptions, templates,
and models (Minnesota Department of Health, n.d.a; NACCHO, 2015).
Such tools help prioritize health issues, develop goals and objectives,
specify interventions, and anticipate client outcomes.
Tools that assist with planning also enable the nurse to test ideas and
adjust solutions before actual implementation. Finally, the use of
standardized tools enhances the planning process and promotes
effectiveness of services, as well as professional standards of practice.

In addition to using tools, a systematic approach guides the community

health nurse in the development of a feasible plan that adequately and
appropriately addresses the needs of the community (Anderson &
McFarlane, 2019). As they do in the rest of the nursing process, community
health nurses collaborate with clients and other appropriate professionals
throughout each of these planning activities.

1318
The Health Planning Process
The health planning process is a four-stage system used to design new
health-related programs or services in the community and includes

Priority setting
Establishing goals and objectives
Implementing health promotion plans
Evaluating implemented programs

The process is often used by health educators when designing

educational programs or by administrators in community health agencies
when initiating new services. The nursing process is similar to the health
planning process. Each model helps to promote service effectiveness in
addition to maintaining standards of practice. Community health nurses
familiar with both the health planning process and the nursing process should
be able to work collaboratively with community health professionals using
either model.

1319
Setting Priorities
Priority setting involves assigning rank or importance to the identified
needs to determine the order in which goals should be addressed.
There are numerous ways to set priorities in the planning process. Many
have identified useful criteria that can guide ranking problems for order of
action (National Association of County & City Health Officials, n.d.; Office
of the Assistant Secretary for Planning and Evaluation, n.d.; Public Health
Institute, 2012). They are presented here as a combination of criteria:
1. Significance of the problem or the number of people affected in the
community 2. Level of community awareness of the problem 3.
Community motivation to act on the problem (or, Is this important to the
community?) 4. Nurse and partnership's ability to reduce risk and/or
influence the solution 5. Cost of risk reduction in terms of financial,
social, and ethical capital 6. Ability to identify a specific target
population for an intervention 7. Availability of expertise to solve the
problem within the partnership, coalition, or community 8. Severity of
the outcome if left unresolved or the consequences of inaction 9. Speed
with which the problem can be resolved
A common test for priority setting is called PEARL, an acronym for
“propriety, economics, acceptability, resources, and legality” (Public Health
Institute, 2012, p. 50). A priority matrix may also be developed, but
decisions must not be unilateral and should include input from all
stakeholders, including community members. For example, a community
assessment not only revealed that a group of elderly residents living within a
specific zip code were fearful of crime but also identified the lack of public
transportation as issues to be addressed. Using the above criteria, the
community health nurse working in this community identified that 85% of
residents of the community had fears about crime but did not see
transportation as an issue. The residents saw crime as an important concern
and were also motivated to act on the crime issue but were not willing to
explore the transportation issue at the current time. The nurse, along with the
community coalition partners, would be better able to influence the crime
problem by helping to form town watch groups and getting the local police
district to provide increased patrols during evening hours when robberies
were more likely to occur. However, the partners had little influence to
extend the hours of operation on buses or influence the creation of new bus
routes. Members of the coalition included the local police chief and chamber
of commerce director. If the crime problem was left unchecked, more people
could be adversely affected, including businesses, because people would not
be willing to leave their homes to shop or might even be forced to move
away. Finally, these initiatives could be put in place rather quickly and

1320
inexpensively after the formation and training of volunteer town watch
groups. There certainly are no adverse social, economic, or ethical
consequences attached to addressing this problem. Therefore, it would seem
that the crime issue would take priority over the transportation issue. It is
important to remember that each community diagnosis is examined
separately and then compared. Priorities for action are discussed, ranked, and
then prioritized for action (Hauck & Smith, 2015).

1321
Establishing Goals and Objectives
Goals and objectives are crucial to planning and should be feasible, specific,
and measurable (Anderson & McFarlane, 2019). The diagnosis that identifies
needs must be translated into goals to give focus and meaning to the nursing
plan.

Goals are broad statements of desired outcomes.

Objectives are specific statements of desired outcomes, phrased in
behavioral terms that can be measured.

Target dates for expected completion of each objective are also stated.
Objectives are the stepping-stones to help one reach the end results of the
larger goal. For the elderly group concerned about crime in the
neighborhood, the need, the goal, and the objectives were defined as follows:

Need: The group of elderly people has altered coping ability related to
their fear of crime.
Goal: Within 6 months, this group of elderly people will feel
comfortable to walk the streets of their neighborhood without
experiencing any incidents of criminal assault.
Objectives:

1. By the end of the 1st month, a safety committee (composed of senior

citizens, nurses, police, and other appropriate community members) will
be established to study the crime patterns in the neighborhood.
2. The safety committee will develop strategies for crime reduction and
elder protection, which will be presented to the city council for approval
by the end of the 3rd month.
3. Safety strategies, such as increased police surveillance, town watch
patrols, and escort services, will be implemented by the end of the 5th
month.
4. By the end of the 6th month, nursing assessment will determine that
senior citizens feel free to walk about the neighborhood.
5. By the 6th month, there will be fewer reported incidents of criminal
assault.
Development of objectives depends on a careful analysis of all the ways
in which one could accomplish the larger goal. C/PHNs should first select
the course of action that is best suited to meet the goal and then build
objectives. For the group of elderly people, other alternatives, such as staying
indoors or always walking in pairs, were considered and rejected. The
ultimate choice was to find a way to make their environment safe and
enjoyable.

1322
 Some rules of thumb are helpful when writing objectives.

First, each objective should state a single idea. When more than one
idea is expressed—as in an objective to both obtain equipment and learn
procedures—it is more difficult to measure the completion of the
objective.
Second, each objective should describe one specific behavior that can
be measured. For instance, the fourth objective from the list states that
the seniors will report feeling free to walk outdoors within 6 months. It
describes a behavior that can be measured at some point in time. One
can more readily evaluate objectives that include specifics—such as
what will be done, who will do it, and when it will be accomplished.
Then it is clear to everyone involved exactly what has to be done and
within what time frame.
Writing measurable objectives makes a tremendous difference in the
success of planning. See Chapter 11 for more information on writing
behavioral objectives.

The acronym SMART is another useful guideline when writing

objectives (Minnesota Department of Health, n.d.b). SMART objectives are

Specific: Concrete, detailed, and well defined so that you know where
you are going and what to expect when you arrive.
Measurable: Numbers and quantities provide means of measurement
and comparison.
Achievable: Feasible and easy to put into action.
Realistic: Considers constraints such as resources, personnel, cost, and
time frame.
Time bound: A time frame helps to set boundaries around the
objective.
Planning means thinking ahead. The nurse looks ahead toward the
desired end and then decides what intermediate actions are necessary to
meet that goal.
Sometimes, an objective itself describes the intermediate actions. At
other times, an objective may be further broken down into several
activities. For example, the second objective states that the safety
committee will be charged with developing strategies, presenting them
to the city council, and gaining their approval. Good planning requires
this kind of detail.
Making decisions is an important part of planning. Decisions must be
made during the process of establishing priorities. Decisions are
necessary for selecting goals and for choosing the best course of action
from many possible courses. Further decision-making is involved in
selecting objectives and taking action to accomplish the objectives.

1323
To facilitate planning and decision-making, the community health nurse
involves other people. Clients must be included at every step because
they are the ones for whom the planning is being done. Without their
insight and cooperation, the plan may not succeed. Additionally, the
involvement of other nurses may be important.
Team meetings, nurse–supervisor conferences, and nurse–expert
consultant sessions are all useful resources for planning. In addition, it
is essential that you confer with members of other health and
professional disciplines (e.g., teachers, social workers, mental health
professionals, hospital representatives, city planners). Interdisciplinary
team conferences are valuable for gaining a broader perspective and
enlisting wider support for the evolving plan.

1324
IMPLEMENTING HEALTH
PROMOTION PLANS FOR THE
COMMUNITY
Implementation is putting the plan into action. The nurse, other
professionals, or clients carry out the activities of the plan.
Implementation is often referred to as the action phase of the nursing
process. In community health nursing, implementation includes not just
nursing action or nursing intervention, but collaboration with clients,
stakeholders, and other professionals. An example of this process can be seen
in the community action plan of the CHANGE tool (CDC, 2019d). After
community data are assessed and analyzed, the final step is to create an
action plan using SMART objectives. The action plan should include big-
picture outcomes as well as incremental progress (CDC, 2019d).
When bringing about change in a community organization,
implementation involves the greatest commitment of time and planning. This
often includes an implementation timetable, as well as funding or organizing
physical/informational/staff/management resources, collaboration with
outside agencies, training staff and working with community volunteers as
needed for program implementation, and actually putting into action those
interventions created during the planning phase (Anderson & McFarlane,
2019; Public Health Institute, 2012).
Certainly, the nurse's professional expertise and judgment provide a
necessary resource to the client group. The nurse is also a catalyst and
facilitator in planning and activating the action plan. However, a primary
goal in community health is to help people learn to help themselves in
achieving their optimal level of health. To realize this goal, the nurse must
constantly involve clients in the deliberative process and encourage their
sense of responsibility and autonomy. Other health team members may also
participate in carrying out the plan. All are partners in implementation.

1325
Preparation
The actual course of implementation, outlined in the plan, should be fairly
easy to follow if goals, expected outcomes, and planned actions have been
designed carefully. Professionals and clients should have a clear idea of who,
what, why, when, where, and how. Who will be involved in carrying out the
plan? What are each person's responsibilities? Do all understand why and
how to do their parts? Do they know when and where activities will occur?
As implementation begins, nurses should review these questions for
themselves, as well as for clients. This is the time to clarify any doubtful
areas, thereby facilitating a smooth implementation phase. An operations
manual may be needed, as well as organizational charts, clear budgets, and
social marketing plans (Anderson & McFarlane, 2019).
Even the best planning may require adjustments. For example, some
nurses who planned a health fair for seniors discovered that the target group
would not have transportation to the site because the volunteering bus
company had withdrawn its offer. To smoothly implement the plan, the
nurses arranged for volunteers from local churches to pick up the seniors,
bring them to the health fair, and deliver them afterward to their homes.
Implementation requires flexibility and adaptation to unanticipated events.

1326
Activities or Actions
The process of implementation requires a series of nursing actions or
activities:

The nurse applies appropriate theories, such as systems theory or

change theory, to the actions being performed.
The nurse helps to facilitate an environment that is conducive to
carrying out the plan (e.g., a quiet room in which to hold a group
teaching session or solicitation of support from local officials for an
environmental cleanup project).
The nurse and other health team members prepare clients to receive
services by assessing their knowledge, understanding, and attitudes and
by carefully interpreting the plan to clients. This interaction nurtures
open communication and trust between nurse and clients. Professionals
and clients (or representatives if the aggregate is large) form a
contractual agreement about the content of the plan and how it is to be
carried out.
The plan is carried out, or modified and then carried out, by
professionals and clients. Modification requires constant observation
and interchange during implementation, because these actions determine
the success of the plan and the nature of needed changes.
The nurse and the team monitor and document the progress of the
implementation phase by process evaluation, which measures the
ongoing achievement of planned actions (Anderson & McFarlane,
2019).

1327
EVALUATION OF IMPLEMENTED
COMMUNITY HEALTH
IMPROVEMENT PLANS
Evaluation is usually seen as the final step, but because the nursing process is
cyclic in nature, the nurse is constantly evaluating throughout the entire
process. For instance, in the assessment phase, the nurse must evaluate
whether the collected data are sufficient and appropriate to beginning
planning.

Evaluation methods must be addressed during the planning phase as

goals and objectives as well as interventions are identified (Anderson &
McFarlane, 2019).
Evaluation refers to measuring and judging the effectiveness of goal or
outcome attainment. Too often, emphasis is placed primarily on
assessing client needs and on planning and implementing service. The
nursing process is not complete until evaluation takes place.
Ideally, the nursing process should be observed as cyclical instead of
linear, and when this occurs, it is obvious that evaluation guides the next
assessment.
The Community Toolbox (2019) provides suggestions for participatory
evaluation that includes examination of the process (e.g., how the
assessment was conducted), implementation (e.g., how the program was
designed and executed), and outcomes (e.g., if desired results were
accomplished). Appropriate questions include the following: Was all
potential information assessed? How effective was the service
provided? Were client needs truly met? How has health status changed?
Professional practitioners owe it to their clients, themselves, and other
health service providers to fully and effectively evaluate a program
(Box 15-7).

BOX 15-7 STORIES FROM THE

FIELD: COMMUNITY ASSESSMENT
OF A RURAL COUNTY IN A WEST
COAST STATE OUR GROUP
COMPLETED A COMMUNITY

1328
ASSESSMENT OF A RURAL
COUNTY IN A WEST COAST STATE.
WE FOUND DATA FROM MANY
SOURCES (E.G., CENSUS, HEALTH
DEPARTMENT REPORTS),
INCLUDING KEY INFORMANTS
AND A COMMUNITY SURVEY
COMPLETED BY COMMUNITY
MEMBERS. MANY RESOURCES
WERE AVAILABLE ON THE CDC
WEB SITE FOR MOBILIZING FOR
ACTION THROUGH PLANNING
AND PARTNERSHIPS (MAPP)
(HTTPS://WWW.NACCHO.ORG/PRO
GRAMS/PUBLICHEALTH-
INFRASTRUCTURE/PERFORMANC
E-IMPROVEMENT/COMMUNITY-
HEALTH-
ASSESSMENT/MAPP/PHASE-3-THE-
FOUR-ASSESSMENTS).
Windshield Survey
The windshield survey had the following findings.

Physical
In touring the area, it is noted that there are many older homes in need
of repair. Some homes are vacant and boarded up on the SW part of
town. Sidewalks are broken up, making them unsafe to walk on. Few
playgrounds are noted on this side of town. The NE area has new home

1329
subdivisions and a new park. the NW area of town has apartment
buildings, while the SE side has a large tomato processing plant. Most
of the county is open land or is used for agriculture. Two state prisons
are at opposite ends of the county. There is a community swimming
pool in the largest town. The downtown areas of the larger towns have
different types of businesses, but some areas are vacant. In the more
rural areas, there are acres of land in production (e.g., dairies, cotton,
cattle, pistachios, almonds, tomatoes, walnuts, corn), and some
abandoned old farmhouses or dilapidated buildings can be found.

Economic
There are two large supermarkets in the largest town, and most of the
smaller towns have at least one local market. Convenience/liquor stores
are found in every community and some rural crossroads areas. There
are a bulk warehouse store and two pharmacies in the largest city and a
small local pharmacy in a smaller community at the far southern edge of
the county. Food stamps are accepted in many places. The largest town
has a farmer's market and a flea market weekly. There is a shopping
mall, and smaller towns have secondhand and antique stores. Most jobs
are agriculture related. People gather in the parking lot of the local
home improvement store looking for day work. There is a small military
base on the outskirts of the county with medical services and a store.
There is an American Indian reservation with housing, a casino, and a
small health clinic.

Services
For transportation, there is a county bus, but times/days are limited;
there is an Amtrak station that includes intercity bus service. Medical
transport services and cabs are available. A freeway runs through the
middle of the county. Most people drive their own cars, but bus
ridership has increased over the past few years. A community hospital is
located in the largest city, and there are two small hospitals in the most
distant small towns (now closed or used as clinic). The county is a
Health Professional Shortage Area (HPSA) for primary care, dental
care, and mental health. There is a county public health department in
the largest town, with satellite clinics or rotating C/PHN access in every
smaller town. There are two dialysis clinics in the largest town and one
in the adjoining town, and several rural health clinics. The nearest
Planned Parenthood clinics are in two adjoining counties. There are
churches in every community (some in poor repair). There is a county
library, with some service to smaller towns. Fire, police, and sheriff
department offices are found in several areas throughout the county,
along with eight post offices. There are high schools in three larger

1330
towns, and K-8 schools are found in local communities throughout the
county. There is also a community college satellite center.

Social
There is a local newspaper. Most people have access to TV/radio, and
there are Spanish language stations available. There are political bumper
stickers on some cars and also billboards in populated areas. People can
be seen smoking and occasionally vaping outside of stores or when
walking downtown. Homeless individuals gather in several areas of the
county. High school students gather after school at local fast food
restaurants and arcades. People shopping at grocery stores are overheard
speaking English, Spanish, and Portuguese.

Data Collection
The data collected are shown in the following table.

1. List the strengths and weaknesses of this community.

2. What diagnoses would you apply, and why?
3. What interventions might be done to address these issues? Identify
one that your student group might be able to complete during this
clinical experience.

1331
 a. Who would be involved (what collaboration would be needed)?
b. What level of prevention (primary, secondary, tertiary) does the
intervention represent?
c. What outcomes could you measure to show improvement?
d. How can your plan best be evaluated?

Evaluation is woven throughout the Community Change Process and the

CHANGE tool. The evaluation process should assist in determining if the
team is creating the measurable impact envisioned (CDC, 2019d). An
example of evaluation to improve program plans includes the Health in
Action Project (Nieves et al., 2019). In conjunction with the East
Neighborhood Health Action Center, this project implemented a participatory
grant-making process to fund projects that improved the community's health.
The project engaged stakeholders in decision-making by including local
residents in the decision-making process for allocation of grant funds.
Evaluation findings showed that inclusion of residents as part of the process
for decision-making was a strength of the project. Participants learned about
the local organizations and services, and they felt included in a process that
affected them and their neighborhood. Reciprocally, the funded organizations
expanded their work and piloted new programs, forming new partnerships
and building community networks (Nieves et al., 2019).
As stated earlier, evaluation is an act of appraisal in which one judges
value in relation to a standard and a set of criteria. Evaluation requires a
stated purpose, specific standards, and criteria by which to judge and
judgment skills.

1332
Types of Evaluations
To determine the success of their planning and intervention, community
health nurses use two main types of evaluation: formative and summative
evaluation.
The focus of formative evaluation is on process during the actual
interventions. In formative evaluation, performance standards are developed
and used to determine what is and is not working throughout the process.
These could include the physical and organizational structure of the agency,
as well as resources that provide a foundation for any interventions.
Formative evaluation essentially looks at the step-by-step process of program
implementation. Could I do anything better or differently to increase my
desired outcome? An example would occur when looking at the poor
attendance at two sessions of an evening health promotion class for senior
citizens. The nurse identifies the reason for poor attendance as being seniors'
reluctance to attend an evening class because they either don't drive at night,
have low vision at night, or fear coming out in the dark. The class is
rescheduled for midmorning, and the attendance dramatically increases.
Summative evaluation focuses on the outcome of the interventions: Did
you meet your goals? Summative evaluation examines outcomes of the
interventions. The effect, or degree to which an outcome objective has been
met, informs the agency or program leader of the program's impact on
clients' health. As an example, one manufacturing company had an 80%
adherence rate for employees who were supposed to wear proper protective
devices (goggles, safety shoes, and hard hats) in the plant. Noncompliance on
the part of some workers was a concern to union representatives, the health
and safety team, and the company management. They were concerned that
20% of their employees were at risk for injury that would cause pain,
suffering, loss of work time, disruption to the manufacturing process, and
reduced profitability. The occupational health nurse along with the safety
officer began a month-long safety campaign that included safety mini-
classes, posters, and incentives for departments with 100% safety equipment
adherence. Three months after the program, 95% of the employees were
adhering to the safety regulations. This 15% increase was attributed to the
effect of the safety program.
The impact of a program determines how close it comes to attaining its
goals. In the earlier example, the objective of the safety campaign was to
increase safety equipment use, and use was significantly increased as a result
of the program. However, if the goal of the program had been to decrease
accidents and save the company money, the result could be determined only
with additional information. Were there fewer injuries caused by accidents?
Were there fewer days lost to injuries? Did the company save money as the

1333
direct result of employee safety adherence? What was the cost–benefit ratio?
Depending on the answers to these questions, the overall goal of the program
may or may not have been met, even though the objective of the program
was met. The full impact of the program cannot be determined without
additional data. See Chapter 12 for more on program evaluation.

1334
Community Development Theory
An outcome of effective community-level nursing practice is community
development. Community development is the process of collaborating with
community members to assess their collective needs and desires for positive
change and to address these needs through problem solving, collaboration
with community stakeholders, and resource development (Leigh & Blakely,
2013). A community development perspective assumes that community
members participate in all aspects of change—assessment, planning,
development, delivery of services, and evaluation. With this approach, the
focus is on healthful community changes generated from within the
community, as a partnership between health care providers and inhabitants,
rather than a commodity dispensed by health care providers.
Houghtaling, Banks, Ahmed, and Rink (2018) addressed breastfeeding in
American Indian culture by looking at the role of American Indian
grandmothers to inform breastfeeding practices in a rural community in the
United States. Interviews with American Indian grandmothers identified the
following: the importance of breastfeeding for healthy maternal–infant
bonding, the passing of knowledge for family support for breastfeeding
including attachment and bonding, and an overburdened health care system
as a barrier to maternal–child health. Outcomes of the study were that
breastfeeding practices need to be grounded in tribal resources and that
American Indian grandmothers and health care professionals need to use a
collaborative community approach (Houghtaling et al., 2018). The
community as partner model exemplifies this approach (Anderson &
McFarlane, 2019). Chapter 11 details community change theory.

The outcomes are more positive when community members have a

sense of ownership in the health programs and services that address
their needs. This enhances empowerment among members of the
community and enables them to more effectively control and participate
in transforming their environment and their personal circumstances.
This implies that health care agency infrastructures are appropriate
additions to services that are planned and delivered in an acceptable
manner to the community. This empowerment leads to greater resilience
and ultimately, wellness (RAND Corporation, 2015).

When applying community development theory, the agent of change

(often the C/PHN) is considered a partner rather than an authority figure
responsible for the community's health. To achieve acceptance as a partner,
the nurse must listen and learn from the community members, because they
are the experts with respect to their health care needs, culture, and values.
They have mastered adaptation to the community, and they have firsthand

1335
knowledge of prevention methods and interventions that are appropriate to
their lifestyles. Members of the community are engaged as coresearchers,
and time is spent building trust and developing collaborative relationships
with community members, stakeholders, and neighborhood health care
providers. The expertise of community members is valued and can be useful
in designing recruitment strategies, as well as in data analysis. This
experience can enrich the community as a whole, as well as the actual
participants.
The outcomes of the services provided by any organization can be
benchmarked against those of other groups. Benchmarking involves
comparing an organization's outcomes against those of a similar organization
or an organization that is known for its excellence in a particular area of
client care (Haustein et al., 2011). Information from this comparison can be
used to identify an organization's areas of weakness and to focus attention on
specific outcomes. The establishment of best practice activities entails
constant comparisons between high-and low-performance programs and
interventions (Ettorchi-Tardy, Levif, & Michel, 2012).
From a global perspective, the Conference on Primary Health Care held
at Alma-Ata in 1978 concluded that people have little control over their own
health care services and that the emphasis should be on health problems
identified by the members of the community in their attempts to attain a state
of wellness (WHO, 2019b). Leadership in the use of community
development methods to improve global health includes

Promote active, representative participation to influence decisions

affecting community members' daily lives.
Engage community members in economic, social, political,
environmental, psychological, and other issues that impact them.
Interest them in learning more about alternative courses of action.
Incorporate diverse cultures, ethnic and racial groups, and varied
interests in the process of community development.
Refrain from supporting efforts that are likely to adversely affect
disadvantaged members of the community.
Actively work to build leadership capacity of community leaders and
groups, and individuals.
Work toward long-term sustainability and community well-being.

1336
SUMMARY
Public health nursing is a community-oriented, population-focused
nursing specialty that is based on interpersonal relationships.
The unit of care is the community or population rather than the
individual, and the goal is to promote healthy communities.
Theories and models of community/public health nursing practice aid
the nurse in understanding the rationale behind community-oriented
care.
Salmon's construct for public health nursing prescribes education,
engineering, and enforcement with individuals, families, communities,
and nations.
Models used in public health nursing practice, the Minnesota
Intervention “Wheel,” the LAC PHN Practice Model, and the Omaha
System Model of the Problem-Solving Process provide guidance for
C/PHNs to assess, plan, intervene, and evaluate the care they provide to
communities.
The eight principles of public health nursing provide a framework
within which the nurse works to promote and protect the health of
populations.
Characteristics of healthy communities include those elements that
enable people to maintain a high quality of life and productivity by
increasing health and decreasing disease and disparities in health and
health care delivery. The effectiveness of community health nursing
practice depends on how well the nursing process is used as a tool to
enhance aggregate or population health. The nursing process involves
appropriate application of a systematic series of actions with the goal of
helping clients achieve their optimal level of health. The components of
this process are assessment, diagnosis, planning, implementation, and
evaluation.
The concept of community as client refers to a group or population of
people as the focus of nursing service. The community's health is
reflected in its status (e.g., morbidity and mortality rates, crime rates,
educational and economic levels), structure (availability, use, and
quality of services and resources), and processes (how well it functions
in regard to its strengths and limitations). The dimensions of a
community's health may be seen in regard to its location (e.g., climate,
vegetation, boundaries), population (e.g., diversity or homogeneity, old,
young, pregnant, addicted, or academic members), and social systems
(e.g., schools, businesses, communications, health care, and religious
organizations, among others).

1337
Assessment for community health nurses means collecting and
evaluating information about a community's health status to discover
existing or potential needs and assets as a basis for planning future
action. Assessment involves two major activities. The first is collection
of pertinent data, and the second is analysis and interpretation of that
data.
Community health nurses may use various assessment methods to
determine a community's needs. They include familiarization
assessments, such as windshield surveys, which involves studying data
already available on a community; problem-oriented assessment,
which focuses on a single problem and looks at the community in terms
of that problem; community subsystem assessment, by which the
community health nurse focuses on a single dimension of community
life; a complicated and often time-consuming comprehensive
assessment, to discover all relevant community health information; or
an assets assessment that focuses on the strengths of a community as
opposed to its deficits. Combinations may also prove useful (e.g.,
problem oriented and assets assessments).
Community data may be provided by many means—surveys,
descriptive epidemiologic studies, community forums, and town
meetings. Focus groups as well as primary and secondary sources (e.g.,
people who are familiar with the community and its character and
history) are also common sources of data, along with Web sites, and
government departments and agencies that compile statistics (e.g., U.S.
Census Bureau, state or county health departments). Sources can
include national, international, state, county, and local agencies, as well
as business and social organizations.
Using the nursing process in the community would not be complete
without looking at the role of the C/PHN as a catalyst for community
health improvement. Community development theory is the foundation
that supports citizen empowerment and use of key players in the
community to plan for the health and safety of that community.

1338
ACTIVE LEARNING EXERCISES
1. Using “Enable Equitable Access” (1 of the 10 essential public health
services; see Box 2-2 ), search your local public health agency's Web
site to determine what population-focused programs are offered in
your locality. How do you know if the programs are population-
focused?
2. Talk with a public health nursing director or a program manager to
explore nursing's role in the assessment, development,
implementation, and evaluation of population-focused programs
offered by the local health department.
3. Discuss with a public health nursing director or supervisor how public
health nurses might expand their population-focused interventions.
4. Describe a situation in community/public health nursing practice in
which the use of an educational intervention would be most
appropriate. Do the same with engineering (Salmon) and enforcement
interventions. Discuss your rationale for matching each situation with
that intervention.
5. What populations define your community? What are the needs and
deficits for specific groups? Use the nursing process to assess
potential or actual problems. Using data and your assessment,
determine a community diagnosis. As the community/public health
nurse, what are next steps in addressing your community's issues?

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!

1339
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1347
CHAPTER 16
Global Health Nursing
“When it comes to global health, there is no ‘them’… only ‘us’.”

—Global Health Council (2010)

KEY TERMS
Community health worker (CHW) Demographics Disability-adjusted life
year (DALY) Era of Chronic, Long-Term Health Conditions Era of
Infectious Diseases Era of Social Health Conditions Global health Global
burden of disease (GBD) Primary health care (PHC) Sustainable
Developmental Goals (SDGs) Years lived with disability (YLD) Years of life
lost (YLL) World Health Organization (WHO)

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Describe a framework for delivering community-based nursing care
within the context of global health.
2. Explain how epidemiologic and demographic transition theories assist in
understanding the impact of disease patterns on the health of a
community, country, or region.
3. Define the global burden of disease according to common social
determinants of health.
4. Describe the major health care trends currently affecting the world's
populations.
5. Explain how a focus on primary health care provides the basis for health
promotion and disease prevention.
6. Describe issues of global health conduct and regulation, including
ethical concerns.

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INTRODUCTION
The world has come to us; we encounter the world every day where we live.
In the Los Angeles Unified School District, second largest K-12 district in
the nation, students speak 92 languages other than English at home (Los
Angeles Regional Adult Education Consortium, 2018). Even Montana, a
sparsely populated state, has identified 22 world languages spoken in their
homes (City-Data, 2020). Local health has become global health.
What do you think of when you hear the phrase “global health?” Would
you first think about the survival rates of women and children? Or basic
nutrition as a foundation for health worldwide? More likely, you might think
about the news of respiratory pandemics spreading from one country to
another. What would you do if an international traveler from a pandemic area
is admitted to your unit for care? Knowledge about global health could guide
you to find targeted resources when you write a nursing care plan for your
traveler patient. What are the special health needs of refugees fleeing conflict
or extreme weather, or of immigrants simply looking for better
opportunities? These questions all point to the importance of understanding
the concept of global health, or the “world as client,” which is the focus of
this chapter. How can the whole world be our client as the recipient of
nursing care? Even if you think you will never practice nursing overseas, it is
important to realize that global events affect nursing actions locally and the
health of others globally.
This chapter describes the intersection of global health and
community/public health nursing. It introduces basic global health concepts
and how global events can impact the health and health care of a community,
country, region, or the world.

We begin with a quick review of the context for global health and some
key events over the years that show the evolution of global health.
Global health includes health within the borders of each nation, within
population groups with unique cultures and languages, and across
international borders and cultures.
We briefly examine selected global health trends and examine the
influence of global political initiatives. Usually when we think of global
health trends, we think of data describing epidemiology and contagious
diseases. Other trends are equally important, such as management of
noncommunicable diseases and increased access to primary health care
(PHC). One important initiative is Health in All Policies (HiAP), which
aims to address the health impact of every program or initiative.

1349
 We also consider how these trends influence global health goals. We
know health promotion and disease prevention are important goals, but
do some strategies work better than others? Smaller nations with
emerging economies have figured out how to deliver quality health care
despite limited resources and challenging infrastructure. How do these
countries achieve success? Sometimes they partner with a
nongovernmental agency (NGO), which is a nonprofit or voluntary
citizens' group formed to address a social issue. Which agencies achieve
the best results? Could we adapt their successes for our local
communities? Good ideas anywhere can improve good health
everywhere and make the world a better place for all.

This chapter ends with a brief discussion of global health ethics. You are
already familiar with the primary ethical concept in nursing of
nonmalfeasance, “first do no harm” (see Chapter 4). This is also a key
principle in global health ethics. Someday you might have the opportunity to
participate in an overseas internship or perhaps volunteer as a nurse
following a disaster in another country. Being aware of the special ethical
concerns unique to global health will help you be successful wherever you
practice nursing. Ultimately, we want the nursing care we provide to be
ethical and positive with lasting benefits, whether we care for patients down
the street or across the world.

1350
A FRAMEWORK FOR GLOBAL
HEALTH NURSING ASSESSMENT
The slogan, think globally and act locally, captures the essence of caring for
our interconnected world. When community/public health nurses (C/PHNs)
partner with the community client to assess health status, one useful guide is
the universal imperatives of care. For instance, determining how many nurses
a community needs depends in part on knowing the characteristics of the
community, the people, and the predominant state of health. These universal
imperatives are reflected in the elements of the following community
assessment framework:

Patterns of care
Demographic transitions
Epidemiologic transitions

After completing a community assessment, C/PHNs determine which

services to provide by referring to the core functions and 10 essential public
health services to guide their care (CDC, 2017c). See Chapter 2 and
examples throughout this book.

1351
Patterns of Care
As with any assignment in nursing, our first task is to assess the client. When
the client is an entire population, the assessment can be quite substantial. In
this case, we can use a framework to guide our review. Certain social
conditions of living are known to influence and even determine health among
all populations. When the social determinants of health are reviewed
together, we quickly learn about the client population and their knowledge,
behavior, and values. We also assess the health infrastructure within their
country or region. Data describing these patterns have proven to be good
predictors of the overall health of a population. Patterns allow us to design
culturally appropriate care solutions affecting health, wellness, and illness of
populations, both within and between countries and communities. These
patterns of demographics are recognizable and measured across populations.
What other aspects can you think of to add to the categories shown in Box
16-1?

BOX 16-1 Patterns of Care

Patterns of place or the lived environment
Rural
Urban
Climate influence
Patterns of perceptions of health care
Influence of culture
Influence views and acceptance of healing treatments
Influence acceptance of nurses and other health care providers
Affected by attitudes toward women
Patterns of privilege or inequality
Living conditions, including access to nutritional food and
clean water
Daily functioning including physical safety
Quantity and quality of education for children, especially girls
and women
Level of health literacy
Preference of learning style
Access to employment
Access to affordable health care resources
Informed health care decisions, including who lives or dies
Patterns of population health differences (demographics)
Birth rates (fertility)
Infant and child survival rates

1352
 Life expectancy rates
Rates of infectious and communicable diseases
Rates of noncommunicable diseases and chronic illnesses
(morbidity)
Death rates (mortality)
Patterns of providers
Traditional healers
Trained community health workers
Community health nurses
Midwives and physician extenders
Physicians
Differing education levels and requirements for licensure
Patterns of procedures and interventions
Sustainable and culturally appropriate
Primary care
Health promotion
Primary prevention
Patterns of partnerships
Peripheral health unit and health station
District hospitals
Public health and governmental health care agencies
Nonprofit and nongovernmental organizations (NGOs)
Universities
Patterns of politics and policies
Universal health care
Access to treatment and pharmaceuticals
Payment to providers
Local health care policies
Municipal governments
National governments
International collaboration
Cooperation versus conflict or violence
Patterns of personal insight of health care workers
Personal health and physical well-being
Personal values and cultural beliefs, including religious
beliefs and attitudes
Personal knowledge of community health nursing theory and
practice

1353
Demographic Transitions
The next type of assessment is to determine the demographics of a
population group by evaluating whether they are increasing or decreasing in
number based on the balance between births and deaths and whether there
are any migrations, such as rural-to-urban (Slogett, 2015). Demographic
transition theory explains that population demographics in high-income
countries changed slowly over several centuries. As low-and middle-income
countries began to evolve in the 20th century, populations changed more
rapidly over a few decades. Below is a summary of both demographic
transition trends (Colburn & Seymour, 2018). Where do you see
opportunities for nursing care?

“Long life, small family”: Starting in the 18th century, high-income

Western European and English-speaking countries followed four stages
in population change at a fairly slow rate. The final result for such
populations today is a demographic with low fertility rates, an aging
population, and decline in total numbers. Reasons for decline in
mortality are thought to be from advances in public health, nutrition,
medical care, and management of infectious disease.
“Short life, large family”: During the 20th century, low-income
countries experienced a rapid growth in the total population, primarily
from a rapid decline in deaths while birth rates remained high resulting
in a very young population. Socioeconomic development in low-income
countries also resulted in the movement of populations from rural to
urban settings in search of employment while also gaining improved
access to health. The availability of family planning has also had a
stabilizing influence on population size (Colburn & Seymour, 2018).

1354
Epidemiologic Transitions
The third concept in our framework of population assessment is to evaluate
epidemiologic transitions. These are grouped according to the predominant
health outcomes, or levels of public health, experienced by a society. There
are three eras of epidemiologic transitions of public health, named according
to historical trends of health and health conditions as described in a classic
articles by Breslow (2006) and Omran (2005). In high-income nations, these
eras progressed sequentially. However, in our world today, some countries
may experience two or all three eras in different regions of their nation at the
same time.

The Era of Infectious Diseases: Throughout most of history,

populations died from infectious diseases such as the plague,
tuberculosis, puerperal fever, measles, and others. The death rate was
high, and life expectancy was not very long. During this era, the birth
rate was also high. Families had many children because they knew that
most children would die before adulthood and yet as adults aged, they
depended on their children for care.
The Era of Chronic, Long-Term Health Conditions: With the advent
of antibiotics, people survived common infections and started to live
longer. Because children survived into adulthood, the birth rate dropped.
As people survived infections and aged, they developed chronic, long-
term illnesses such as heart disease, cancer, and arthritis.
The Era of Social Health Conditions: More recently, a new array
of health conditions are affecting world populations. These new
problems are anchored in social issues, as reflected in the slogan,
where you live determines your health (Colburn & Seymour,
2018).
The wealth or poverty of your neighborhood reflects whether the
streets are safe, housing is adequate, healthy food options are
available, and schools and municipal services are adequate.
Personal lifestyle behaviors contribute to social health conditions,
such as addictions and obesity, while social behaviors contribute to
others, such as gang membership, prostitution, sexual abuse, and
deviant behavior. The popular press has exposed many of these
conditions.
Documentaries and reports have helped raise awareness about the
effects of methamphetamine on entire communities, the abuse of
opioid prescription painkillers, the obesity epidemic growing
throughout the world, and the exploitation of children through
human trafficking (Brundage & Levine, 2019; Bureau of Justice
Assistance, 2019; Colburn & Seymour, 2018).

1355
Bringing Together the Framework Components
Review each component in the community assessment framework. What
examples from your own experience explain longevity in your community?
Consider the combination of patterns of care, the demographic transition
theory, and the epidemiology transition theory together. What is the impact
of communicable diseases and noncommunicable diseases? See Figure 16-1.

FIGURE 16-1 Demographic and epidemiologic transition theories

combined. (Reprinted with permission from Seymour, B., &
Colburn, C. (2018). Module 1: Global trends. In: B. Seymour, J.
Cho & J. Barrow (Eds.), Toward competency-based best practices
for global health in dental education: A global health starter kit (p.
18). A project of the Consortium of Universities for Global Health
Global Oral Health Interest Group. Retrieved from
https://hsdm.harvard.edu/globalhealth-starter-kit; Data from:
Omran, A. R. (2005). The epidemiologic transition: A theory of the
epidemiology of population change. Milbank Quarterly, 83(4),
731–757.)

Explore differences between the development of countries through the

concept of “we” in the Western world and “them” in the third world. In his
Ted Talk, Hans Rosling debunks myths about the “developing world” in The
best stats you've ever seen (19:46):
https://www.ted.com/talks/hans_rosling_the_best_stats_you_ve_ever_seen?
utm_campaign=tedspread&utm_medium=referral&utm_source=tedcomshare

1356
GLOBAL HEALTH CONCEPTS
Key global health concepts, discussed below, include global burden of
disease (GBD), the Health for All and HiAP initiatives, primary health care
(PHC) achievements, sustainable development goals (SDGs), telehealth, and
women's health.

1357
Global Burden of Disease
Data collection and data analysis are an important part of the C/PHN toolkit.
In addition to morbidity and mortality rates, one data tool used in global
health helps to measure what it costs society when not everyone is healthy
and helps answer the following questions.

If a member of your family dies, what is the impact to your family?

What does it cost if you miss a month of work or school because of an
illness?
What does it cost a country when adults have high rates of diabetes or
depression, or when the greatest cause of disability in children age 5 to
14 years is from iron deficiency?

When populations or societies experience disadvantages socially,

economically, or environmentally, these differences are called health
disparities. The calculation of health disparities is the goal of a series of
studies known as the global burden of disease (GBD).
The first GBD study was commissioned by the World Bank in 1990. It
was unique for its time because it brought together economists and health
experts to evaluate health as an economic investment. That same year, the
World Health Organization (WHO) assumed responsibility for the GBD
study which emphasized the impact of disability (morbidity) and death
(mortality) rates (Institute for Health Metrics and Evaluation (IHME), 2019a,
2019b; WHO, 2020f). Since 2010, the IHME has repeated the study at
regular intervals. Because the GBD studies attempt to assess all health
conditions using the same methodology, comparison of one condition to
another is now possible. We can also compare disease rates and trends over
time and by location.
The 2017 GBD report published by the independent IMHE provided data
for 195 countries and territories around the globe. Updated mortality and
morbidity estimates covered 359 diseases and injuries and 80 new risk-
outcome data pairs were added (IMHE, 2019a). GBD data were also used to
generate projections of health into the future (WHO, 2020b, 2020f). Review
the report and other GBD resources at the IHME Web site
(http://www.healthdata.org/gbd/gbd-2017-resources).
How is the GBD calculated? GBD is the measure for a population of
disability-adjusted life years (DALY), which is an equation that adds the
total years of life lost (YLL) due to diseases and premature mortality to the
years lived with disability (YLD) (Population Services International [PSI],
2014; WHO, 2014). The impact of public health interventions is calculated
the same way, but using presumed years saved. See Figure 16-2.

1358
 FIGURE 16-2 Calculating the global burden of disease by
DALYs. (Reprinted from Newton, J. (September 15, 2015). The
burden of disease and what it means in England. Public Health
Matters Blog. Retrieved from
https://publichealthmatters.blog.gov.uk/2015/09/15/the-burden-of-
disease-and-what-it-means-in-england/)

For example, let's say one community has a high rate of death from
measles for children under 5 years of age, but after a measles vaccine
campaign the next year, there are no deaths from measles. When the DALYs
are calculated from the year with measles, they are able to demonstrate the
burden of measles on that community related to the lost lifetime productivity
of the children who died. Comparing DALYs to the year without measles
demonstrates the impact of the vaccine. Children who might have died did
not die and are now counted among those in the community who are healthy.
Children who received the vaccine can become productive adults. The GBD
on the community is lessened with the vaccine.
The information obtained from calculating the GBD informs decisions
related to investments in health, research, human resource development, and
physical infrastructure. Assessment of global and regional information on
diseases and injuries can be reviewed directly online using the GBD
Compare interactive tool at http://www.healthdata.org/data-
visualization/gbd-compare.

1359
 Compare the global disease trends by DALYs for 1990 and 2017 in
Figure 16-3. Notice that 1990 had a greater area for burden of communicable
disease. By 2017, there was a shift, showing a greater burden of
noncommunicable disease. How might changing demographics account for
that?

FIGURE 16-3 Global disease trends in DALYs by cause, 1990 (A)

and 2017 (B). (Reprinted with permission from Institute for Health
Metrics and Evaluation. (2020). GBD Compare DALYs (global, by

1360
cause, all ages, both sexes). Retrieved from
https://vizhub.healthdata.org/gbd-compare/)

1361
Health for All: A Primary Health Care Initiative
In its earlier years after World War II, the focus of the WHO was on building
hospitals and costly health establishments throughout the world. The thinking
was that hospitals brought health to a region. However, many countries could
not afford to build health care centers, nor could they afford to train large
numbers of health professionals. Because of those emerging trends and,
believing that a major change in thinking and practice was needed, many
health leaders from throughout the world met in AlmaAta, Kazakhstan, in
1978 at the International Conference on Primary Health Care. They created a
sweeping set of recommendations emphasizing the importance of PHC that
became the Declaration of AlmaAta (see Chapter 1) or Health for All.
Section VI in the Declaration (International Conference on Primary Health
Care, 1978) states that primary health care (PHC) “is essential health care
based on practical, scientifically sound and socially acceptable methods and
technology made universally accessible to individuals and families in the
community through their full participation and at a cost that the community
and country can afford to maintain… spirit (underscoring) self-reliance and
self-determination” (p. 1–2).
It was a lofty goal to implement PHC for all by the year 2000. Each
country was encouraged to develop goals for their specific population needs
(WHO, 2019c). The United States responded by launching Healthy People in
1979 with the specific goal to reduce preventable death and injury. Updated
every decade since the first report, Healthy People 2030 represents the
nation's current health goals and objectives for the next decade. Healthy
People 2030 covers many objectives for health attainment while still
including objectives for the prevention of death and injury. Global health
objectives can be found at https://health.gov/healthypeople/objectives-and-
data/browse-objectives/globalhealth Compared to the initial goals from 40
years ago, one can see the evolution in our understanding of how to best
achieve health for all (Haskins, 2017; USDHHS, 2020).
Health for All emphasized PHC that is affordable, culturally acceptable,
appropriate, accessible, and delivered through partnerships between national
health services and local communities. Communities assumed responsibility
for identifying their own priority health concerns, with planning and
implementing PHC services that match their unique needs. Common PHC
services include health promotion, disease prevention, treatment, and
rehabilitative care provided by health care workers who live in the same
community (Fig. 16-4) (WHO, 2020a).

1362
FIGURE 16-4 Community health worker measuring a child's head
circumference at a community health clinic in Surabaya, Indonesia.

1363
Health in All Policies
In 2006, Health for All was expanded to HiAP as an essential component of
PHC. The idea of HiAP is that good health in any society requires policies
across all sectors to actively support health. This expanded approach requires
policymakers to incorporate consideration of the health impact in policies for
transportation, housing, employment, nutrition, water and sanitation, and
education. By acknowledging the impact that any policy has on health,
optimal health is maintained for the community's benefit (WHO, 2020e). See
Chapter 13 on policymaking and advocacy.

1364
Achievements of PHC
One example in the achievement of PHC is in Portugal with the extensions of
comprehensive services to their full population. In a classic example,
Waddington (2008) reported how Portugal organized Family Health Units
(FHU) across the country. FHUs are designated groups of physicians, nurses,
and staff who work to provide care to local patients and families and make
decisions together with them about health needs. Since the 1970s, Portugal's
infant mortality rate has dropped by 50% every 8 years to only 3 per 1,000
by 2006. Life expectancy jumped 9.2 years in one generation. Patients
register for government-sponsored health services through their family
physician, which guarantees each patient has a PHC medical home. MD/RN
salaries are based on FHU productivity and performance. However,
continued improvement in life expectancy (81.3 years in 2014) has been
tempered by ongoing health inequalities. Since 2011, efforts at cost
containment have included a greater focus on governance and regulation,
health promotion, more reliance on generic drugs, and increased taxes and
cost-sharing. The total health expenditures in 2014 totaled 9.5% of GDP, or
about half the amount paid in the United States (Simoes, Augusto, Frontiera,
& Hernandez-Quevedo, 2017).
Many other nations are working toward Health for All by making health
care a right for all citizens and expanding services to meet the needs of rural
populations and high-risk groups. Future action regarding PHC calls for
strengthened collaboration among governmental agencies and NGOs in
public and private sectors. Only when PHC is accessible to all people will the
world have a realistic chance of achieving all the goals set out in the
Declaration of AlmaAta (WHO, 2020l).

1365
Sustainable Development Goals
In 2000, during the Millennium Summit, the United Nations (UN) approved
eight international health goals for the year 2015. These goals were named
the Millennium Development Goals (MDGs), targeting health improvement,
eradication of poverty and hunger, and achievement of universal education
and gender equality. All UN member states and 22 international
organizations committed to developing global partnerships. By combining
resources, skills, and knowledge, these partnerships were assumed to
facilitate goal achievement. Although some MDGs were accomplished
before the 2015 deadline, progress between countries was uneven. Some
countries found some of the goals were not appropriate for their populations.
Drawing on the experience from the MDGs, a revision and expansion
was approved. The Sustainable Development Goals (SDGs) were launched
as the future global development framework to be achieved by 2030 (Fig 16-
5).

FIGURE 16-5 Sustainable development goals. Reprinted with

permission from United Nations Sustainable Development Goals.
Retrieved from https://www.un.org/sustainabledevelopment/. The
content of this publication has not been approved by the United
Nations and does not reflect the views of the United Nations or its
officials or Member States.

1366
 The SDGs are a collection of 17 global goals and “are a call for action
by all countries—poor, rich, and middle-income—to promote prosperity
while protecting the planet” (UN, 2020, para. 1).
Interestingly, only goal 3, Good Health and Well-Being, is specifically
devoted to health and wellness. However, because the goals are all
interconnected in the spirit of HiAP, each one of the goals reflects an
important health element.

Through the pledge to leave no one behind, the SDGs are looking for
“life-changing zeros”: zero “poverty, hunger, AIDS, and discrimination
against women and girls” (UN Development Program, 2020, para. 3).

1367
Telehealth
Achieving these goals has been facilitated by the expansion of broadband
and the Internet throughout the world. Ministries of health are training
community care workers in communication, observation, and technical skills
for telehealth systems that link remote areas to academic health centers (Fig.
16-6). For example, in Brazil's Minas Gerais state, PHC centers in 608
municipalities, some in remote areas, are now connected through the
country's Telehealth Network (TN). In the first 5 years of the TN, 6,000
health professionals were trained in its use. The system was shown to be
cost-effective and simple to use. With access to specialist teleconsultations,
users of the TN were able to prevent 81% of case referrals from leaving the
local community (Alkmim et al., 2012). A 2016 evaluation study found that
the network had expanded to include 88% of Minas Gerais state with 40
teleconsults occurring each day. User satisfaction with the services provided
through the TN was reported at 95%, demonstrating that this telehealth
service is successful and sustainable (Marcolino et al., 2016).

FIGURE 16-6 Mother and child sleeping in a hammock near the

Amazon River in Peru.

A feasibility study in India networked five rural health clinics with a

large teaching hospital. Electrocardiographs (EKGs) were transmitted from
portable EKG tablet devices using WiFi hotspots at the clinics. The 12-lead
EKGs were transmitted as secure PDF files for cardiologists to read (Shetty,
Samant, Nayak, Maiya, & Reddy, 2017). Individuals and their local primary
care providers now receive support and information from distant providers

1368
without traveling or being away from home. See Chapter 10 for more on
technology and telehealth.

1369
Women's Health
The WHO estimates that almost 295,000 women died in 2017 from
complications of pregnancy and childbirth. Ninety-four percent of these
deaths are in economically poor countries. Nigeria and India had an
estimated 35% of all maternal deaths in 2017. Pregnant women living in
rural areas and adolescent mothers face higher mortality rates. The death of a
mother profoundly impacts the well-being of the entire family. Between 2000
and 2017, due to efforts to improve prenatal and delivery care, global rates of
maternal mortality dropped by 38% (Box 16-2; WHO, 2019a, 2019b).
Women's health continues to be a major emphasis in Health for All. See
Chapters 19 and 21.

BOX 16-2 PERSPECTIVES

Volunteering as a Nurse-Midwife in Africa

Delivering babies in the United States is vastly
different from experiences I encountered while
delivering babies for 1 year in remote areas near
the Ethiopian border. I remember one case in
particular. It was during the monsoon season, and
I was called to help a young woman having her
first baby. Because a hospital delivery was
impossible due to a powerful rainstorm that made
roads impassable, my aide and I walked for miles
on very soggy dirt roads to reach her village.
When we arrived, people in the village said that the baby had died, and
upon entering the house I rushed toward the limp baby girl. The mother had
delivered the baby on the mat used to cover the dirt floor. I could still feel a
very muffled heartbeat on the umbilical cord that was still attached to the
young mother. I reached for my mask and bag and started resuscitation. I
checked the heartbeat and continued bagging the baby.

1370
 Women in the small village had crowded into the house, which could be
described as a hut; some had been crying and wailing. Now, they were
quietly sitting or standing near the door, speaking to each other in hushed
tones while watching me work. My aide checked the mom, who appeared to
be stable and had only a little bleeding. I kept bagging the baby and asked
the women to get me some warm water to help keep the baby's temperature
stable. I alternated warm water with cold water to try to stimulate the baby
to breathe on her own; she produced only an occasional breath. I removed
excess air from the baby's stomach after inserting a nasogastric tube, and
she pinked up. Within a short while, she began to breathe independently.
The mother was relieved, and I checked her to be sure that there had
been no tearing. My aide and I remained there through the night to be sure
that no further respiratory problems returned. Word of the baby's recovery
spread quickly through the village. I felt that we had truly made a
difference!

Robin, nurse–midwife

All populations we serve deserve respect for their personal choices,

including our health care colleagues. See Box 16-3.

BOX 16-3 PERSPECTIVES

A Nurse Volunteer's Viewpoint on Personal

Challenges While Serving Overseas From an early
age, I was exposed to nursing. My mother was a
nurse, and I saw firsthand how she cared for us as
a family and how she cared for her friends when
they were in need. I also listened intently when she
talked about the patients she helped over the
years. Furthermore, I witnessed how she
integrated her own faith with her nursing practice
in the simplest of forms: genuine service to others.

1371
After I became a nurse, I also felt a deep calling to
use my nursing skills in volunteer ways to serve
others.
My first volunteer experience was in the rural mountains of Guatemala
where I worked with indigenous women to improve birth practices. I
thought I was going there to teach them how to safely deliver babies. But
after spending 2 months caring for women during pregnancy and childbirth,
they actually taught me more about the miracle of birth than I ever learned
in my hospital-based experiences. We shared our knowledge with each
other and I came away from the experience with a deeper understanding of
what it means to become a mother.
Later in life, I met a nurse with the same deep passion for service to
others. She was preparing to move to West Africa to serve women with
childbirth injuries. She and I had both been raised within the same Christian
faith and we both felt our nursing practice was very integrated into our
values and beliefs. Then, we fell in love with each other. This was a
challenging time for us, as we navigated the minority of being in a same-sex
relationship within the Christian community. We struggled as some of our
friends and family made it clear they did not approve of our relationship.
But we also found new friends and family in the journey as well who were
willing to see the greater value of who we were together.
In addition to navigating our home-front challenges, we also had to
negotiate our relationship abroad. My wife was working for a faith-based
organization in a predominately Muslim country, both of which do not
condone same-sex relationships. In order for me to visit with her, to spend
time together, and to also offer myself for service when I was there, we had
to be silent about the depth of our relationship. We acted only as friends,
with no public displays of affection. This was a compromise we both felt
committed to in order to make a difference in the lives of the nurses and the
women we cared for. Although some might find this compromise too costly,
we continue to be grateful for the opportunities we had to serve and would
do it again in a heartbeat.
Posted anonymously in order to protect future service opportunities.

1372
GLOBAL HEALTH TRENDS
The overarching perspective of global health nursing is one planet of
interdependent nations. What happens in one country affects others in
important ways. For example, air travel can transport health problems from
any remote village halfway around the world to any major city within 36
hours. Detecting disease quickly has become more urgent for everyone's
health since the outbreak of SARS in 2003 and more recently the COVID19
pandemic, caused by the novel coronavirus SARS-CoV2. By February 16,
2020 China had 51,174 cases and 1,666 deaths, but there were only 683 cases
and 3 deaths outside of China (WHO, 2020b). By October 2, 2020, the
United States had 7,260,425 total cases and 207,302 deaths, with 302,093
new cases in the last 7 days (CDC, 2020a). Other global issues with an
impact on population health include ongoing efforts to eradicate old diseases
such as TB or malaria while maintaining ongoing efforts to improve basic
health care services. See Box 16-4.

BOX 16-4 STORIES FROM THE

FIELD
Addressing Malaria in the Community The
Kenya Strategy for Community Health 2014 to
2019 included an objective to “enhance
community access to health care in order to
improve productivity and thus reduce poverty,
hunger, and child and maternal deaths, as well
as improve education performance across all
stages of life” (Kenya Ministry of Health, 2014,
para. 1). The goal was to empower Kenyan
communities to take charge of improving their
own health. One community strategy was to
develop the capacity of the community health
extension workers (CHEWs) and community-
owned resource persons (CORPs) to recognize

1373
and respond to emerging health trends in the
community.
Atieno is a community nurse working as a CHEW in Siaya County.
Over a period of 3 months, she noted a rise in the number of malaria
cases involving children in one particular community. Though the
county is a malaria endemic area, Atieno was concerned about the new
trend and began to have conversations with the mothers.
The steady increase in the number of children under 5 years of age
with fever-related symptoms coincided with the start of the rainy
season. Some of the mothers thought the fever was from children
playing in the stagnant ponds and catching cold.
On her return to her health unit, she proposed a visit by the
extension team. The visit was arranged with the community elders.
During the visit, the team learned that the community had recently
started making clay bricks as an income-generating venture. Almost
every home was participating and had built furnace-like structures.
These were surrounded by freshly dug clay pits that quickly became
small ponds of stagnant rainwater which attracted mosquitoes. The team
sought permission to check sleeping areas and noticed that most did not
have mosquito bed nets.
A “baraza” (public meeting) with the brick works managers, the
community elders, and CHEWs was arranged to discuss the situation.
The team shared the connection between their findings and the new
cases of malaria. The community acknowledged that the brick-making
venture had contributed to the increase in stagnant water that became
breeding pools for malaria-transmitting mosquitoes. Together, they
developed a plan to reduce and treat the cases of malaria without
compromising the community's new business venture:

Drain stagnant water around the homesteads.

Use treated bed nets, especially with pregnant women and young
children.
Monitor malarial symptoms. When fever develops, seek immediate
medical attention.

Collaborative roles and shared responsibilities were also approved:

All households were encouraged to purchase and use locally

available bed nets treated with approved insecticides. The
community leader negotiated for free insecticide-treated bed nets
for the most vulnerable households.

1374
 Workers committed to relocating their brick works away from
homes.
The local brick works leader coordinated with health dispensary
officials for fumigation of existing mosquito breeding grounds.
The CHEW enhanced existing community-based health services
for malaria with additional health education, outreach services, and
community–facility referrals.
Community nurses provided information directly to residents of the
community on the causes, symptoms, and the importance of early
treatment of malaria. They also demonstrated the proper treatment
and use of bed nets.

Once the plan was put into action, malaria cases decreased in the
community overall while encouraging their new business venture. The
community leaders and local population had the tools and knowledge to
manage their own environment and take preventative steps against
future cases of malaria. This account demonstrates highly effective PHC
and community-owned action, all spurred by one community nurse's
observations and follow-up.

1. What steps of the nursing process are demonstrated in this global

health nursing story where the community is client?
2. Which of the 10 essential public health services are pertinent to
this situation?
3. What was the role of the community meeting (the “baraza”) in
reducing the number of malaria cases?
4. What would happen if the solution for malaria prevention and
treatment were not managed by the community, but by health
experts coming from outside the local area?

Missie Oindo, BA, MCHD, and Serah Malaba-Kambale, BSc,

MPH, PRINCE2 Practitioner, Kenya
Source: Kenya Ministry of Health (2014).

While we think of the CDC as a U.S. government agency, it also has a

global focus that includes global health security and outbreak investigation
(Fig. 16-7).

1375
FIGURE 16-7 Global disease detection accomplishments.
(Reprinted from Centers for Disease Control and Prevention
(CDC). (2017). Global disease detection by the numbers: Select
accomplishments from GDD centers, 2006-2016 [Infographic].
Retrieved from
https://www.cdc.gov/globalhealth/infographics/uncategorized/glob
al_disease_detection.htm)

1376
UN and WHO
At the end of World War II after earlier attempts to form international
agreements, the United Nations (UN) Charter was signed and ratified in
1945 by 50 countries who were “committed to maintaining international
peace and security, developing friendly relations among nations and
promoting social progress, better living standards and human rights”
(UN Systems Chief Executives Board for Coordination [UNSCEB],
2016, para. 1). The UN today supports and manages several
international funds, programs, and specialized agencies that focus on
health. Some of these existed before World War I, some were part of the
League of Nations, and some were established more recently to meet
emerging needs such as the Joint UN Programme on HIV/AIDS
(UNSCEB, 2016).
Located in Geneva, Switzerland, the World Health Organization
(WHO) is a specialized agency under the UN with the objective for “the
attainment by all peoples of the highest possible level of health” (WHO,
2006, p. 2). As of 2020, there are 194 member states in the WHO
divided into 6 geographical regions for the purposes of reporting,
analysis, and administration (WHO, 2020m).

Other organizations are also active in promoting health internationally

but are not necessarily sponsored by governments. Nongovernment
organizations (NGOs) are often philanthropic and some are for profit. See
Table 16-1 for a list of selected global health organizations and their areas of
focus.

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TABLE 16-1 Global Health Organizations

NGO, nongovernmental organization; UN, United Nations.

Source: Bill and Melinda Gates Foundation (2019); Doctors Without Borders USA (n.d.);
International Council of Nurses (2020); Kaiser Family Foundation (January 24, 2019); Partners in
Health (2020); PAHO (n.d.); UNICEF (2016); World Bank Group (2020).

1378
Managing Global Diseases During Epidemics and
Pandemics
An example of the interdependency of all nations is the cooperation needed
when epidemics or pandemics occur. The WHO has led the way with
developing an approach to respond to, coordinate, and assist all nations
during such outbreaks.

The Global Outbreak Alert and Response Network (GOARN) was

established by WHO in 2000.
GOARN initially responded to national outbreaks such as cholera and
yellow fever.
Today GOARN is made up of more than 600 partners, including public
health institutions, government agencies, NGOs, and labs specializing in
epidemiology.

Through GOARN, the WHO's true impact was first realized with the
coordination of the global response to the SARS epidemic in 2002 to 2003.
From this response, the WHO established international networks and created
standards for mutual assistance in anticipation of future threats (WHO,
2020d). The WHO Health Emergency Dashboard is an interactive web-based
platform, refreshed every 15 minutes, that shares real-time information about
global public health events and emergencies. Review current public health
emergencies on the WHO public emergency dashboard at
https://extranet.who.int/publicemergency.

International Health Regulations

In 2005, the International Health Regulations (IHR) of the WHO (2008) was
accepted as a legally binding, international treaty between all member states.
The IHR require that all countries will independently perform the following
(Fig. 16-8):

1379
FIGURE 16-8 International health regulations. (Reprinted from
CDC. (2015). International Health Regulations (IHR). Protecting
people every day. Retrieved from
https://www.cdc.gov/globalhealth/healthprotection/ghs/ihr/ihr-
infographic.html)

1380
 Detect: Make sure surveillance systems and laboratories can detect
potential threats
Assess: Work together with other countries to make decisions in public
health emergencies
Report: Report specific diseases, plus any potential international public
health emergencies
Respond: Respond to public health events (CDC, 2015)

Each nation has committed to meeting these four obligations within their
own borders and to the development of an internal public health strategy and
implementation plan for addressing domestic public health emergencies
(WHO, 2020b).
Before public health events happen,

The IHR direct the WHO (2020a) to provide tools, guidance, and
training in support of any country.

During public health events,

The WHO offers decision support to affected areas for rapid assessment,
critical information, and communications, and
GOARN coordinates sending teams with technical expertise upon
request as needed.

According to the IHR reporting protocols, when there is a new reportable

event, the affected nation first assesses the public health risk within 48 hours.
If the event meets IHR reporting criteria, the country notifies the WHO
within 24 hours. The WHO will then assess the event using the Emergency
Response Framework (ERF). The ERF provides guidance for the level of
response that is indicated. There are four response levels, from Ungraded
(requiring no response or monitoring only) to Grade 3 requiring a major
response across regions); see Table 16-2. The response needed is based on
risk, as follows:
TABLE 16-2 WHO Emergency Response Framework (ERF)
Levels for Graded Emergencies

1381
Source: WHO (2018a).

Very low or low risk event: The WHO team may simply monitor the
event. Mitigation, preparedness, and readiness may be part of the low-
risk response.
High or very high-risk event: The Incident Management System may be
activated with an appropriately scaled response.

Public Health Emergencies of International Concern

Once Public Health Emergencies of International Concern (PHEIC) are
declared, the WHO coordinates an active response with the reporting country
and with other countries as indicated (WHO, 2020b). The response may
include controlling borders as well as containing the source of the public
health threat (WHO, 2020a). These were the steps followed in 2016 by Brazil
with the Zika virus outbreak and in 2019 with the novel, SARS-CoV2
outbreak in Wuhan, China (CDC, 2020b, 2020d; CDC Division of Global
Health Protection, 2019). Most epidemics or emergencies do not fulfill
criteria to be considered a PHEIC. For example, WHO Emergency
Committees (ECs) were not convened for the cholera outbreak in Haiti after
the earthquake, for the use of chemical weapons in Syria, or following the
Fukushima nuclear disaster in Japan (WHO, 2020b).

1382
 Four critical diseases will always be considered extraordinary and
require mandatory notification: smallpox, poliomyelitis due to wild-type
poliovirus, human influenza due to a new subtype, and severe acute
respiratory syndrome (SARS).
Other conditions are potentially notifiable events according to IHR
criteria, whether infectious disease, biological, radiological, or chemical
events (CDC Division of Global Health Protection, 2019). See Figure
16-8.
Review the IHR reporting requirements at
https://wwwn.cdc.gov/nndss/ihr.html

Global Influenza Surveillance Network

Another important cooperative agency is the Global Influenza Surveillance
and Response System (GISRS), a network of international laboratories
established in 1952 by the WHO. GISRS has emerged as a critical player
coordinating worldwide efforts for surveillance and control of influenza.
Functions of GISRS include the following:

Maintaining physical presence in 144 National Influenza Centres

(NICs), 6 WHO Collaborating Centres, 4 Essential Regulatory
Laboratories, and 13 WHO H5 reference laboratories (WHO, n.d., p. 1)
Recommending the composition of twice yearly seasonal influenza
vaccine, and aid in its development
Posting on an open access platform for the specific gene sequence of an
influenza virus (reference viruses)
Providing open access to confirmed lab protocols for testing and disease
confirmation
Developing test kits for shipping to requesting countries free of charge
(Association of Public Health Labs, 2011)

Global Health Security Agenda

In 2014, the United States helped launch the Global Health Security Agenda
(GHSA), an independent group of 67 countries, international organizations,
nongovernmental organizations, and private sector companies who also have
as their vision a world that is safe and secure from infectious diseases. The
GHSA (n.d.) 2024 target is for 100 countries to complete assessment,
planning, and mobilization to minimize gaps in health care services. Each
country has agreed to demonstrate improvement in at least 5 of 11 technical
areas according to measures within the WHO IHR Monitoring and
Evaluation Framework. Because of GHSA partnerships, when SARS-CoV2
became a PHEIC, there was more information readily available to all nations
than in any previous outbreak (CDC, 2020f). See Figures 16-9 and 16-10.

1383
FIGURE 16-9 Key achievements in 5 years of GHSA. (Reprinted
from Centers for Disease Control and Prevention (CDC). (2020).
Key achievements in five years of GHSA. Retrieved from
https://www.cdc.gov/globalhealth/resources/factsheets/5-years-of-
ghsa.html)

FIGURE 16-10 Outbreak response in Liberia before and after

GHSA. (Reprinted from Centers for Disease Control and
Prevention (CDC). (2020). Retrieved from
https://www.cdc.gov/globalhealth/security/ghsa5year/outbreak-
response.html)

1384
One Health
One Health is a coordinated approach, recognizing that PHEICs are
increasingly related to the interconnectedness between humans, the health of
animals, and our shared physical environment. The One Health initiative cuts
across all sectors of society from local, regional, national, and global levels.
It is especially crucial for low-resource emerging economies, but novel
infectious diseases (e.g., Ebola, COVID19) can impact many countries
around the world (Gebreyes et al., 2014).

The Food and Agricultural Organization of the U.N. (FAO, 2020) uses a
One Health interconnected approach with an established early warning
monitoring system to alert for changes in zoonotic diseases, food safety,
and agricultural production.
In the United States, the CDC uses One Health to gain an understanding
about how diseases spread among people, animals, and the environment.
The foundation of One Health is three-fold: the multidisciplinary
cooperation for communication, coordination of effort, and
collaboration on activities at the animal–human–environment interface
(CDC, 2018). See Figure 16-11.

FIGURE 16-11 One health. (Reprinted from Centers for Disease

Control and Prevention (CDC). (2018). Retrieved from
https://www.cdc.gov/onehealth/images/multimedia/onehealth-
definition-graphic-with-bats.jpg)

Review the One Health in Action Web site:

https://www.cdc.gov/onehealth/in-action/index.html

Select one of the listed case studies. Identify the partnerships across
disciplines, involved animals, and the environmental impact.

1385
 What resolution for health was achieved? What was the role of cross-
discipline cooperation?

The Centers for Disease Control and Prevention

In the United States, the Centers for Disease Control and Prevention (CDC,
2020b, 2020c) is the agency responsible for leading the federal response to
an internal public health emergency. Each state is also required to have a
strategic plan outlining the response of each local health agency (LHA).
When a local public health event or emergency occurs somewhere within the
United States, the LHA reports upstream to the state who then reports to the
CDC. If the event has a potential international impact, the CDC evaluates the
event according to the WHO IHR, as described above, and reports the
concern to the WHO, as indicated for monitoring or mobilization of
international support (CDC, 2017a, 2020e). See the infographic Anatomy of
an Outbreak at http://thepoint.lww.com/Rector10e.
The CDC also has an outward facing global mission supporting global
health security and disease outbreak investigation throughout the world.
CDC scientists work collaboratively through 10 state-of-the-art global
disease detection (GDD) Centers located in different regions of the world
(CDC, 2017b). The expertise of the GDD centers evolved over the first four
global epidemics of the 21st century (see Fig. 16-7).
The CDC plays a lead role in global health security when outbreaks
occur anywhere. CDC disease experts join with stakeholders to address more
than 400 diseases and health threats. Strengthening critical public health
services globally protects Americans and saves lives worldwide. The CDC
also maintains an emergency surge staff of responders ready to be deployed
as needed. See Figure 16-12.

1386
 FIGURE 16-12 CDC's emergency response surge staff. (Reprinted
from Centers for Disease Control and Prevention (CDC). (2017).
Retrieved from
https://www.cdc.gov/globalhealth/infographics/globalhealth-
security/global-rapid-response-team.html)

Partners in the CDC response effort include the following:

Foreign governments and ministries of health

Other U.S. government agencies
The WHO and other international organizations
Academic institutions
Foundations
Nongovernmental organizations (NGOs)
Faith-based organizations
Businesses and other private organizations

The C/PHN may participate with One Health principles anywhere and
everywhere. The C/PHN's response during an infectious disease epidemic or
pandemic may include one or more areas of focus as described by the WHO
(2018a, 2018c):
Focus 1. Provide community education in support of an individual's
response, such as wearing masks in public, handwashing, and physical
distancing.
Focus 2. Explain evolving risk with communication to support life-saving
actions using local data indicators.
Focus 3. Facilitate access to timely treatment for persons who display
symptoms and ensure protection of the health care workforce.
Review the variety of disciplines represented in the CDC's Emergency
Response Surge Staff (depicted in Fig. 16-12).

Which disciplines are a surprise?

Which surge staff role would you be interested in joining? Why?

View stories on creative global health partnerships with the CDC.

https://www.cdc.gov/globalhealth/stories/

SARS-CoV2 (COVID19)
In late December 2019, China gave an initial report to the WHO about an
outbreak cluster of an unusual respiratory disease in the city of Wuhan. A
week after the Chinese report, the WHO (2020h) announced to the world the
preliminary identification of a previously unknown novel coronavirus named

1387
SARS-CoV2. At that time, nothing was known about where the virus came
from or how it spread.

Within 2 weeks of the report to the WHO in mid-January 2020, Chinese

health officials posted the full genetic sequence of the virus online in the
public genetic sequencing database, GenBank, at the National Institutes
of Health (NIH). This made it possible for labs worldwide to develop
lab tests and to make firm diagnoses on travelers from China who
showed symptoms (National Center for Biotechnology Information
[NCBI], 2020).
By late January 2020, the CDC activated its Emergency Operations
Center to assist in the global response to the epidemic. A few days later,
the CDC had developed a real-time test to diagnose the disease using
clinical specimens from affected patients. Several different lab assays
from top labs worldwide were also posted online, providing lab
protocols freely and globally (CDC, 2020c).
The UK provided a large grant to the Coalition for Epidemic
Preparedness Innovations (CEPI), a global pharmaceutical company
whose goal was to release a vaccine within 6 to 8 months of the first
announcement of the epidemic (CEPI, 2020). On the 11th of August,
2020, the Russian Federation reported approval of a vaccine (Sputnik
V), bypassing the usual protocol of completing phase three trials before
release. By the end of August, 2020 4 other vaccines were in phase
three trials, 7 others were in phase two, and 15 others were in phase one.
Additional vaccine candidates were in either early research or
preclinical phases (Craven, 2020).

This initial response between the member states of the WHO in the first
month after identification of the new disease demonstrated a coordinated
worldwide action following the guidelines of the IHR. As the virus spread
worldwide, different countries implemented their national plans in whole or
in part, while some countries delayed their plans or ended efforts
prematurely.
New Zealand was successful in eliminating COVID19 within 6 months
of the initial outbreak by embracing standard epidemiology measures
(Ministry of Health–Manatū Hauora, 2020a). These actions included the
following:

Sequestering at home during the initial outbreak

Maintaining robust border controls
Implementing widespread testing of the population
Providing rapid isolation of infected individuals
Managing comprehensive contact tracing of patients with confirmed
cases using public health informatics

1388
 Launching a personal phone app for creating the digital diary of places
visited (NZ Covid Tracer app)
Enforcing quarantine of those who had contact with confirmed cases
Encouraging public adoption of personal hygiene behaviors when in
public

Central to the approach in New Zealand was the responsibility of each

person to record their whereabouts every day to accelerate contact tracing. To
accomplish their cyber-tracing, businesses and public locations posted QR
codes which persons could scan with their smartphones. These QR scans
created digital diaries of an individual's daily itineraries. Then when a case of
COVID19 was confirmed, the NZ Covid Tracer app notifies the app user that
they have been exposed. The user decides if and to whom to disclose their
movements in society. With strong data privacy provisions completely under
control of the user, contacts with infected cases could be easily identified.
The phone app supplemented official contact tracing by expediting
communication. With that level of speedy notification, community spread
could be more successfully managed as New Zealand society reopened.
New Zealand citizens were quick to participate, following the slogan of
the app: “Protect yourself, your whānau [extended family], and your
community” (Ministry of Health, 2020b, para. 1).
As stated by the New Zealand Ministry of Health (2020a, para. 1), their
elimination strategy was a “sustained approach to keep it out, find it out, and
stamp it out.” The goals embraced standard public health epidemiology
responses to prevent transmission of new cases from overseas travelers,
develop effective treatments, and embrace an eventual vaccine.

Watch a video explaining the use of the NZ Tracer App at

https://youtu.be/j3GdnugLles.
Explore this novel use of public health informatics at the NZ Tracer
App Web site: https://tracing.covid19.govt.nz/.

As of early May 2020, no new, locally spread cases were reported in

New Zealand, but a cluster of cases (about 30) erupted in early August 2020.
The alert level was quickly raised to 3 in the affected Aukland area, and only
essential movement was permitted, while the remainder of the country was
raised to a level 2 that prohibited mass gatherings and promoted more social
distancing. The search for the source of the outbreak was ongoing during
early September (Lewis, 2020).
By August 31, 2020, the United States had 6,023,368 confirmed cases of
COVID19, and 183,431 confirmed deaths—the highest total numbers in the
world. However, the U.S. case fatality ratio falls in the middle of the 20 most
affected countries. Worldwide, a total of 25,344,339 confirmed cases were

1389
reported, and confirmed deaths were reported at 848,084 (Johns Hopkins
Coronavirus Resource Center, 2020). For a world map indicating outbreaks,
see: https://extranet.who.int/publicemergency.

Ebola
Ebola disease virus (EDV) is an infectious disease with repeated outbreaks,
mostly in Africa. Although EDV was first identified in 1976 in an outbreak
near the Ebola river in the Democratic Republic of Congo (DRC),
epidemiologic data suggests the virus has been around much longer.
Population growth, deforestation, and cultural food habits (eating exotic
animals or “bushmeat”) are thought to have contributed to the frequency of
EVD outbreaks in our world today (CDC, 2019).
The 2014 to 2016 EVD outbreak in West Africa became a global PHEIC
crossing international borders within months. Numerous emergency
responders from a variety of disciplines including nursing rushed to help as
teams tried to contain the spread of the deadly virus. They reported
challenges that were met with ingenuity as they struggled without adequate
supplies. One challenge was working with the communities to adapt cultural
burial practice traditions that contributed to the spread of the disease. Two
vaccines were ultimately developed and continue to be administered to
vulnerable populations (CDC, 2019). For stories of responders to EVD and
how they overcame challenges, visit these Web sites:

Ebola outbreak responder stories: https://www.cdc.gov/about/24-

7/cdcresponders/
Ebola reports on overcoming challenges:
http://www.cdc.gov/about/ebola/overcoming-challenges.html

Tuberculosis
Tuberculosis (TB) is an infectious disease caused by the tubercle bacillus
(see Chapter 8). TB has been known for hundreds of years and was
commonly referred to as consumption. Over time, the causative organism has
become resistant to the medications used to treat it. TB continues as a
worldwide chronic endemic disease. The WHO continues the Stop TB
campaign that realized a milestone in 2018 when 7 million people were
diagnosed and treated. There is an SDG to eradicate TB by 2030; however,
large gaps in detection and treatment have led to an estimated 3 million
people still not receiving the care they need (WHO, 2020k).

One quarter of the world's population is thought to be infected, but only

5% to 15% of those become symptomatic within their lifetime.
TB disproportionately affects poor people around the world.

1390
 Multidrug resistant TB (MDR-TB) is an increasing problem around the
world.

Globally, estimates of new cases of MDR-TB are 4.1%, with 240,000

deaths from MDR-TB in 2016.
MDR-TB threatens to reverse progress made with the Stop TB
campaign (WHO, 2020c).

Malaria
Malaria is a serious and sometimes fatal disease caused by the parasite
Plasmodium falciparum or Plasmodium vivax. Malaria is a vector-borne
disease spread by bites of the female Anopheles mosquito. Vaccines against
parasites are difficult to create. Even though it is a serious disease, illness
and death from malaria can usually be prevented with appropriate
interventions such as sleeping under bed nets (Fig. 16-13) and complying
with medical treatment. Malaria disproportionately affects people living in
poverty, especially impacting people of working age with damaging effects
on emerging economies.

FIGURE 16-13 A child sleeping under a mosquito net in a refugee

camp in South Sudan.

In 1998, half the world was at risk for malaria. The Roll Back Malaria
(RBM) Program, an ambitious international campaign, was launched
with the goal to reduce the global burden of malaria (CDC, 2020g).
Led by the WHO, UNICEF, UN Development Programme (UNDP), and
the World Bank, 500 partners joined together in the RBM worldwide
action plan.
By 2003, RBM showed disappointing results.

1391
 By 2010, a revised goal was accepted to reduce the incidence of malaria
by 50% worldwide.
In 2019, half the world remained at risk (End Malaria, n.d.).

Then, three interventions were developed in rapid order that gave the
world hope that malaria could be entirely eliminated. A new campaign, End
Malaria (EM), replaced RBM. The three ongoing interventions with EM are
as follows:
1. Artemisinin-based oral drug therapy: An estimated 3 billion courses of
therapy were completed between 2010 and 2018.
2. Insecticide-treated mosquito nets (ITNs): Between 2016 and 2018, 578
million ITNs were delivered globally.
3. Rapid diagnostic lab tests (RDTs): In 2018, 412 million RDTs were
distributed globally (End Malaria, n.d.).
The End Malaria program was renewed to focus on endemic regions with
the goal to control malaria by 2030.

By 2018, 27 countries reported fewer than 100 indigenous cases.

By 2019, the WHO awarded certification of elimination with zero
indigenous cases to Paraguay, Uzbekistan, Algeria, Argentina, China, El
Salvador, Iran, Malaysia, and Timor-Leste.
Current focus is on sub-Saharan Africa to eliminate 228 million global
cases and eliminate 405,000 deaths (End Malaria, n.d.).

The challenge remains in countries with emerging economies where

there are large populations without sewer systems and clean water sources.
Because people prefer to build their homes close to sources of water,
mosquitoes that carry malaria are attracted to the standing water in those
communities (Fig. 16-14).

1392
 FIGURE 16-14 A woman gets water from a well to take back to
her village.

The primary role of the C/PHN to end malaria is as a community

educator. The topics of client education would cover simple measures:

Proper placement and use of netting around a bed during the night
Elimination of pools of standing water around the home
Covering the body with light cotton clothes (Department of Health,
Republic of South Africa, 2020). Balami, Said, Zulkefli, Bachok, and
Audu (2019) provided a malaria education program to pregnant women
and found significant improvements in motivation, knowledge, and
skills. Women were taught how to use insecticide-treated bed nets and
received intermittent preventive medication during their clinic visits.
See Box 16-4.
Watch this video to see how the RBM campaign evolved. Partnership to
End Malaria—20th Anniversary (2:23): https://youtu.be/iuq6-
H1HuAM.
Visit the Malaria Vaccine Initiative Web site to see the challenges for
making a vaccine: https://www.malariavaccine.org/malaria-and-
vaccines/vaccine-development/life-cycle-malaria-parasite.

Global HIV/AIDS Response

HIV has claimed the lives of more than 32 million people since HIV was
identified in 1985. Between 2000 and 2018, as a result of global initiatives
implementing evidenced-based practices, new HIV infections fell by 37%
saving 13.6 million lives (WHO, 2020).
By the end of 2019, this was the global status of HIV/AIDS:

New cases: approximately 800,000 new HIV cases confirmed with Sub-
Saharan Africa accounting for nearly 66% of new infections globally
Living with HIV: an estimated 38 million people worldwide lived with
HIV

Annual deaths: 690,000 million people died annually from HIV-related

causes. (Avert, 2018; WHO, 2020g). Although there remains no cure for HIV
infection, effective treatment controls the virus so people live productive
lives. Treatment also helps prevent transmission. Current trends in HIV care
focus on prevention, early testing, and treatment. With surveillance testing,
people can know their status and take measures to either remain HIV
negative or start treatment, thus preventing transmission to others. See
Chapter 8.

1393
 HIV is diagnosed through rapid diagnostic tests that provide same day
results.
Once HIV-positive status is known, treatment with antiretroviral therapy
(ART) is initiated.
Globally, in 2018, 62% of adults and 54% of children living with HIV
were receiving ART.
Concurrent assessment and treatment for possible TB infections and
prevention of mother-to-child transmission have shown positive
outcomes for improving maternal health and reducing HIV transmission
to newborns (WHO, 2020a).

The success of HIV/AIDS management is noted by its change in status

among the top 10 causes of death between 2000 and 2016, comparing the
World to African and European Regions (Fig.16-15).

1394
FIGURE 16-15 Ranking of 10 leading causes of death worldwide:
European and African regions compared, all ages, both sexes,
2016. (Reprinted with permission from Global Health Observatory
(GHO). (2018). Top 10 causes of death [Online interactive
dashboard]. Available at
https://www.who.int/gho/mortality_burden_disease/causes_death/t
op_10/en/)

1395
 Examine how other top 10 causes of death worldwide have changed
between 2000 and 2016 (Fig. 16-16).
Explore the WHO interactive webpage, Sexual and Reproductive Health
and Rights and HIV (SRHHIV) linkages toolkit, to learn more about
recent, relevant, and important resources:
http://toolkit.srhhivlinkages.org/.

FIGURE 16-16 Global death rate per 100,000: Selected causes,

2000 and 2016 compared. (Reprinted with permission from Global
Health Observatory (GHO). (2018). Top 10 causes of death
[Online interactive dashboard]. Available at
https://www.who.int/gho/mortality_burden_disease/causes_death/t
op_10/en/)

Acute Respiratory Tract Infections

The most common illness in the world and a leading cause of mortality is
acute respiratory tract infection (ARI; Box 16-5). Pneumonia is the leading
cause of death in children under 5 years of age, claiming nearly 1 million
children annually. It is treatable, especially when caught early. Simple
interventions such as vaccines, good nutrition, safe hygiene practices, and
improved indoor air quality can help avoid ARI altogether (WHO, 2018b).

1396
BOX 16-5 Levels of Prevention Pyramid
Acute Respiratory Infection in Children
SITUATION: Acute respiratory tract infections
(ARIs) that affect the lower respiratory tract and
lungs, such as pneumonia and influenza, are
among the leading causes of death in children
worldwide.
GOAL: Prevent acute respiratory tract infections in children in developing
countries. Using the three levels of prevention, partner with communities
and families to avoid risk factors, to promptly diagnose and treat negative
health conditions, and to restore health to the fullest possible potential.

1397
Primary risk factors include low birth weight, poverty, crowding, lower
educational levels, poor nutrition including early weaning, inadequate
childcare practices, a lack of health education about ARI, and delays in
seeking treatment.
Additional risk factors include smoking and air pollution, both indoor
and outdoor.
Indoor air pollution is much higher among villages in areas
experiencing poverty.
Indoor air pollution is mostly from indoor cook stoves that use organic
fuel and kerosene.
Worldwide, over 2.4 billion people, mostly living in poverty, burn
wood, coal, peat, and dung-cake inside their homes.
Indoor cooking stoves kill 3.8 million people annually and are a
contributing factor in 45% of all pneumonia deaths in children <5 years
old.
The risk of pneumonia in children is doubled with exposure to indoor
air pollution (Ashwani & Kalosona, 2016; WHO, 2018b). See Fig. 16-
17.

1398
 FIGURE 16-17 Protecting children from the environment.
(Reprinted with permission from World Health Organization
(WHO). (2020i). Protecting children from the environment [PHE
Infographic]. Retrieved from
https://www.who.int/phe/infographics/protecting-children-from-
the-environment/en/)

Measures for better control of ARI include immunizations, birth spacing,

better nutrition including breast feeding, improved living conditions
(including the use of smokeless cooking stoves), and immunizations.
One threat to reducing the incidence of pneumonia, however, is the
increase in drug-resistant organisms. Community health workers (local
people trained by health professionals) are being trained to diagnose and
promptly treat early signs of pneumonia, when drugs will be the most
effective, along with other environmentally related interventions. The C/PHN

1399
can also provide community education encouraging mothers to seek care and
treatment early. See Figure 16-17.
These selected conditions show the impact when people are exposed to
emerging health conditions with environmental impact. Global health issues
become everyone's concerns when conditions spread within or beyond
borders. When we commit resources to any country in need, we all benefit.

1400
Interdependence of Nations During Migration
When hardships come, people would rather try to adapt and stay where they
are, but if there is limited assistance from their government to remain, then
people will leave. Populations may relocate within their own countries or
move across borders or oceans to find safety after natural disasters. Climate
change in today's world, which causes more frequent and severe wildfires
(Fig. 16-18) and rising oceans (from melting glacial ice), can result in
population migration. Population movement may also be in response to

FIGURE 16-18 An Australian brushfire.

Economic opportunities for workers and their families

a nation's need to invite immigrants to offset low birthrates
Large migrations of people fleeing violence or armed conflict (Fig. 16-
19), or
Food insecurity (UN Department of Economic and Social Affairs, 2017)

1401
 FIGURE 16-19 Syrian people in a refugee camp in Suruç, Turkey,
in 2015 who escaped from Kobane because of Islamic state attack.

In each case, the challenge is to ensure that human rights are met first,
followed by the maintenance of environmental law and refugee or migration
law. In 2016, the UN adopted the Global Compact for Migration as a
framework for international cooperation for orderly migration.
Unfortunately, the actual migration process has become quite political. As of
2020, there were no global agreements or policies to support either present
migration humanitarian crises or the impact on environmental rights breaches
(Corendea, 2018; Gamlen & Gamlen, 2019).

View the UN University video, How-to Guide for Environmental

Refugees, describing the migration events of Carteret Islanders in Papua
New Guinea at https://ourworld.unu.edu/en/how-to-guide-for-
environmental-refugees
Explore the Web site for the UN International Organization for
Migration at: https://www.iom.int/wmr/

1402
Armed Conflict, Uprisings, Wars, and
Humanitarian Emergencies
An armed conflict is defined as major if the number of deaths has reached
1,000. Increasingly, conflicts are internal rather than between nations.
Combatants seeking economic and political power often target the lives and
livelihoods of civilians associated with opposing factions (Clark & Simeon,
2016; Themnér & Wallensteen, 2013).

Armed conflicts and uprisings initially cause governments and agencies

to place a high priority on injuries, but the ability to sustain routine
health care is reduced as time goes on.
The health infrastructure itself becomes vulnerable during conflicts and
uprisings as a consequence of political instability. Often, opposing
factions raid hospitals and clinics.

During national conflicts, health services become disorganized with

decreased resources from disrupted supply chains. Such actions have been
repeated over the years as conflicts have emerged. See Box 16-6.

BOX 16-6 PERSPECTIVES

A World Health Organization Regional Advisor's

Viewpoint on the Effect of War on International
Cooperation During the war in Yugoslavia,
Bosnians and Serbs worked with the European
Regional Office of the World Health Organization
(WHO/EURO) in Copenhagen, Denmark, to
develop interventions for women and children's
health. WHO/EURO developed the training
program to be held in Denmark but was not
certain that the roads between Sarajevo and the

1403
coast would be open and safe for travel. Snipers
had continued operating in the mountains
surrounding Sarajevo and along the roads to the
country's borders. Once the workshop started in
Copenhagen, the nurses, physicians, and
midwives, both Bosnians and Serbs, collaborated
professionally during breakout sessions. However,
the facilitator had to ensure separate dining
spaces, because casual communication was
difficult and awkward while the conflict was
ongoing.
Marie, WHO regional advisor

C/PHNs need to become aware of who is involved in an immediate local

conflict and who is influencing the situation from abroad. Outside help is
needed in these instances, and often, international help is available. Funding
and sustaining health projects may depend ultimately on a variety of factors,
not the least of which is providing care when the safety and survival of
patients and nurses may also be threatened.
The CDC describes complex humanitarian emergencies as situations that
affect civilian populations and distinguishes them from factors related to war
or civil strife, shortage of necessities such as food, and the displacement of
local populations. During wars and other man-made disasters, infrastructures
fail, and epidemics are almost inevitable. As conflict wears on, the health
care needs of the combatants often take priority over health care needs of
civilians. As communities and families are relocated, thousands of children
may be injured, orphaned, or become at risk for disease. Additionally,
conflict disrupts food cultivation, harvest, and distribution, leaving
populations at risk for malnutrition, which can lead to disease (Clark &
Simeon, 2016; WHO, 2017). These circumstances can result in complex
humanitarian emergencies, with increased mortality rates beyond what is
expected under normal circumstances (Abbas et al., 2018). See Box 16-7.

BOX 16-7 What Do You Think?

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Effects of Conflict on International Cooperation
In today's world, international cooperation could
collapse due to changing national relationships,
internal disruptions from natural disasters or
violence, or political disagreements over policies
such as withdrawal from the Paris Agreement on
climate. What would be some of the social,
political, and economic consequences in terms of
health if international cooperation were
diminished?

1405
GLOBAL HEALTH ETHICS
Certain ethical considerations guide global health even as basic ethical
principles guide the delivery of health care. Ethics of justice, equality,
diversity, and inclusivity become even more important in an interconnected,
multicultural world.

1406
Clinical Service Learning for the C/PHN
Opportunities for participating in a global health activity may be offered for
experiential learning. C/PHNs should familiarize themselves with global
health ethical considerations whether engaging with global communities to
conduct research or deliver clinical care in the community. Positive outcomes
for the C/PHN from community and global health service learning include
the following:

Increased awareness caring for patients who are economically and

socially disadvantaged
Improved cultural awareness
Increased interest in public health and primary care career-related
opportunities.

Communities who host C/PHN students also enjoy documented benefits.

These include the following:

An influx of resources
Extra hands
Extra supplies and equipment

The presence of well-trained health volunteers can lead to skills transfer

within the community, either intentionally through education or more
indirectly through observation. Volunteers and host communities may
develop a sense of solidarity. Sometimes the host community may gain social
capital with nearby communities because foreign health care providers have
spent time with them (Lasker et al., 2018).

1407
Ethical Considerations for the Global Health
Volunteer
C/PHNs and host communities. Enjoy mutual benefit when all parties are
mindful of three main ethical considerations:
1. The weight of authority
2. The volunteer effect
3. The burden of hosting (Lasker et al., 2018, p. 22)
The weight of authority is a concept observed by Minkler in 2004 when,
despite her positive intentions, she ended up creating distrust in a host
community. This happened because she “was of a dominant culture (urban,
white), received significant financial support…, and came from an outside
institution” (Lasker et al., 2018, p. 22). Whether real or perceived, weight of
authority can happen due to power differentials that often exist between
volunteer students and the host community. As mentioned in the example,
power differentials could be financial, racial, educational, or even
institutional. Power dynamics are often deeply embedded in the political,
social, and economic histories of the community, yet students might present
themselves to the community without full awareness of these factors (Lough,
Tiessen, & Lasker, 2018).
The volunteer effect happens when the C/PHN volunteer “travels to a
community because the existing health care system there is weak or under
resourced” (e.g., low-resources, disaster) (Lasker et al., 2018, p. 23).
Volunteer nurses bring “donated equipment and supplies or provide
education and training” to supplement the care that the existing system is
unable to provide (Lasker et al., 2018, p. 23). Even though the volunteers are
well-intentioned, their efforts might not be in tune with the area's health care
system, or they may undermine local methods. Volunteer efforts may
duplicate local services and thus waste important resources. It has been
reported that some community members wait for volunteers to return rather
than seek care from local health care sources, because the services of
volunteers are free of charge. This devalues the local health care providers
even further, creating dependency on the volunteers and their services The
result is that the volunteer promotes “direct competition with local providers
trying to make a living in their own communities” (Lasker et al., 2018, p. 23;
Lough et al., 2018).
The burden of hosting is from the perspective of the host in the
community who houses the C/PHN volunteer. Even though the C/PHN is
providing services and activities at no cost, the host must provide housing,
meals, transportation, and perhaps pay for a translator. In addition, hosts
commit to accommodate learning experiences, often suspending their own

1408
work to do so. Typically, these learning opportunities are created for the
student and are not spontaneous. Providing necessary support to “keep
students safe, healthy, and productive during their time” with the community
can place an extensive burden on the hosts (Lasker et al., 2018, p. 24).
Volunteers should always be respectful to hosts and be helpful guests (Lough
et al., 2018).
C/PHN volunteers should not presume that good intentions providing
free health care activities or work exempt them from ethical concerns.
Rather, regular self-reflection on how to embrace the ethical principle of
“first do no harm” should come first before attempting to do good.
Furthermore, it is important to consider that in any endeavor, we are all
learners who first listen and observe, rather than begin with “doing” (Lasker
et al., 2018, p. 24).

Individual Motivations
The C/PHN volunteer should honestly assess personal motivations when
considering global health service. Motivations generally fall into one of two
types: “volunteer-centric” focused on the volunteer's personal goals and
interests and “community-centric” focused on the community's beneficial
outcomes (Aluri et al., 2018; Lasker et al., 2018, p. 25; Philpott, 2010). See
Table 16-3.

TABLE 16-3 Motivations for Global Health Service

Source: Lasker et al. (2018).

Consequences of Being a Global Health Volunteer

Global volunteering can be very expensive and may not offer long-term
health or financial benefits to the communities served; it may actually be
burdensome. Identifying opportunities that are both “ethical and sustainable”
will preserve the dignity of the communities while supporting local
empowerment and developing leadership opportunities (Lasker et al., 2018,

1409
p. 41). This approach will also provide a more meaningful experience for
volunteers.
C/PHNs who develop and nurture community-centric positive
motivations are in a position to make a positive impact on themselves and
their host communities. The C/PHN volunteer is likely to acquire the state of
mind of a global citizen (Lasker et al., 2018, p. 25; Philpott, 2010). The result
for the C/PHN volunteer is as follows:

Improved understanding of global health and disease

Developing new partnerships and teamwork in challenging settings
Implementing shared solutions
Experiencing the scope of social determinants of health
Acquiring specific skills, especially those of improved patience,
listening, and observation.

Ultimately, optimal global health learning opportunities will provide

C/PHNs with increased insights while developing experience with disease-
specific interventions and activities. Overall, C/PHN contributions to
community-led efforts can become part of the community's long-term
sustainable goals. In the end, the outcomes will be better for communities.
Global C/PHNs experience a more robust career where their unique skills
and knowledge can be applied in a globalizing world (Lasker et al., 2018).
Like transcultural nursing, described in Chapter 5, expanding one's horizons
either in unfamiliar neighborhoods here or abroad (see Box 16-8) can
promote a broader understanding and provide richer experiences for the
C/PHN. Many of our clients are not far-removed from their countries of
origin, and a global perspective provides C/PHNs with a more welcoming
presence. The skills gained from global health experiences can help us better
understand and work with all of our clients, wherever they may live.

BOX 16-8 PERSPECTIVES

A Student Nurse's Viewpoint on Studying Abroad

in Ecuador I never thought I would study abroad,
but when the opportunity arose to take one of my
nursing classes in Cuenca, Ecuador, I decided to

1410
embrace it, expecting a great learning experience.
Little did I imagine that it was going to be
anything short of life changing. Simply stated, it
was humbling to be a guest in a host family's
home, accepted like family. It was awesome to
become immersed in a culture so different from
our own. During our 1-month stay, our itinerary
was packed with school as well as experiences in
hospitals, clinics, school, and even an orphanage.
I recall a particular hospital where I assisted a compassionate nurse in
giving bed baths with limited resources. I ripped three pairs of small-sized
latex gloves before managing to keep a pair on my large hands. I learned
that being a good nurse was not dependent on the availability of supplies
but rather in maximizing the potential to deliver compassionate care in any
circumstance.
I am happy I made the decision to study abroad. In addition to the
learning experience, I gained insight, respect, humility, and gratitude for life
and for others. It is as if I have become aware of what living fully is,
something unattainable without the smells, sights, sounds, and interactions I
encountered abroad.

Ella, student nurse

1411
SUMMARY
Community/public health nursing services are critical to the ultimate
health of a community, providing important primary, secondary, and
tertiary levels of health promotion and prevention throughout the world.
Community assessment includes a comprehensive review of the patterns
of care, demographic transitions, and epidemiologic transitions.
Major principles of global health care include the global burden of
disease (GBD), Health in All Policies (HiAP), Sustainable Development
Goals (SDGs), and One Health.
The GBD is calculated in a population or country by adding Years of
Life Lost (YLL) to Years Lived With Disability (YLD) to determine the
Disability-Adjusted Life Year (DALY). The higher the DALY, the
greater the GBD.
The United Nations and the World Health Organization are the
integrating agencies for health around the world. Additional
international agencies also support global health efforts.
The International Health Regulations (IHR) guide the interdependence
of nations at times of global epidemics or pandemics.
Global ethical considerations include understanding of the weight of
authority, the volunteer effect, and the burden of hosting.
Global service-based learning requires careful self-reflection of one's
own personal motivation behind volunteer efforts.

1412
ACTIVE LEARNING EXERCISES
1. Describe three infectious diseases that are common around the world.
What current efforts are being implemented to combat them? Over
the last 25 years, what progress been made in reducing incidence, as
well as morbidity and mortality for these diseases? List 4 (or more) of
the 10 essential public health services that have been utilized to
combat these infectious diseases.
2. Which of the worldwide leading risk factors for health are also present
in the United States? Why? How can a local C/PHN address these
risk factors? What partnerships could be developed locally that reflect
international approaches? What interventional programs are available
from your state or county health agencies that could be used to reduce
these risk factors?
3. Conduct your own needs assessment in a familiar community. Use the
community assessment framework described in this chapter to
identify strengths of the community and gaps of care. After your
assessment, select one C/PHN intervention as a priority for that
community. Which of the 10 essential public health services support
your proposed intervention? Provide a rationale for your choices.
4. Using the GBD, compare interactive tool at
http://www.healthdata.org/data-visualization/gbd-compare, examine
the most current results for a country with an emerging economy
compared to the United States. Use all ages and both sexes in your
comparison (e.g., all cause DALYs per 100,000 map; DALYs by
causes treemap). How are the patterns different or similar? What
factors could influence your findings? Compare the same two
countries in 1990 and evaluate how the patterns of causes have
changed for both.
5. Identify a country or community in which you would like to practice
community/public health nursing. Before you begin a review of this
country or community, write down your own knowledge, attitudes,
and beliefs about the country or community, the people, and the
culture. Examine your own motivations for wanting this experience.
Identify how you might feel if you received services rather than
provided services.

thePoint: Everything You Need to Make the

Grade!

1413
 Visit http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, study aids for
all learning styles, and more!

1414
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018_EN.pdf?ua=1

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CHAPTER 17
Disasters and Their Impact
“If we do not succeed in understanding what it takes to make our societies more resilient to
disasters, then we will pay an increasingly high price in terms of lost lives and livelihoods.”

—Robert Glasser (2017), United Nations Disaster Risk Official

KEY TERMS
Biologic warfare Casualty
Chemical warfare Crisis intervention Critical incident stress debriefing
(CISD) Directly impacted by disaster Disaster
Disaster planning Displaced persons Incident command system (ICS)
Indirectly impacted by disaster Intensity
Manmade disaster Mass-casualty incident Moulage
Multiple-casualty incident Natural disaster Phases of disasters Posttraumatic
stress disorder (PTSD) Refugee
Resilience
Scope
Terrorism
Triage

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Describe a variety of disasters, including their causation, number of
casualties, scope, and intensity.
2. Discuss three factors contributing to a community's potential for
experiencing a disaster.
3. Identify the four phases of disaster management.
4. Describe the role of the community/public health nurse (C/PHN) in
preventing, preparing for, responding to, and supporting recovery from
disasters.
5. Use the levels of prevention to describe the role of the C/PHN in relation
to acts of chemical, biologic, or nuclear terrorism.

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INTRODUCTION
Have you, or someone you know, been affected by a recent disaster? In this
millennium, we have witnessed multiple devastating natural disasters, such
as Category 5 hurricanes, tsunamis, and earthquakes, and manmade
destructive acts of terrorism (e.g., bombings) causing multiple fatalities.
Natural and manmade disasters are ever-present possibilities regardless of
where one lives or works, and health care professionals have an obligation to
be skilled in disaster preparedness and response. This chapter will increase
your understanding of the community/public health nurses (C/PHN's) role in
preparing for, responding to, and recovering from natural disasters and
terrorism.

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DISASTERS
A disaster is any natural or manmade event that causes a level of destruction
or emotional trauma exceeding the abilities of those affected to recover from
without community assistance. Airplane crashes, mass shootings, and
chemical explosions are all situations that are devastating to a community
and, by definition, constitute disasters.
The geographic distribution and types of disasters vary around the world
due to environmental, sociopolitical, and topographic factors. For example,
California, Alaska, and Tennessee are associated with earthquakes and the
Gulf Coast with hurricanes and oil spills. Similarly, it is not surprising to
hear of drought in Ethiopia, floods in India during the monsoon season, or
bombings in Afghanistan or Syria. When certain types of disasters are
anticipated, communities are usually prepared for them. For instance,
California has strict building codes to prevent destruction of structures in the
event of earthquakes, but most California homes lack the basements and
insulation that characterize homes east of the Rocky Mountains, which may
be subject to severe storms or tornados. Similarly, residents of the northern
United States, Germany, Austria, and Russia are better prepared for blizzards
than are the southern regions of the United States and Europe.
Sadly, throughout history, disasters have affected every section of the
globe. Table 17-1 lists only a few of them. However, technological advances,
such as satellite data, have improved disaster management worldwide
(International Charter, 2019).

TABLE 17-1 Major Disasters: 2015 to 2020

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1428
Characteristics of Disasters
Disasters are often characterized by their cause.

A natural disaster is caused by natural events, such as earthquakes and

tsunamis.
A manmade disaster is caused by human activity, such as mass
shootings, the bombing of significant landmarks in major cities, or the
riots in major cities after a sociopolitical event. Other manmade
disasters include nuclear reactor meltdowns, industrial accidents, oil
spills, construction accidents, and air, train, bus, and subway crashes. In
fact, manmade disasters can and frequently do follow natural disasters,
as occurred with the nuclear reactors in Japan following the earthquake
and tsunami in 2011.
A casualty is someone who has been injured or killed by or as a direct
result of an accident or natural disaster.
If casualties number more than two people but fewer than 100, the
disaster is characterized as a multiple-casualty incident.
Although multiple-casualty incidents may strain the health care systems
of small or midsized communities, a mass-casualty incident—often
involving many casualties—can completely overwhelm the health care
resources of even large cities (DeNolf & Kahwaji, 2019).

Preparedness for mass-casualty incidents is essential for all communities.

For instance, community leaders should closely track and report through
various media the path and time of landfall of a hurricane to inform residents
in the storm's path and support early evacuation of families and businesses.
Communities can help minimize devastation from flooding by building
reservoirs or refusing to grant building permits in flood-prone areas and by
reinforcing areas around waterways with sandbags during rainy weather. In
fire-prone areas, communities can heighten awareness of fire danger and
enforce regulations supporting precautionary preventive measures
Unfortunately, some disasters occur without warning. For example:

The terrorist attacks in New York City caught thousands of civilians by

surprise. They were trapped in buildings with limited escape routes and
very little time to retreat to safety.
During the 2015 Paris terrorist attacks, survival depended on being in
the right place at the right time.
Coworkers were trapped in a building during the 2015 San Bernardino,
CA terrorist attack when a married couple fired on them with automatic
weapons. A total of 14 were killed and 27 were injured.
Wildfires in California during 2017 and 2018, though not completely
unanticipated, were uncharacteristically large, and control was hindered

1429
 by drought conditions, along with heat and high winds.
The mass shootings in Newtown, Connecticut; Aurora, Colorado; Las
Vegas, Nevada; and Thousand Oaks, California occurred without
warning and were the result of mentally unstable individuals acting
alone.

Some disasters, such as the natural gas leak in a southern California

community during 2015–2016, are at first unknown to the public. After
residents began noticing headaches, nosebleeds, respiratory problems, and
other symptoms, the Southern California Gas Company acknowledged that a
deep well gas leak had occurred in a difficult-to-reach canyon miles away.
The company assured the public that the leak did not pose an imminent
health risk, although it had been occurring for months and would take several
more months to stop. It was estimated that over 30,000 kg/hour of methane
was released into the atmosphere, and the area became a no-fly zone per the
Federal Aviation Administration (Reilly, 2016). The gas leak was finally
stopped and “permanently sealed” in late February 2016 (Pamer, Wynter, &
McDade, 2016, p. 4).
The scope of a disaster is the range of its effect, either geographically or
in terms of the number of people impacted. The intensity of a disaster is the
level of destruction and devastation it causes. For instance, an earthquake
centered in a large metropolitan area and one centered in a desert may have
the same numeric rating on the Richter scale yet have very different
intensities in terms of the destruction they cause. As of seven months after its
initial detection, the COVID19 pandemic, stemming from a novel
coronavirus that started in Wuhan, China in December 2019, had infected
more than 12.5 million worldwide and caused over half a million deaths
(CDC, 2020a).
The terrorist attacks on September 11, 2001 are the worst disaster in U.S.
history, as a total of 2,996 people, including 19 terrorists, died in three
attacks on U.S. soil. Terrorists took control of four airplanes and used them
as missiles. Two planes hit the World Trade Center in New York City, killing
2,753 (Engel & Ioanes, 2020). The third plane hit the Pentagon, killing 125
in the Pentagon and the 64 aboard the plane. Passengers in the fourth plane,
United Flight 93, were aware of the attacks and, once their plane was
hijacked, attempted to take back the plane. The plane crashed in a field in
Shanksville, Pennsylvania, killing 40 (Englel & Ioanes, 2019). Every year on
September 11th, the country remembers those who perished in the attacks.
Only 60% of the bodies have been identified thus far. The remains of
firefighter Michael Haub were identified this year (Karimi, 2019). At least
200 firefighters have died to date from Ground Zero–related illnesses
(Stanglin, 2019).

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Persons Impacted by Disasters
Because disasters are so variable, there is no typical person impacted in a
disaster, nor can anyone predict whether he or she will ever be impacted by a
disaster. Those who are directly impacted by disaster experience the event
firsthand, whether fire, flooding, mass shooting, vehicular accident, or
bombing. They also constitute the dead and the survivors of the event; these
survivors are likely to have health effects from their experience, even if they
are without physical injuries directly caused by the event. Some may be
without shelter or food, and many experience serious psychological stress
long after the event is over, such as victims of the Thomas Fire. This fire,
California's largest wildfire to date, was started by sparks from powerlines
during a powerful wind, destroyed 1,063 structures, and burned 281,893
acres (Box 17-1; Diskin, 2019).

BOX 17-1 PERSPECTIVES

Viewpoint of a Victim of the Thomas Fire Dry

easterly winds and a spark of fire on the night of
December 4, 2017 changed many lives, including
my own. That spark of fire grew to be known as
the Thomas Fire that destroyed over 500
structures, including our home of 20 years. The
power had been out and the glow of flames
appeared incredibly close—a setting for panic that
told me to just get out. We left fast with only
clothes for the next couple of days. My husband
and I learned the next afternoon that our home
had burned with nothing left but ashes and odd
pieces of survival, like a whole wall of decorative
master bathroom tile!

1431
Over the next month, I felt a wave of emotions that included not only the
obvious of sadness but a conflict between feeling both immense gratitude
and highly overwhelmed from the countless people who reached out to us.
It often seemed like I was just floating to get through the day yet
appreciating the little things, like the smell of shower soap and taste of
coffee at our daughter's home where we were staying. Interestingly, one
word kept popping into my head over that immediate time period:
resilience. I found strength in knowing I could be resilient through the
kindness of others who truly cared.
Ever since the fire, I feel anxious during dry windy weather, the sound
of fire department sirens and seeing the outbreak of fire. California has
continued to be affected by devastating fires. The aftermath of fire
destruction leads me to wonder where those people are at emotionally and
physically in rebuilding their lives, knowing from personal experience how
some plow through and others go through extreme grief. Each day I wake
up taking a deep breath, reminding myself of having resilience, and
knowing I have the ability to rebuild anew.

Colleen Nevins, DNP, RN

Depending on the cause and characteristics of the disaster, some direct

survivors may become displaced persons or refugees. Displaced persons are
forced to leave their homes to escape the effects of a disaster. Usually,
displacement is a temporary condition and involves movement within the
person's own country. The term refugee is reserved for people who are
forced to leave their homeland because of war or persecution (United
Nations, n.d). Returning displaced persons or refugees can place economic
and social strains on the county of origin. Along with needs for employment
and shelter, these influx situations raise concerns, especially regarding early
or forced marriages, child labor, and human trafficking (United Nations,
n.d.). Whether the displacement of refugee status is permanent or not, the
lasting impact to both the country of origin and the host country is
significant.
Those who are indirectly impacted by disaster are the relatives and
friends of persons directly impacted by the disaster. These supporters often
undergo extreme anguish while trying to locate loved ones or accommodate
their emergency needs. If bodies cannot be found or are unidentifiable, the
supporting persons experience even greater anguish and may not be able to
accept that a loved one did not survive. Family members of those killed on
9/11 in New York City worked with architects to develop a memorial that
meets the expectations of most of those indirectly impacted by the attack and
honors their loved ones. This effort, along with the Flight 93 National
Memorial in Shanksville, PA, and the Pentagon Memorial, helps with the

1432
long healing process of the supporters and serves as a reminder of the impact
that day had on each of our lives.

1433
Factors Contributing to Disasters
It is useful to apply the host, agent, and environment model (epidemiological
triad) to understand the factors contributing to disasters, because
manipulation of these factors can be instrumental in planning strategies to
prevent or prepare for disasters. See Chapters 7 and 8.

Host Factors
The host is the human being who experiences the disaster. Host factors that
contribute to the likelihood of experiencing a disaster include age, general
health, mobility, psychological factors, and socioeconomic factors. For
instance, older residents of a mobile home community may be unable to
evacuate independently in response to a tornado warning if they can no
longer drive. Residents of a low-income apartment complex in a large city
may be aware that their building is not compliant with city fire codes but
avoid alerting authorities for fear of the complex being closed and being
homeless due to their inability to afford new, safe housing.

Agent Factors
The agent is the natural or technologic element that causes the disaster. For
example, the high winds of a hurricane and the lava of an erupting volcano
are agents, as are radiation, industrial chemicals, biologic agents, and bombs.

Environmental Factors
Environmental factors are those that could potentially contribute to or
mitigate a disaster. Common environmental factors include a community's
level of preparedness; the presence of industries that produce harmful
chemicals or radiation; the presence of flood-prone rivers, lakes, or streams;
above-average amount of rainfall or snowfall; above-or below-average high
or low temperatures; proximity to fault lines, coastal waters, or volcanoes;
and the presence or absence of political unrest.

1434
Agencies and Organizations for Disaster
Management
In 1803 the United States first recognized the need to prepare for
emergencies through law and dedicated organizations. The first law was
written as a direct response to a major disaster, the Portsmouth, New
Hampshire fire of 1803, which swept through the seaport town. The majority
of subsequent legislation was in response to specific crises and created many
different agencies to respond to those disasters. The one constant was that the
response of the federal government to disasters remained more reactive than
proactive and was ad hoc in nature, only becoming coordinated with the
establishment of the Federal Emergency Management Agency (FEMA) in
1979 and the passage of the Robert T. Stafford Disaster Relief and
Emergency Assistance Act of 1988 (Haddow, Bullock, & Coppola, 2016). In
response to World War II and the specter of all-out nuclear war with the
Soviet Union, the United States created Civil Defense, a series of programs
and agencies designed to protect the population from “counter-value” nuclear
strikes and increase the survivability of a nuclear war. The U.S. Department
of Health, Education, and Welfare (USDHEW), predecessor to the U.S.
Department of Health and Human Services, created the Handbook for Civil
Defense Emergency Planning in Welfare Institutions, which was a guide to
protect individuals and help staff prepare for fallout from a nuclear event
(USDHEW, 1961). Significant in this handbook was the attention given to
family responsibilities and the likelihood that staff, including nurses, would
choose family responsibilities over professional responsibilities. To help
alleviate the problems associated with absenteeism as a result of the nurses'
conflicting responsibilities, the handbook recommended:

Reminding staff of their responsibility as public servants,

Providing shelter for families within the institution,
Planning for getting families to the shelter,
Planning for families to assist the staff during a crisis (USDHEW,
1961).

Under the 1950 version for the United States Civil Defense Plan, health
services were to remain under the control of existing health agencies to avoid
unnecessary duplication of services and would be subject to the rules and
regulations of civil defense. The U.S. Public Health Service (USPHS) was
responsible for providing staffing for civil defense offices and would work
for the state health officer who would have the lead. The roles have been in
continual transition since that time, but the basic principles remain the same.
Public health has become recognized as a critical component of
emergency planning, preparedness, and response. National public health

1435
response requires coordination with state and local authorities, to include
nongovernmental agencies (Centers for Disease Control and Prevention
[CDC], 2019a). The CDC website has an assortment of educational materials
to explore disasters such as videos, online modules, and statistics.
Among disaster-relief organizations, perhaps none is as famous as the
Red Cross, which is referred to as the American Red Cross in the United
States and the Red Crescent Societies in Islamic countries. The American
Red Cross was founded in 1881 by Clara Barton and was chartered by the
U.S. Congress in 1905. It is authorized to provide disaster assistance free of
charge across the country through its more than half a million volunteers and
staff. The duties assumed by the Red Cross in the event of a disaster are to
provide shelter, food, basic health and mental health services, and
distribution of emergency supplies (American Red Cross, n.d.).
President George W. Bush sought to consolidate the roles and
responsibilities of agencies and organizations involved in disaster response
and to align them with emergency support functions (ESFs; Table 17-2).

1436
TABLE 17-2 Emergency Support Functions Responsibilities

DHS, Department of Homeland Security; ESF, Emergency Support Functions; FEMA, Federal
Emergency Management Agency; NGO, nongovernmental organization.
Reprinted from The Department of Homeland Security. (2019 draft). National response framework
(4th ed., pp. 39–42).
Retrieved from https://www.fema.gov/media-library-data/1559136348938-
063ec40e34931923814dd50df638b448/NationalResponseFrameworkFourthEdition.pdf

The Department of Homeland Security (DHS) was organized in 2002

and incorporates many of the nation's security, protection, and

1437
 emergency response activities into a single federal department (DHS,
2015).
In 2003, FEMA, along with parts of 23 agencies, became part of the
DHS.
FEMA, established in 1979, is the federal agency responsible for
assessing and responding to disaster events in the United States and
provides training and guidance in all phases of disaster management.
The DHS includes other widely known agencies, including the
Transportation Security Administration, U.S. Customs and Border
Protection, U.S. Immigration and Customs Enforcement, U.S.
Citizenship and Immigration Services, U.S. Coast Guard, and U.S.
Secret Service (DHS, 2018).

FEMA provides oversight of the National Incident Management System

(NIMS), developed to allow responders from different jurisdictions and
disciplines to work more cohesively and proactively in response to natural
disasters, emergencies, and terrorist acts.
NIMS is the National Incident Command System (ICS), meaning that
it takes a unified approach to incident management, incorporates standard
command and management structures, and emphasizes preparedness, mutual
aid, and resource management (Fig. 17-1; FEMA, 2017a). Nurses and other
health care professionals must understand this system and are encouraged to
take courses dealing with the ICS. These courses are available for free online
from FEMA Emergency Management Institute at
http://www.training.fema.gov/EMI/. The most important courses for a nurse
are (1) IS-100 Introduction to the Incident Command System, (2) IS-200.C
Basic Incident Command System for Initial Response, (3) IS-700
Introduction to the NIMS, and (4) IS-800.b Introduction to the National
Response Framework. Students are encouraged to explore the FEMA
distance learning platform at https://training.fema.gov/is/.

1438
 FIGURE 17-1 Incident command system. FEMA. Incident
Resource Center. (Adapted from
http://training.fema.gov/EMIWeb/IS/ICSResource/index.htm.)

The Department of Health and Human Services (DHHS) is the lead

federal agency for public health and medical services during a public health
or medical disaster. Supplemental services are provided to state, local, and
territorial governments and may include Disaster Medical Assistance Teams
(DMAT), USPHS officers, epidemiological personnel from the CDC, and
veterinary support to name a few. Various international nongovernmental
organizations (such as Doctors Without Borders, the International Medical
Corps, and Operation Blessing), religious groups, and other volunteer
agencies provide needed emergency care (Fig. 17-2; see Chapter 16).

1439
 FIGURE 17-2 Mobile hospitals are often deployed during
disasters.

Governments often send their military personnel and equipment in

response to international disasters. However, political agendas may prevent
aid typically accepted by countries experiencing catastrophe to reach the
impacted communities. Fortunately, the USPHS Commissioned Corps was
allowed to provide aid for the 2008 tsunami and earthquake survivors in
Indonesia and Haiti. The USPHS has also worked collaboratively with the
U.S. Navy to provide nursing and other medical care on combined
humanitarian missions to South America and the South Pacific, and was sent
to Africa to assist with the Ebola crisis (USPHS, 2019). See Chapter 28 for
additional information about the role of the USPHS Commissioned Corps
Nurses in emergency preparedness.

1440
Phases of Disaster Management
In developing strategies to address the problem of disasters, it is helpful for
the C/PHN to consider each of the four phases of disaster management:
preventive/mitigation, preparedness, response, and recovery and become
familiar with the language typically used in disaster preparedness
(Emergency Management terms and definitions, FEMA, 2018).

Prevention or Mitigation Phase

Activities during this phase are focused on preventing future emergencies or
minimizing their effects. The shaping of public policies and plans that either
modify the causes of disasters or mitigate their effects on people, property,
and infrastructure are critical activities during this phase. Mitigation
activities take place before and after disaster emergencies.
To reduce our vulnerability to disasters, the United States has
strengthened its disaster management activities over the past decade and
continues to do so today (FEMA, n.d).

The screening process at airports and shipping ports includes advanced

imaging technology scanning and random hand-carried luggage or
canine searches preboarding.
Nonpassengers cannot go beyond the security entrance area, and
photographic identification is required at two or more points before
boarding.

Although globally we have experienced a pandemic and much will be

learned from it, the Global Health Security has steps in place designed to
help decrease the risk of pandemics. These steps include surveillance
systems that detect possible threats, laboratories to identify the agent, a
workforce for follow-up and containment, and emergency management
systems to coordinate the activities (CDC, 2020b). To prevent possible
contamination by Covid19, individuals are advised to wash hands for 20
seconds, to wear a face mask when going out in public, and to maintain a 6 ft
distance between each other (CDC, 2020c).

Preparedness Phase
Disaster preparedness involves improving community and individual
reaction and responses, so that the effects of a disaster are minimized.
Disaster preparedness includes plans for communication, evacuation, rescue,
victim care, and recovery. Preparedness may be hazard-specific or a general
all-hazard approach. For example, the Centers on Medicare and Medicaid

1441
Services (CMS) recommends that an “all-hazards approach” be taken by
health care agencies when taking into consideration their location and
disasters common to that area (CMS, 2017).

For instance, although plans may differ in states at higher risk of

earthquakes from those in tornado alley, the preparedness plans apply to
numerous disasters.
Communities must ensure that warning systems are tested routinely to
ensure appropriate notifications to the residents of a tornado or
hurricane, or any other potential threat.
The Office of the Assistant Secretary for Preparedness and Response
(2020) oversees the Strategic National Stockpile (SNS), which contains
doses of vaccines, medical countermeasures, and needed medical
supplies stored around the country in various strategic locations.
The CDC reports that the SNS contains enough medications and
medical supplies to manage a large public health emergency and protect
the American public (CDC, 2016).
Examples of preparedness include duck, cover, and hold during an
earthquake and run, hide, or fight for an active shooter incident (FEMA,
2020a).

Nurses have a role in preparedness as well. Leaving one's home to assist

in a disaster is difficult, especially if one, or one's family, is not prepared.
Therefore, nurses need to be prepared with an individual and family plan and
supplies that could possibly be needed. Enrolling in disaster classes or/and
registering with a disaster agency such as the Red Cross, reinforces
professional preparedness. On a community level, nurses can enhance
preparedness by participating in community drills often held by public health
agencies. Preparedness activities take place before an emergency occurs. We
cannot provide adequate disaster relief until we are prepared on all three
levels.

Response Phase
The response phase begins immediately after the onset of the disastrous
event and during the emergency. Response is putting your preparedness plans
into action immediately, with the goals of saving lives and preventing further
injury or damage to property. Activities during the response phase include
rescue, triage, on-site stabilization, transportation of injured, and treatment at
local hospitals and clinics. Disaster triage differs from triage done in the
emergency departments. START, the most commonly used technique in the
United States, consists of triaging individuals in 30 to 60 seconds during a
mass casualty. The four categories consist of the walking wounded/minor
(green tag), delayed (yellow), immediate (red), and deceased (black). These

1442
categories are based on ambulation, respirations, perfusion, and mental status
(Bazyar, Farrokhi, & Khankeh, 2019).
Response also requires recovery, identification, and refrigeration of
deceased remains, until notification of family members is possible
(USDHHS, 2020b). Persons trained in mortuary services are an essential part
of any emergency planning and response effort. The mortuary teams includes
pastoral personnel to ensure that remains are always treated with respect and
in accordance with religious traditions. Supportive care, including food,
water, and shelter for survivors and relief workers, is a critical element of the
total disaster response. Veterinary response teams are essential to address the
acute and long-term needs of the animals impacted by the disaster. Many
shelters will not accept pets, causing confusion and delays in sheltering
displaced persons (Fig. 17-3).

FIGURE 17-3 Victims of Superstorm Sandy receiving assistance

at a temporary shelter.

Individuals with chronic health conditions and/or mental illness may

need specific interventions in recovery from a disaster. Those with serious
mental illness such as bipolar disorder and schizophrenia are less likely to be
prepared for disasters than the general population. Although these disorders
are not caused by disasters, the effects of the disaster can cause higher
hospitalizations and higher levels of avoidance behavior (SAMHSA, 2019).
C/PHNs need to be aware of support agencies for this population because
their needs may increase due to lack of support systems and poor coping
skills. In recent years, it has become clear that all of us need to be have a
plan in place so that we recover as quickly as possible if a disaster arises.

Individuals on medications need at least a 3-day supply of medications.

Special diet foods may be hard to locate during a disaster; therefore,

1443
 advise patients to eat healthy as much as possible if their special diet
foods are unavailable during a disaster.
Be prepared for possible power outages (CDC, 2019a).
The Emergency Prescription Assistance Program helps to replace
medications and equipment that is lost due to a disaster (Public Health
Emergency, 2020).
Knowledge of the community assists the C/PHN in ensuring all
populations have services needed, with special attention paid to those
who are most vulnerable.

Recovery Phase
During the recovery phase, the community joins together to repair, rebuild,
or relocate damaged homes and businesses, and restore health, social, and
economic vitality to the community. There will be many opportunities during
this phase to enhance prevention and increase preparedness, thus reducing
future vulnerabilities. Both survivors and relief workers may experience
psychological trauma and should be offered mental health services to support
their recovery (Box 17-2). The traumatic emotional scars may last a lifetime.
The Substance Abuse Mental Health Services Administration (SAMHSA)
offers guides and a disaster kit for managing stress in crisis for both
professionals and victims (SAMHSA, 2011). Recovery activities take place
after an emergency, and may extend over a period of months or even years.

BOX 17-2 PERSPECTIVES

Viewpoint of a Survivor of the Route 91 Mass

Shooting As the first volleys of automatic gunfire
rained down upon myself and the other 20,000
people watching Jason Aldean perform at the
Route 91 Harvest Music Festival in Las Vegas, NV,
my three friends and I looked around, trying to
determine the source of the horrific sound that we
had thought were firecrackers. Until that point, it

1444
had been one of the best weekends of my life and
it seemed as if nothing could bring me down from
the mountain of joy I felt. However, as Jason
Aldean ran off stage and someone running past us
yelled, “There's blood! That girl has been shot!”
the mountain of joy came crumbling down and the
devastation of what would eventually become an
estimated 1,200 rounds of lethal ammunition,
killing 58 beautiful souls, began to sink in.
Quickly, we moved towards the exit and stopped behind a barrier, trying to
determine where the shooting was coming from and which way to go. As I
looked back towards the emptying venue, I saw a young girl, shot through
her eye, lying there. My work experience as an EMT kicked in, and a small
group of strangers and I quickly carried her to the outer walls of the venue,
passing her off to other strangers who said they had medical experience.
From there, the adrenaline rushing through my veins led me and many
others to aid and carry other gunshot victims out of what had become a war
zone.
As the shooting eventually stopped and the only victims left inside the
venue were those who were covered in a makeshift shroud to shield our
eyes from the horror that lay underneath, the emotional roller coaster set in.
I teetered between anger, extreme sadness, numbness, and confusion. I
could not comprehend the magnitude of what had happened in front of my
eyes. For weeks, it was all I could think about, replaying the steps I took,
the sounds of gunfire, the cries, the feeling of a stranger's blood across my
skin. Unless I was around my friends I had been at the concert with, I felt
alone and uneasy in a crowded room. The posttraumatic stress was real, and
it would take months of therapeutic counseling before I even felt remotely
close to “normal.”
Over 2 years later, I still occasionally see a counselor to discuss the
emotions and visions that are only a loud “pop” away. Though I do not bear
any physical scars from the night of October 1, 2017, the emotional scars
run deep and can be easily broken open. While I am able to function
throughout my daily life and work life as an EMT in the emergency
department seemingly fine, there is still not a day that goes by that I am not
somehow reminded of that night.

Gabriel Mosse

1445
 During the recovery phase, special attention should be given to the needs
of children who are approximately 25% of the population in the United
States and even higher in other countries. The CDC has resources in English
and Spanish to assist children that have experienced disasters. One example
is the coloring book Coping After a Disaster (CDC, 2019b).

1446
Role of the Community/Public Health Nurse
The C/PHN has a pivotal role in preventing, preparing for, responding to, and
supporting recovery from a disaster (Association of Public Health Nurses
[APHN] Public Health Preparedness Committee, 2014). After a thorough
community assessment for risk factors, the C/PHN may initiate the formation
of a multidisciplinary task force to address disaster prevention and
preparedness in the community.

Preventing Disasters
Disaster prevention may be considered on three levels: primary, secondary,
and tertiary (Box 17-3).

BOX 17-3 Levels of Prevention Pyramid

Responding to a Tornado SITUATION: A
natural disaster—tornado GOAL: Prepare,
promptly diagnose, and treat and/or restore
individuals, families, and communities to the
fullest by using the three levels of prevention.

1447
Primary Prevention
Primary prevention of a disaster means keeping the disaster from ever
happening by taking actions that completely eliminate its occurrence—or, if
that is not possible, to minimize damage through primary prevention.
Primary prevention includes providing and participating in training sessions
on prevention of disaster risk factors, knowing high-risk groups through
community assessments, and working with community partners (CDC,
2019a). Primary prevention of disasters can be practiced in all settings in the
workplace and home—with defined processes to reduce safety hazards and in
the community, to monitor risk factors, reduce pollution, and encourage
nonviolent conflict resolution (CDC, 2019b). Primary disaster prevention
efforts should include awareness of a community's physical, psychosocial,
cultural, economic, and spiritual stance. The C/PHN educates people at
home, at work, at school, or in a faith community, and has a unique
opportunity to be aware of the community perspective about safety and
security focused on preventing a disaster. There are many prevention actions
the C/PHN can initiate (APHN Public Health Preparedness Committee,
2014). These prevention actions can include the following:

Completing a community assessment, including the residents with

special needs and those in high-risk categories
Collaborating with community leaders to provide general community
prevention and preparation education activities. For instance, working
with community partners C/PHNs promote policies that better prepare
vulnerable populations. These relationships are built on trust and a
common goal of serving the population. C/PHNs work closely with
these community partners acting in a leadership role to ensure
populations are assessed and have the services needed if a disaster
occurs (APHN, 2014). The second aspect of primary disaster prevention
is anticipatory guidance. Disaster drills and other anticipatory exercises
help the community and relief workers experience some of the feelings
of chaos and stress associated with a disaster before one occurs (APHN,
2014). It is much easier to do this when energy and intellectual
processes are at a high level of functioning.

1448
 The C/PHN has a role in community collaborative disaster drills
through committee membership, organization of drills at the place of
employment, or activism at the grassroots level to assist in holding
community-wide disaster drills on a regular basis.

Secondary Prevention
Secondary disaster prevention focuses on the earliest possible detection and
treatment. After a disaster, the local health department's C/PHNs work with
the American Red Cross to coordinate and provide emergency assistance.
Secondary prevention corresponds to immediate and effective response.
Agencies who provided early evacuation, identified shelters for special-needs
patients outside the high-risk area, implemented volunteer cascading
communication systems, and conducted pre-event mock evacuation plans
and included volunteers in their disaster plan were most successful with their
response efforts. Recommendations to improve responses include
identification of patients who may be reluctant to evacuate, the provision of
adequate security at special-needs shelters, and, most importantly, practice
drills (APHN, 2014; DHS, n.d.). Many local communities have developed
preparedness programs to inform, prepare, and ensure residents are ready for
any type of manmade or natural disaster, such as the City of New Orleans's
NOLA READY (for more details, visit https://ready.nola.gov/home/).

Tertiary Prevention
Tertiary disaster prevention involves reducing the amount and degree of
disability or damage resulting from a disaster. This level involves
rehabilitative work and can help a community recover and reduce the risk of
further disasters.
Since 9/11, the American Psychiatric Nurses Association has provided
access to many resources for nurses dealing with traumatic events (American
Psychiatric Nurses Association, 2016). Visit
https://www.apna.org/m/pages.cfm?pageID=5196 for a detailed list of
resources for dealing with traumatic events, and SAMHSA apps at
https://store.samhsa.gov/product/samhsa-disaster for easy access when in the
field. In addition to these references, the Office of the Assistant Secretary for
Preparedness and Response (2019) offers a three-module series on
compassion fatigue and secondary trauma for health care providers that can
be found at https://files.asprtracie.hhs.gov/documents/asprtracie-dbh-self-
care-for-health care-workers-modules-description-final-8-19-19.pdf

Preparing for Disasters

Disaster planning is essential for a community, business, and hospitals.
Details of preparation and management by all involved, including

1449
community leaders, health and safety professionals, and lay people must be
considered. Despite many disaster drills and numerous iterations of disaster
plans before Hurricane Katrina, some hospitals in New Orleans were better
prepared for terrorism events than for the hurricanes and flooding that were
not uncommon to that geographic area. C/PHNs can be very instrumental in
disaster preparedness (APHN, 2014). and must ensure they have their own
family disaster preparation plan in place. For information on nurses' personal
preparation for disaster and online courses on disaster preparedness, see Box
17-4.

BOX 17-4 Nurses' Personal Preparation

for Disasters and Available Training
Nurses are ready, willing, and well
positioned to respond to disasters;
however, nurses receive minimal
disaster-focused instruction as part of
their formal education. Due to the
reality that a disaster can occur at any
time, it becomes all the more urgent for
nurses to be well prepared through valid
and low-cost education in disaster
management (Brand, 2016).
American Nurses Association (ANA) has educational opportunities
for nurses on disaster preparedness. When we are a prepared profession,
we can cope and help our communities recover from disasters better,
faster, and stronger. See https://www.nursingworld.org/practice-
policy/work-environment/health-safety/disasterpreparedness/ for the
following documents from the ANA:

Position Statement Background Information: Registered Nurses'

Rights and Responsibilities Related to Work Release During a
Disaster
Position Statement Background Information: Work Release During
a Disaster—Guidelines for Employers

1450
 Other educational opportunities include:

HHS Guidance for Mass Decontamination: Patient

Decontamination in a Mass Chemical Exposure Incident: National
Planning Guidance for Communities (available at
http://www.phe.gov/Preparedness/responders/Documents/patient-
decon-natl-plng-guide.pdf)
A Nurse's Duty to Respond in a Disaster: Unresolved issues of
legal, ethical, and professional considerations of disaster medical
response remain a challenge, and could hamper the ability of
nurses to respond. A concerted effort to solving these problems is
needed, with nurses and stakeholders at the national, state, and
local levels (available at
https://www.nursingworld.org/~4ad845/globalassets/docs/ana/who-
will-be-there_disaster-preparedness_2017.pdf).
IOM Report on Establishing Crisis Standards of Care to use in
Disaster Situations (PDF) (available at
https://www.nursingworld.org/~4ad845/globalassets/docs/ana/stds-
of-care-letter-report-2.pdf)

The American Nurses Association also offers the National

Healthcare Disaster Certification (NHDP-BC); information on this
program can be found at https://www.nursingworld.org/our-
certifications/national-healthcare-disaster/. Nurses are able to take the
certification exam once certain requirements are met.
Personal preparedness means that the nurse has read and
understands workplace and community disaster plans and has developed
a disaster plan for his or her own family (San Diego County Office of
Emergency Services, n.d.). The prepared nurse should also have
participated in disaster drills, have documented up-to-date vaccinations,
be a certified basic life support (BLS) provider, and be able to provide
basic first aid. Nurses preparing to work in disaster areas as
“spontaneous volunteers” should have copies of their nursing license
and driver's license, durable clothing, and basic equipment, such as
stethoscopes, flashlights, and cellular phones to facilitate appropriate
task assignments during the disaster response.
To increase understanding of and the ability to work within an
emergency situation, every nurse should become familiar with the
National Incident Management System (NIMS). The NIMS is “a
systematic, proactive approach to guide all levels of government,
NGOs, and the private sector to work together to prevent, protect
against, mitigate, respond to, and recover from the effects of incidents.”
(FEMA, 2017a, p. 77). In essence, NIMS provides a framework for
management of incidents in support of the national preparedness

1451
 system. Free online courses are offered through FEMA at
www.fema.gov. In addition to the FEMA courses, other options include
the following

CDC Emergency Preparedness and Response Training and

Education: https://emergency.cdc.gov
Federal Emergency Management Agency (FEMA):
http://training.fema.gov/emi.aspx
Public Health Foundation—Train.org: https://www.train.org
National Institutes of Health—Radiation Emergency Medical
Management: http://www.remm.nlm.gov/training.htm
University of Minnesota, School of Public Health:
http://www.sph.umn.edu/academics/ce/tools/

Assessment for Risk Factors and Disaster History

The C/PHN is uniquely qualified to perform a community assessment for
risk factors that may contribute to disasters (Quad Council Coalition, 2018).
In addition, the nurse should review the disaster history and preparedness
plans of the community. Have earthquakes, tornadoes, hurricanes, floods,
blizzards, riots, or other disasters occurred in the past? If so, what (if any)
were the warning signs? Were they heeded? Were people warned in time?
Did evacuation efforts remove all people in danger? What were the
community's on-site responses, and how effective were they? What programs
were put in place to rehabilitate the community? Community health
assessment tool may assist with identifying critical needs of the community
(FEMA, 2020b).

Establishing Authority, Communication, and

Transportation
In addition to assessing for preparedness, the effective disaster plan follows
the NIMS model and establishes a clear chain of authority, develops lines of
communication, and delineates routes of transport. Establishing a clear and
flexible chain of authority is critical for successful implementation of a
disaster plan (CDC, 2018).

Usually, the chain is hierarchical, with, for example, the community's

governmental head (e.g., mayor) initiating the plan, alerting the media
to broadcast warnings, authorizing the police to begin evacuations, and
so on.
Within each level of the organization, the hierarchy continues. For
example, at the local hospital, the hospital administrator may be
responsible for alerting nurse managers to call in additional personnel.

1452
 Flexibility is essential, because key authority figures may themselves be
survivors of the disaster. If the home of the chief of police is destroyed
in an earthquake, his or her second-in-command must have equal
knowledge of the community's disaster plan and be able to step in
without delay.

Effective communication is often a point of breakdown for communities

attempting to cope with major disasters. After the terrorist attacks in
Oklahoma City and New York City, phone lines were damaged and cellular
sites were overwhelmed, making communication difficult. Communication
was possible only through handheld radios or by way of couriers on foot. At
times of heightened chaos and stress, as well as after physical damage to
communication facilities and equipment, misinformation and
misinterpretation can flourish, leading to delayed treatment and increased
loss of life.
Again, clarity and flexibility are the watchwords for establishing lines of
communication.

How will warnings be communicated?

What backups are available if the normal communication systems are
destroyed in the disaster?
How will communication between relief workers at the disaster site,
hospital personnel, police, and governmental authorities be maintained?
What role will local media play, both in keeping information flowing to
the outside world and in broadcasting needs for assistance and supplies?
Significant forms of communication have developed since the 9/11
terrorist attacks. Social media has become a critical method of
communicating important health and safety information to the public
since the 2001 terrorist attacks. Social media and disaster
communication leaderships have collaborated and formed a partnership
to disseminate information as quickly as possible (FEMA, 2020c).
How will friends and family members be informed of the whereabouts
or health status of loved ones?
The CDC offers Crisis and Emergency Risk Communication (CERC) to
ensure the correct messages by the correct authorities are communicated
during emergencies. The training materials can be found on the CDC
Web site at https://emergency.cdc.gov/cerc/index.asp.

The CDC Sample Single Overriding Communications Objective (SOCO)

is an effective template to disseminate information concisely and quickly to
the media during a disaster (see Box 17-5).

1453
 BOX 17-5 THE CDC SAMPLE SINGLE
OVERRIDING COMMUNICATIONS
OBJECTIVE (SOCO) TEMPLATE
In one BRIEF paragraph, state the key point or objective you want to
accomplish by doing the interview. This statement should reflect what
you, the author or speaker, would like to see as the lead paragraph in a
newspaper story or broadcast report about your topic.
What are the three or four facts or statistics you would like the public
to remember as a result of reading or hearing about this story?
Who is the main audience or population segment you would like this
message to reach?
What is the ONE message you want the audience to take away from
this interview/report?
Reprinted from CDC. (n.d.). Sample single overriding communications objective (SOCO). Retrieved
from
https://www.cdc.gov/tb/publications/guidestoolkits/forge/docs/13_samplesingleoverridingcommunica
tionsobjective_soco_worksheet.doc

Closed or inefficient routes of transportation can also increase injury and

loss of life. For example, if a single, narrow mountainous road is the only
means of transporting firefighters to or evacuating residents from the scene
of a forest fire, then disaster planners should propose widening the road or
clearing a second road. Disaster planners must also consider what routes
emergency vehicles will take when transporting disaster survivors to local
and outlying hospitals or health care workers to the disaster site. What if the
chosen routes are inaccessible because of floodwaters, advancing fires,
mountain slides, avalanches, or building rubble? Are alternative routes
designated? Also, how will people move about after the disaster? For
example, after the Japanese earthquake and tsunami in 2011, Nakanishi,
Matsuo, and Black (2013) examined planning methodologies and future
hypothetical disaster scenarios to help answer these types of questions.

Mobilizing, Warning, and Evacuating

In many natural disasters, local weather service personnel, public works
officials, police officers, or firefighters have the earliest information
indicating an increasing potential for a disaster. These officials typically have
a plan in place for providing community authorities with specific data
indicating increased risk (FEMA, 2018). They may also advise the mayor's
office or other community leaders of their recommendations for warning or

1454
evacuating the public. Additionally, they may recommend actions the
community can take to mitigate damage, such as spraying rooftops in the
path of fires, sandbagging the banks of rising rivers, or imposing a curfew in
times of civil unrest.

Disaster plans must specify the means of communicating warnings to

the public, as well as the precise information that should be included in
warnings (DHS, 2016).
Planners should never assume that all citizens can be reached by radio
or television or that broadcast systems will be unaffected by the disaster.
Broadcast media may indeed be a primary means of communicating
warnings, but alternative strategies, such as social media or police and
volunteers canvassing neighborhoods, should be considered.
Social media options such as Facebook, Twitter, and blogs are reliable
methods used by news stations and public health agencies that must not
be ignored. Over 20 million tweets were sent by utilities after Hurricane
Sandy, and Google's Web application, Person Finder, was especially
helpful during the Boston Marathon bombings (SAMHSA, 2020a).
In multilingual communities, messages should be broadcast in multiple
languages.
Not only homes but also businesses must be informed.
Information that should be communicated includes the nature of the
disaster; the exact geographic region affected, including street names if
appropriate; and the actions citizens should take to protect themselves
and their property.
A study on the use of GPS devices in a simulated mass casualty found
the devices useful in tracking patient locations throughout the drill
(Gross et al., 2019). Technology improves tracking of injuries and
fatalities.

An evacuation plan is an essential component of the total disaster plan

(CDC, 2019a). The plan should include notification of the police, local
military personnel, or voluntary citizens' groups of the need to evacuate
people, as well as methods of notifying and transporting the evacuees. A plan
should also be made for responding to citizens who refuse to evacuate. For
example, will police authorities forcibly remove an elderly citizen from his
home to a shelter? Will evacuation plans include household pets? If farms or
ranches are in the path of fires or floods, will animals be evacuated? How?
Who will do this and where will they be taken/sheltered?

Responding to Disasters
At the disaster site, police, firefighters, nurses, and other relief workers
develop a coordinated response to rescue, triage, and treat disaster survivors.

1455
One of the first obligations of relief workers is to remove survivors from
danger (Fig. 17-4).

FIGURE 17-4 Rescue of a Hurricane Katrina victim.

Rescue
The job of rescue typically belongs to firefighters and urban search and
rescue teams that have personnel with special training in search and rescue.
Depending on the disaster agent, protective gear, heavy equipment, and
special vehicles may be needed, and dogs trained to locate dead bodies may
be brought in (Fig. 17-5). Sometimes, the immediate disaster site is not the
best place for the disaster nurse, who can be far more effective in triage and
treatment of survivors during this time. However, the C/PHN's population-
based approaches, as well as knowledge of community resources and
particularly vulnerable aggregates (Quad Council Coalition, 2018) are
needed during this response phase.

1456
 FIGURE 17-5 A firefighter-handler with a canine rescue dog.

Rescue workers face the logistically and psychologically difficult task of

determining when to cease rescue efforts. Some factors to consider include
increasing danger to rescue workers, diminishing numbers of survivors, and
diminishing possibilities for survival. For example, after a plane crash on a
snowy mountain, rescue efforts may cease if it is deemed that anyone who
might have survived the crash would subsequently have died of exposure.

Triage
Knowing the prinicples and practices of triage allows the responding C/PHN
to provide the most effectvie nursing skills (Wagner & Dahnke, 2015).
Triage is the process of sorting multiple casualties in the event of a war or
major disaster. It is required when the number of casualties exceeds
immediate treatment resources. The goal of triage is to effect the greatest
amount of good for the greatest number of people. For an image showing the
four basic categories of the international triage system on a triage tag
commonly used in disaster responses, visit .

The most common method of triage used by first responders at a mass-

casualty incident in the United States is the simple triage and rapid
treatment (START) for adults and JumpSTART for pediatric patients.
(For other triage methods, see .)
START and JumpSTART are forms of triage used to sort victims into
four categories (immediate, delayed, minor, or morgue/deceased) and
are consistent with international triage system.

Prioritization of treatment may be very different in a mass-casualty event

as opposed to an average day in a hospital emergency department. Under
normal circumstances, a person presenting to a hospital emergency

1457
department with a myocardial infarction and showing no pulse or respirations
would receive immediate treatment and have a chance of recovery. At a
disaster site, a person without a pulse or respirations would most likely be
placed in the nonsalvageable category.

The term mass casualty refers to a number of persons impacted that is

greater than that which can be managed safely with the available
community resources, such as rescue vehicles and emergency facilities
to serve disaster survivors while also meeting the needs of the rest of the
community (Zarocostas, 2017).
In mass-casualty occurrences, the broader community will need to
become involved, including requests for rescue vehicles, firefighters,
and police officers from neighboring towns, and/or the use of
neighboring hospitals. Depending on the magnitude of the mass
casualty, state and federal resources may also be needed.

This adds another layer of disaster management coordination that must

be considered. The hurricane season of 2017 was one of the worst in US
history (FEMA, 2017b) and, along with the California wildfires of 2017,
stretched FEMA resources. FEMA provided support to millions of
individuals. “By May 2018, nearly 4.8 million households…registered for
assistance-more than the previous 10 years combined” (FEMA, 2018, p. 6).
Based on the disasters of 2017, FEMA is revising the National Response
Framework to improve relationships with the private sector and to improve
their readiness outside the continental United States to name a few of the
new revisions (FEMA, 2018).
C/PHNs should acquaint themselves with the phases of disaster a
community experiences. According the Substance Abuse and Mental Health
Services Administration (SAMHSA) there are six phases of disasters (Fig.
17-6; SAMHSA, 2018).

1458
 FIGURE 17-6 Six phases of disasters. (Reprinted from Substance
Abuse and Mental Health Services Administration. (2020). Phases
of disasters. Retrieved from
https://www.samhsa.gov/dtac/recovering-disasters/phases-disaster.
Adapted from Zunin & Myers as cited in DeWolfe, D. J. (2000).
Training manual for mental health and human service workers in
major disasters (2nd ed., HHS Publication No. ADM 90–538).
Rockville, MD: U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration,
Center for Mental Health Services.)

Phase 1: Predisaster phase—fear and uncertainty

Phase 2: Impact phase—range of intense emotional reactions
Phase 3: Heroic phase—high level of activity with a low level of
productivity
Phase 4: Honeymoon phase—dramatic shift in emotion
Phase 5: Disillusionment phase—realize the limits of disaster assistance
Phase 6: Reconstruction phase—overall feeling of recovery

Immediate Treatment and Support

Disaster nurses provide treatment on-site at emergency treatment stations, at
mobile field hospitals, in shelters, and at local hospitals and clinics (Box 17-
6). In addition to direct nursing care, on-site interventions might include
arranging for transport once survivors are stabilized, and managing the
procurement, distribution, and replenishment of all supplies. The nurse may

1459
also manage provision or distribution of food and beverages, including infant
formulas and rehydration fluids, and arrange for adequate, accessible, and
safe sanitation facilities at the treatment location. Finally, the nurse often
may also arrange for psychological and spiritual care of survivors of disasters
(APHN Public Health Preparedness Committee, 2014).

BOX 17-6 Mobile Field Hospital On

August 25, 2007, California featured the
first state-owned mobile field hospital in
a statewide disaster-training exercise.
The tent hospital is one of three 200-bed
hospitals purchased by California and
prepositioned around the state in the
event of a major emergency. The
hospital can be deployed and on-site
within 72 hours and comes equipped for
7 days of full patient care. Used together,
the hospitals can be reconfigured into a
400-or 600-bed hospital, if needed. This
is the same type of mobile field hospital
used by the military, and it was modeled
after the hospitals used by the Air Force
and Navy. The various units within the
hospital mirror services provided in any
modern facility including emergency
room, surgical suite, laboratory, x-ray,
surgical intensive care, and even a
pediatric unit.

1460
 More recently, mobile field hospitals were erected worldwide to
treat patients with Covid19, such as in New York's Central Park (below
exterior view) and in Lombardia, Italy (below interior view).

Source: Rodriguez (2016).

Some survivors who seem physically uninjured may, in fact, be suffering

from major injuries but be unable to relate their symptoms to a relief worker
because of shock or anxiety. For instance, a father pulling debris away from
his collapsed house after a tornado may be so worried about a missing child
that he does not realize that he has a broken arm.
Other survivors may be so emotionally traumatized by the disaster that
they act out, disrupting efforts to assist them and other survivors and possibly
engaging in dangerous activities. These survivors must be assessed for head
trauma and internal injuries, because their behavior may have a physiological
cause (SAMHSA, 2020b).

1461
Care of Bodies and Notification of Families
Identification and safe transport of the dead to a morgue or holding facility is
crucial, especially if a contagion is feared, though this is rare in mass-
casualty situations. Toe tags make documentation visible and accessible.
Records of deaths must be accurately documented and maintained, and
family members should be notified of their loved ones' deaths as quickly and
compassionately as possible. If feasible, a representative from each of the
area's faith communities should be available to assist families awaiting news
of missing loved ones. A family's recovery from loss is often delayed when
notification of their relative is not possible because the recovered bodies are
badly damaged or not found (USDHHS, 2020b).

Supporting Recovery From Disasters

Disasters do not suddenly end when the rubble is cleared and the survivors'
wounds are healed. Rather, recovery is a long, complex process often
including long-term medical treatment, physical rehabilitation, financial
restitution, case management, and psychological and spiritual support
(FEMA, 2019).

Long-Term Treatment
Long-term treatment may be required for many survivors of disasters,
straining the local rehabilitative care facilities and resources.

Children who are survivors may have to deal with lifelong disabilities or
scars from their ordeal, and families may be without adequate financial
support for their child's medical care.
Elderly citizens who had been in excellent health but who sustained
serious injuries in the disaster might suddenly find that they can no
longer live independently and must move to a long-term care facility.
After floods, landslides, fires, or earthquakes, extensive property
damage may cause some residents or businesses to relocate rather than
rebuild on land they now deem to be disaster prone.
A disaster that creates numerous persons impacted in a small
community may alter the entire social fabric of that community
permanently (SAMHSA, 2020b).

Long-Term Support
Immediately after a disaster, some survivors may be unable to concentrate on
anything beyond fulfilling their immediate needs and those of their family.
Disaster survivors may need funding to repair or rebuild their homes or to
reopen businesses, such as stores, restaurants, childcare facilities, and other

1462
services needed by the community. Insurance settlements, FEMA funding,
and private donations may assist in financing community rehabilitation. The
FEMA Individual Assistance Program and Policy Guide can be found at:
https://www.fema.gov/media-library-data/1551713430046-
1abf12182d2d5e622d16accb37c4d163/IAPPG.pdf
Psychological support is often required after a disaster, both for survivors
and for relief workers. Some individuals may experience posttraumatic stress
disorder (PTSD). Many survivors, especially elderly persons displaced from
their homes, may quietly lose their will to live and drift into apathy and
malaise. Depression and anxiety are positively correlated in the elderly
following earthquakes (Liang, 2017). While, some individuals may question
their faith after a disaster, a systemic review found religion and spirituality
may assist with coping and coming to terms with the disaster (Aten et al.,
2019). These survivors in spiritual distress often require not only empathetic
listening but also long-term skilled spiritual counseling. In assessing a
community's citizens for counseling needs after a disaster, the PHN should
not forget to include children. Often, children do not have words to express
their feelings or fears and may act out in ways adults find difficult to
understand, unless age-appropriate psychological intervention is provided.
Medical responders to disasters are at risk of depression and PTSD with
nurses being a greater risk than physicians. Risk factors included inadequate
social support, inadequate coping skills, and insufficient training (Naushad et
al., 2019).
Long-term support must be considered when assessing a community and
planning for disasters. Each community may be unique in their needs, and
each disaster requires a unique array of services and planning. Many
communities may be efficient in providing services in quick response to a
disaster; however, they often do not factor in the long-term needs and
provide the structure and support (Reifels et al., 2015) needed by the
community residents.

Need for Self-Care

Self-care, including stress education for all relief workers after a disaster, is a
common practice and actively encouraged in many communities. Proponents
report that stress education helps to reduce anxiety and put the situation into
proper perspective. Critical incident stress debriefing (CISD) provides
relief workers with professional debriefing that consists of phases followed
by individual sessions and support services as needed (Harrison & Wu,
2017). CISD is generally provided between 24 and 72 hours after the disaster
event. Proponents of CISD claim that it typically produces positive effects
by:

Accelerating the healing process

1463
 Equipping participants with positive coping mechanisms
Clearing up misconceptions and misunderstandings
Restoring or reinforcing group cohesiveness
Promoting a healthy, supportive work atmosphere
Identifying individuals who require more extensive psychological
assistance

A CISD addresses all components of the human response to trauma,

including physiologic effects, emotions, and cognition (Occupational Safety
and Health Administration, n.d.). The research on CISD has been mixed, but
Mitchell (n.d.) reports that if the personnel providing the intervention are
well trained and follow acceptable CISD practice standards, the outcomes are
more positive. Self-care comes in many forms and is part of a prescription
for emotional healing after a traumatic event. Self-care is for everyone
touched by trauma including the rescue workers (CDC, 2018).
Trauma-informed care acknowledges the impact of various types of
trauma on the individual's lifetime potential for health problems and
“engaging in health-risk behaviors” (Menscher & Maul, 2016, para. 2). Both
relief workers and recent trauma victims can benefit from this approach,
which seeks to limit secondary traumatic stress by promoting empowerment
and collaboration, as well as providing safety and choice. Earlier life
experiences, such as abuse and neglect or systemic bias, may exacerbate
experiences with traumatic events.

1464
Psychological Consequences of Disasters
More research is needed in the monitoring of long term psychological effects
and the evaluation of interventions following disasters (Généreux et al.,
2019). It is estimated that 20% of Americans will experience a natural
disaster (Wilson-Genderson, Heid, & Pruchno, 2018). Awareness of your
perceptions and how your actions are viewed are essential in dealing with
trauma victims. Fitzgerald & Hurst (2017) identify the prevalence of implicit
bias even in health care providers. Their review of literature indicates that
health care professionals exhibit the same amount of implicit bias as the
general public and that diagnosis and treatment may be affected. In addition,
trauma victims during a crisis may have previous trauma experiences related
to power inequities, preventing a willingness to seek care or comply with
medical instructions (Tello, 2018). Trauma-informed care requires the
C/PHN to ask permission and be supportive (Tello, 2018). As health
professionals, C/PHNs must be aware of their biases and prejudices (see
https://implicit.harvard.edu/implicit/takeatest.html for a self-test for implicit
bias).
Survivors of natural disasters experience a significant increase rate of
psychological distress, PTSD, and depression (Beaglehole et al., 2018) The
C/PHN and community mental health nurses, through education, screening,
assessment, and referral, have an important role in the primary, secondary,
and tertiary prevention of psychological disturbances due to a disaster.

Primary Prevention
Although a disaster, by its very nature, is often unforeseen, people's ability to
cope with the disaster can be determined in part by their previous
experiences and resources available.
Behavioral health is essential for overall health and wellness especially
in the face of a disaster. Due to the uncertainty of when a disaster might
occur, it is imperative to fortify personal and external resources before one
happens. Interventions should include strengthening of cognitive,
psychosocial, psychological, physical, and emotional domains of the
individual and the community (Makwana, 2019). During these times, lessons
learned from primary health education and interventions may help with the
survival and recovery phases. Consideration must be given to the life stages
of the survivors.
The American Psychological Association (2016) describes resilience as
a process of behaviors, thoughts, and actions. The building of competency or
resilience is an important primary prevention strategy, since a competent
person or community can make informed decisions based on availability of

1465
resources and problem-solving skills. Community disaster training must
include information on resiliency and resources to support individual and
community resilience (APHN, 2014; CDC, 2019c; Makwana, 2019).
C/PHNs can contribute to primary prevention in the face of disaster by
advocating for improving the social structure and economic conditions of the
community, including housing, work, schools, child care, and recreational
areas. it is also important for the C/PHN to advocate for the resources
necessary for the community to meet both the physical and psychological
challenges of a disaster.

Secondary Prevention
Survivors of disasters often feel anxious and overwhelmed and may be in
mental health crisis, where the usual coping mechanisms are no longer
effective in the face of the overwhelming disaster (Boyd, 2018). Crisis
intervention is a secondary prevention intervention that the trained C/PHN
can employ to minimize the stress and psychological consequences of the
disaster (American Psychiatric Association [APA], 2016). Crisis intervention
is a short-term intervention with the goal of alleviating negative effects of a
disrupting, unexpected event such as disasters (APA, 2018) The phases of
crisis interventions are closely related to the nursing process: assessment,
planning of interventions, implementing the interventions, and evaluation
and future planning (Townsend & Morgan, 2018).

Tertiary Prevention
People who have experienced or witnessed a disaster and have been unable
to adequately cope with its consequences can develop acute stress disorder
or the long-term effects of PTSD. According to the fifth edition of
Diagnostic and Statistical Manual of Mental Disorders (DSM-5), text
revision (American Psychiatric Association, 2019), both acute stress disorder
and PTSD can occur after any traumatic event to which a person responds
with intense fear, helplessness, or horror.
Posttraumatic stress disorder (PTSD), an anxiety disorder, occurs in
some people after a traumatic event such as a disaster, crime, combat, or an
accident (APA, 2019). It is important for the C/PHN to be aware of the
symptoms of stress-related disorders and make referrals to the available
mental health professionals.

1466
TERRORISM AND WARS
At the start of the 21st century, the world is a global community. This is
particularly evident with the increased international communication and
travel practices. The incidence and sophistication of terrorist threats and acts
around the world highlights our vulnerability, and dramatically emphasizes
the need for increased preparedness within our communities for any type of
biological, chemical, or nuclear terror attacks. One only needs to turn on the
news to learn of terror attacks throughout the world.

1467
History of Terrorism
The U.S. Federal Bureau of Investigation (FBI, n.d.b.) categorizes terrorism
in one of two ways—as international terrorism or domestic terrorism.
International terrorism is committed by persons or groups allied with foreign
terrorist groups, whereas domestic terrorism is executed by individuals
linked to U.S.-based extremist groups (FBI, n.d.b.). Generally, terrorism
involves dangerous acts, violating laws, that are injurious to human life; it
also involves a type of coercion or intimidation that affects government (U.S.
Department of Justice, 2020). Terrorism and terrorist acts are not new. The
term terrorism can be traced to 1798, and the use of terrorist tactics precedes
this date. See Box 17-7 for a brief history of terrorist acts.

BOX 17-7 A Brief History of Terrorist

Acts
A highly organized religious sect called the Sicarii attacked crowds
of people with knives during holiday celebrations in Palestine at
about the time of Christ.
During the French and Indian War of 1763, British forces gave
smallpox-contaminated blankets to Native Americans.
During World War I, the German bioweapons program developed
anthrax, glanders, cholera, and wheat fungus as weapons targeting
cavalry animals.
In World War II, the Japanese tested biologic weapons on Chinese
prisoners, and the Nazis conducted medical experiments with Jews
forced into concentration camps (Spendlove & Simonsen, 2018).

1468
Bioterrorism and Nuclear and Chemical Warfare
Three major countries operated offensive bioweapons programs in recent
years: the United Kingdom until 1957, the United States until 1969, and the
former Soviet Union until 1990. Iraq started its bioweapons program in 1985
and continued to develop weapons until 2003. Bioweapons include mustard
gas, sarin, and VX gas, as well as anthrax (Spendlove & Simonsen, 2018).
Terrorists typically use biologic or chemical agents, explosives, or incendiary
devices to deliver the agents to their targets.
A terrorist attack using nuclear weapons or destruction of a nuclear plant
would cause multiple and prolonged deaths with extensive damage and
negative effects for decades.
Chemical warfare involves the use of chemicals such as explosives,
nerve agents, blister agents, choking agents, and incapacitating or riot-control
agents to cause confusion, debilitation, death, and destruction (Organisation
for the Prohibition of Chemical Weapons [OPCW], 2020).

Terrorists in the Middle East, willing to murder others and knowing they
will be committing suicide, strap bombs to their bodies and detonate the
explosives in or near targets.
Others plant explosives at large outdoor events like the 2013 Boston
Marathon (CNN, 2020) or crash vehicles loaded with explosives into
crowds of people or into a building.
The aircraft used on September 11, 2001, were incendiary devices
because they were carrying thousands of tons of jet fuel.

The success of the mission depended on the surprise of the attack, severe
damage to recognizable buildings, and the deaths of many people.
Biologic warfare involves using biologic agents to cause multiple
illnesses and deaths. Biologic agents are graded as category A, B, or C by the
CDC (see Table 17-3 for some examples). There are over 180 pathogens that
have been used or studied as possible biologic warfare (Smith, Hayoun, &
Gossman, 2019). Typical biologic agents are anthrax, botulinum, bubonic
plague, Ebola, and smallpox. These agents could be used to contaminate
food, water, or air. Deliberate food and water contamination remains the
easiest way to distribute biologic agents for the purpose of terrorism
(American Academy of Pediatrics, 2020).

1469
TABLE 17-3 Categories of Biologic Agents

CDC, Centers for Disease Control and Prevention.

Reprinted from the CDC Emerging Preparedness and Response. (2018). Bioterrorism agents/disease.
Retrieved from https://emergency.cdc.gov/agent/agentlist-category.asp#b

The United States is very concerned about the possibility of biologic

warfare or bioterrorism. The anthrax infections and deaths that occurred after
September 11, 2001, added to these concerns. It was years before the
government investigation led to a scientist at Fort Detrick as the cause of this
terroristic act. Although charges were never filed because of the individual's
suicide, the FBI believes that he was solely responsible for this act of
domestic terrorism (FBI, n.d.a.). Regardless of the source of terrorism, the
outcomes are the same: fear, death, and destruction.

1470
Trauma From the Warfront
Nurses, or men and women acting in that capacity, have provided comfort
and care to soldiers long before Florence Nightingale arrived in the Crimea
during the mid-19th century (see Chapter 3). Nurses continued to help during
the Civil War and both World Wars, and their services continue today
(Brooks & Hallett, 2015; Judd & Sitzman, 2014). Military nurses serving in
the wars provide care to those with serious injuries and multiple casualties
many times for extended periods of time. They may experience disturbing
long-term psychological effects when returning home including feeling
disconnected from civilian hospitals and feeling isolated upon their return
(Finnegan, Lauder, & McKenna, 2016). It is important that appropriate
psychological and physical interventions are provided for these servicemen
and women (Krueger et al., 2015).
The trauma of warfare can be devastating and may continue to affect
individuals for many years after completion of active service (Box 17-8;
Magruder et al., 2016). Traumatic brain injury (TBI) is considered to be the
“signature injury of the Iraq and Afghanistan wars” (Department of Defense,
2017, p. 3).

BOX 17-8 STORIES FROM THE

FIELD
Missed Opportunities for an Older Veteran
Tom Walton is a 70-year-old retired salesperson
from an equipment manufacturer and a
Vietnam veteran who served in the U.S. Navy.
He has been a widower for the past year, and
his adult children live out of state. Tom's health
has declined dramatically since his wife's death,
and he is struggling to control his hypertension
and diabetes. Tom is noncompliant with
medications and diet restrictions, and he seems
to have more frequent outbursts of anger than
usual.

1471
 Sadly, Tom's case is not one that is rare or unusual. I work at a
Veteran's Administration (VA) clinic, and I often see cases like Tom's in
our clinic. Many veterans do not deal with the traumas they experienced
during warfare, and when support systems are weakened or they are no
longer busy with work and family, these long-repressed feelings begin
to reemerge. For Tom, his case could easily result in a deteriorating
health care spiral that will ultimately lead to multiple hospitalizations or
his demise. But, as a veteran, Tom may be a candidate for posttraumatic
stress disorder (PTSD) treatment, mental health care treatment
programs, or other proven treatment modalities offered by the VA.
Unfortunately, many of our nation's veterans fail to take advantage of
this resource, or even acknowledge that they may have this type of
problem. In this case, having a working knowledge of the resources
available to veterans in your community provides an opportunity for
you, as a public health nurse, to assist Tom in accessing services that
meet his health care needs and may prolong his life.

1. What might you consider in providing care to veterans?

2. What resources are available in your area for veterans?

—Bryan, VA Clinic Manager

Between 2000 and 2018, a staggering 383,947 Armed Service members

were diagnosed with TBI peaking between 2011 and 2012 (Defense and
Veterans Brain Injury Center, 2019).
The most common causes of TBI include blast, object hitting head, and
falls.
TBI is associated with higher depression, PTSD, and suicidal ideation
(Lindquist, Love, & Elbogen, 2017).
Caregivers of veterans with traumatic brain injury are four times more
likely to experience depression than the general population (Malec, Van
Houtven, Tanielian, Atizado, & Dorn, 2017).
Military personnel that have experienced a TBI are at a 4 times greater
risk than personnel without a history of TBI (Loignon, Ouellet, &
Belleville, 2020).
One study found combat experiences and severity of PTSD were factors
if the PTSD was chronic or not (Armenta et al., 2018).

C/PHNs should be aware of the needs of veterans, especially during

disasters, terrorist attacks, and other traumatic events that may bring these
past experiences to the forefront again. It is also important to ask patients if
they have military experience during the initial assessment. This information
may impact the planned interventions. C/PHNs should be aware of services

1472
available to veterans and treatments that are effective (Jain, McLean, Adler,
& Rosen, 2016).

1473
Factors Contributing to Terrorism
Political factors are the most common contributors to terrorism. Anti-
American sentiment runs high in many foreign countries, especially those
that perceive the United States as a threat to their military, economic, social,
or religious self-determination. Terrorist acts are committed against
American military installations abroad, in airports, in airplanes, at American
embassies, and even on American soil targeting civilian populations. The war
in Iraq in 2003 was based on information about suspected bioterrorism
weapons and reports that Iraq was harboring anti-Western terrorists; these
two pieces of information resulted in the toppling of the Saddam Hussein
political regime. However, hundreds of military lives were lost and many
thousands of civilians were killed, and no weapons of mass destruction were
found (History, 2020).
Within the United States, domestic terrorism involves extremist views of
a social, environmental, racial, political, or religious nature (FBI, n.d.b.). In
2019, a young man fatally shot 22 people at a Wal-Mart in El Paso, Texas.
The FBI considers it an act of terrorism (Dilanian, 2019). As of November
2019 there have been 372 mass shootings, almost as many days in a year
(Gun Violence Archive, 2020).

1474
Role of the Community/Public Health Nurse
C/PHNs need to be prepared for the possibility of terrorist activity. They
have a role in primary, secondary, and tertiary prevention.

Primary Prevention
C/PHNs are in ideal situations within communities to participate in
surveillance. They must look and listen within their communities for
antigroup sentiments, for example, antireligion, antigay, or antiethnic
feelings, and appropriately report any untoward activities accordingly.
Nurses should be alert to signs of possible terrorist activity and develop
the basic knowledge and skills to plan and respond to disasters including acts
of terrorism (Veenema, 2018). The National Prevention Framework,
produced by Homeland Security, provides guidelines to prevent or stop an
act of terrorism. Pre-and postdisaster preparation to include critical, specific
nursing competencies and evidence-based practices are strongly
recommended by many hospitals and health care organizations for all health
care personnel. The American Nurses Association (ANA, 2016) has
developed policies, resources, and educational opportunities for nurses on
disaster preparedness acknowledging the importance of nurse preparation
before a critical event (Fig. 17-7). The American Nurses Credentialing
Center (ANCC) offers a certification in National Healthcare Disaster at
https://www.nursingworld.org/our-certifications/national-healthcare-disaster/.

FIGURE 17-7 Disaster drills help prepare communities and health

care workers.

Secondary and Tertiary Prevention

1475
Although prevention of terrorist incidents is primarily the responsibility of
the Department of Defense, the DHS, and public health and law enforcement
agencies, C/PHNs must be ready to handle the secondary and tertiary effects
of such attacks. Knowledge of the lethal and incapacitating chemical,
biological, and radiological weapons potentially used by terrorists is
important. Many of the communicable disease organisms that could be used
by terrorists were discussed in Chapter 8.
Realizing that terrorist attacks may result in large numbers of casualties,
the C/PHN must be prepared to act quickly, safely, and competently, and to
access information and effectively use resources rapidly. Formulating,
updating, and following a disaster plan is one of the most effective
community-based strategies to minimize injury and mortality from terrorism.
However, a recent systematic review discovered that nurses were unprepared
to manage a disaster and did not feel confident (Labraque et al., 2018).
Most C/PHNs will not be on the front line of uncovering or immediately
responding to terrorist activities; however, their skills will be needed with
groups, families, or individuals who experience a terrorist-related event.
C/PHNs provide direct care to survivors, help survivors with coping, or
provide guidance to those who want to do something to help. After
experiencing a traumatic event such as a terrorist attack, people do not know
how to cope; they are warned to expect more attacks and to be vigilant. The
terror we are fighting is often our own. This is a new experience for most
people, and assistance from the C/PHN can help them cope effectively.
C/PHNs can make major differences in grassroots efforts to bring about
change, on a day-to-day basis. For example, providing information on foods
to avoid and nonmedical treatment options such as support groups, hypnosis,
and biofeedback are a few examples of how nurses can assist with coping
mechanisms. Community resilience is the goal of the interventions.

1476
Current and Future Opportunities
There are many ways in which nurses, especially nursing students, can
prepare both personally and professionally for emergency events in their own
communities. Various governmental and educational programs are available
as free online training covering a broad range of topics. Many schools of
nursing have now begun to formalize their emergency preparedness plans in
coordination with local hospitals, public health departments, or faith
institutions. Nursing students should discuss their role, in the event of a local
emergency with their faculty.
Knowing the nurse's role in an emergency will provide peace of mind
regarding response capabilities and expectations. FEMA offers four
particular courses within the incident command system (ICS 100, ICS 200,
IS 700, & IS 800B), which are recommended for all health care personnel.
Finally, make sure you have a family plan to reconnect with and care for
children, spouses, and parents.
Increasingly, communities are conducting emergency preparedness
exercises (e.g., mass-casualty exercises and tabletop exercises) in response to
the need to prepare local resources to coordinate emergency response efforts
for maximum effectiveness (CDC, 2016). Nursing students may be asked to
participate in one of these exercises as a “victim.” Take the opportunity
anticipating the knowledge you gain from this experience will enhance your
understanding of the process, and you may be able to help identify gaps in
services or areas in need of improvement. You may be asked to have
moulage applied to simulate injuries, and you will likely be given a brief
description of your trauma (Box 17-9). Your assigned health problem may be
emotional and not physical, allowing you to utilize your understanding of
behavioral health issues and crisis intervention. Just as immunizations help
fight against infections, participating in an emergency preparedness drill can
build your tolerance and competency for responding appropriately in a real
event.

BOX 17-9 What is Moulage?

Pronounced mü-läzh, the term moulage comes from the French word
mouler, which means “to mold.” In emergency preparedness training,
moulage refers to the art of applying mock injuries for use in mass-
casualty exercises. These injuries can be very simple or more complex,
depending on available resources and the skills of the person applying
the moulage. The use of moulage typically provides a more realistic
experience for personnel participating in mass-casualty exercises.

1477
 Of the many online resources for information regarding equipment
needed and how-to advice, one such Web site is Community Emergency
Response Team (CERT) LAFD CERT, Moulage (https://www.cert-
la.com/cert-training-education/moulage/).

Many organizations, both private and governmental, are seeking

volunteers. If you wish to become more active in emergency preparedness
volunteer efforts, the American Red Cross and your local Medical Reserve
Corps are two options. You can continue your relationship with these
organizations after you receive your nursing license, and your role with them
will likely evolve.
As a registered nurse, you may add your name to the registry along with
your specialty training and contact information. Registration does not
obligate you to any service; you agree only to be contacted if the need arises.
The APHN Public Health Preparedness Committee (2014) position
paper, The Role of the Public Health Nurse in Disaster, Preparedness,
Response, and Recovery, presented specific core competencies for public
health nurses related to emergency preparedness, which can serve as a guide
for students and practicing public health nurses. Please see for
more information.
An adapted version of the 2014 position paper's table of disaster phases
and corresponding nursing process actions is found in Box 17-10. Many
options are available to you as both a student and a practicing nurse. What is
important is that you are prepared. Assuring that you understand the role you
may assume in the event of a local disaster or emergency situation is critical
to your own welfare as well as to your community. You decide your level of
participation, and be aware that resources are available for you to become as
prepared as possible.

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 BOX 17-10 C/PHN USE OF THE
NURSING PROCESS

Disaster Preparedness, Response, and Recovery

Source: Association of Public Health Nurses, Public Health Preparedness Committee. (2014).

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Objectives for Healthy People 2030
Healthy People 2030 includes four developmental objectives related to
preparedness in disasters. These include (1) parents/guardians are aware of
their children's school emergency and evacuation plans, (2) actions to take
should a contagious disease occur, (3) adults who are aware of the
transportation needs should a disaster occur and they need to evacuate, and
(4) household emergency plan that includes vulnerable individuals
(USDHHS, 2020a).
Healthy People 2010 focused upon increasing quality and years of
healthy life and to eliminating health disparities. Formulated in the years
before January 2000, many disasters, both natural and manmade, were
unknown in recent times. The United States had not yet faced the national
failures in the response to the hurricanes Katrina and Rita. We would also
learn 18 months after the publication of Healthy People 2010 that our nation
was not immune from acts of terrorism. The objectives of Healthy People
2020 directly addressed issues of emergency preparedness and response
under the new topic of Preparedness. Additional topics also included
preparedness activities, such as the objectives for public health infrastructure.
The goal of the new topics and objectives were to improve our “ability to
prevent, prepare for, respond to, and recover from a major health incident”
(USDHHS, 2016, p. 1). Those specific objectives provide the support needed
to enhance public health surveillance activities, laboratories, training,
development of professional competencies, and performance standards for
public health organizations. Healthy People 2030 builds on this with personal
plans, awareness of the needs of vulnerable groups, and inclusion of
contagions as part of a disaster response (USDHHS, 2020a). See Box 17-11.

BOX 17-11 HEALTHY PEOPLE 2030

Objectives Related to Disaster Preparedness

1480
Reprinted from U.S. Department of Health & Human Services (USDHHS). (2020). Healthy People
2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

1481
SUMMARY
A disaster is any event that causes a level of destruction that exceeds the
abilities of the affected community to respond without assistance.
Disasters may be caused by natural or manmade/technologic events and
may be classified as multiple-casualty incidents or mass-casualty
incidents.
Persons impacted by disasters include those directly impacted (those
injured or killed) and indirectly impacted (the loved ones of directly
impacted). Displaced persons are those who are forced to flee their
homes because of the disaster, and refugees are those who are forced to
leave their homelands.
Host factors that contribute to the likelihood of experiencing a disaster
include age, general health, mobility, psychological factors, and
socioeconomic factors. The disaster agent is the fire, flood, bomb, or
other cause. Environmental factors are those that could potentially
contribute to or mitigate a disaster.
In developing strategies to address the problem of disasters, it is helpful
for the C/PHN to consider each of the four phases of disaster
management: mitigation, preparedness, response, and recovery.
Communities experience six phases in a disaster: predisaster, impact,
heroic, honeymoon, disillusionment, and reconstruction.
An effective disaster plan establishes a clear chain of authority, develops
lines of communication, and delineates routes and modes of transport.
Plans for mobilizing, warning, and evacuating people are critical. At the
disaster site, police, firefighters, nurses, and other relief workers
develop a coordinated response to rescue survivors from further injury,
triage survivors by seriousness of injury, and treat survivors on-site and
in local hospitals. Care and transport of the dead bodies and support for
the loved ones of the injured, dead, or missing need to be included in the
disaster plan as well.
Survivors of disasters suffer physical injuries and psychological trauma
that can affect them for life. The importance of prevention, early crisis
intervention, and ongoing treatment for those in need is evident. The
C/PHN plays a key role in assessing individuals for symptoms of
psychological trauma and intervening to prevent long-term
consequences. Self-care, including stress education for all relief workers
after a disaster, helps to lower anxiety and put the situation into
perspective.
Terrorism is the unlawful use of force or violence against persons or
property to intimidate or coerce a government or civilian population in

1482
the furtherance of political or social objectives. Terrorism may be
nuclear, biologic, or chemical and may involve the use of nerve agents
and explosive devices. The C/PHN should be alert to signs of possible
terrorist activity and prepared to address the secondary or tertiary effects
of such attacks.
Many opportunities are available for both student nurses and
experienced C/PHNs to become involved in emergency preparedness
and response efforts. Agencies such as the American Red Cross and the
Medical Reserve Corps are options available to students and at a higher
level of involvement, once licensed. With the development of Healthy
People 2030, ongoing efforts to help communities prepare for disasters
and emergencies will require more nurses willing and able to respond to
a call for action.

1483
ACTIVE LEARNING EXERCISES
1. Think about your own community and its residents. What
environmental factors might be significant? What interventions could
be included in a disaster plan to reduce these risk factors?
2. Think about your state and any sites that might be a target of
terrorism. What is your state doing to address these issues? Examine
Web sites (e.g., U.S. Homeland Security, Centers for Disease Control
and Prevention, World Health Organization) for strategic planning or
documents that could be helpful in assessing terror threats and
preventing attacks. If an attack does occur, how would health
professionals be most effective?
3. Using “Build a Diverse and Skilled Workforce” (1 of the 10 essential
public health services; see Box 2-2), check with your local hospital
about their disaster plan. Do they collaborate with your local health
department and other agencies in designing and executing this plan?
How often are “disaster drills” or simulations occurring? Who is
involved in these? How many types of emergency situations do they
cover?
4. As a C/PHN practicing in an area with a high concentration of
veterans, what knowledge and skills do you think are necessary to
provide culturally competent, evidence-based care to this segment of
the population?
5. Interview a C/PHN who was involved in a disaster. Some topics to
discuss might be—what kind of disaster preparedness did they have?
Was their family affected by the disaster and what was it like to leave
their family to help others?

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!

1484
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[C/PHN] competencies. Retrieved from http://www.quadcouncilphn.org/wp-
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Reifels, L., Bassilios, B., Spittal, M. J., King, K., Fletcher, J., & Pirkis, J.
(2015). Patterns and predictors of primary mental health service use
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Smith, M. E., Hayoun, M. A., & Gossman, W. (2019). Biologic warfare
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1494
CHAPTER 18
Violence and Abuse
“The right things to do are those that keep our violence in abeyance; the wrong things are those
that bring it to the fore.”

—Robert J. Sawyer (1960), Calculating God

KEY TERMS
Abusive head trauma (AHT) Child abuse Child maltreatment Cycle of
violence Elder abuse Emotional abuse Implicit bias Infanticide Intimate
partner violence (IPV) Mandated reporters Neglect
Neonaticide Physical abuse Protective factors Risk factors Sexual abuse
Spectrum of prevention

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Explain the dynamics of a crisis.
2. Discuss community risk factors and protective factors related to
violence.
3. Describe the history of violence against women and children in the
United States.
4. Identify the different types of violence against children and specific
abusive situations.
5. Define intimate partner violence and explain the stages of the circle of
violence.
6. Define elder abuse and discuss related vulnerability factors and
prevention measures.
7. Identify other types of violence affecting individuals and communities.
8. Explain how each of the levels of prevention applies to addressing
violence in individuals, families, and the community.
9. Use the nursing process to outline nursing actions in response to acts of
violence.

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INTRODUCTION
Violence is a global public health issue. It is not limited by
sociodemographic or geographic factors—anyone may experience violence
or abuse at any point in one's lifetime. For example, a toddler who is
intentionally burned with a hot curling iron, a teenager who is being
emotionally and physically bullied at school, an adult strangled by an
intimate partner, an older adult restrained and left sitting for hours in urine
and feces, a person stabbed during a physical assault, or a nurse violently
attacked when triaging a patient. George Floyd, an African American man,
died while being arrested by a white police officer. The deputy restrained Mr.
Floyd by kneeling on his neck, causing neck compression and
cardiopulmonary arrest; his death was ruled a homicide. The police officer
has been charged with murder. This event set off largely peaceful
demonstrations around the country highlighting Black Lives Matter, but in
some cities, small groups looted, set fires, and committed other acts of
violence (Eligon, Furber, & Roberston, 2020; Kazan, 2020). Acts of violence
may occur once or multiple times and involve a single perpetrator or a group
of perpetrators who may or may not be known to the person experiencing
violence. Violence and abuse may occur in any setting—at home, in public,
at work, or at school.
The World Health Organization (WHO, 2020a, para. 2) defines violence
as “the intentional use of physical force or power, threatened or actual,
against oneself, another person, or a group or community, that either results
in or has a high likelihood of resulting in injury, death, psychological harm,
maldevelopment, or deprivation.” Violence is a complex phenomenon
affecting individuals, groups, communities, and all of society. There is no
single factor or group of factors to explain why a specific person is at risk of
using violence or why one community experiences a higher incidence of
violent acts than another community. Likewise, there is no single factor that
specifically identifies an individual's or a community's vulnerability for
experiencing violence.
In 1985, Surgeon General C. Everett Koop placed the concept of
violence as a public health issue into the consciousness of the health care
community and onto the national agenda. In 1992, the Centers for Disease
Control and Prevention (CDC) formalized its role in addressing violence
through the National Center for Injury Control and Prevention
(https://www.cdc.gov/injury/index.html). Today, the CDC (2018c, para. 1)
continues to address the public health issue of violence across the life cycle,
stating: “Violence is a serious public health problem. From infants to the

1496
elderly, it affects people in all stages of life. Many more survive violence and
suffer physical, mental, and or emotional health problems throughout the rest
of their lives.” These statements are supported by research findings,
including the Adverse Childhood Experiences Study; the National Intimate
Partner and Sexual Violence Survey; and other violence-related research. The
effects of violence are seen across the biopsychosocial and spiritual
continuums of health (CDC, 2020a). Community/public health nurses are
uniquely positioned to respond to populations affected by violence through
trauma-informed practices and violence prevention activities.
Acts of violence can result in a crisis, which is a stressful and disruptive
event (or series of events) that comes with or without warning and disturbs
the equilibrium of the individual, family, or community. A crisis can occur
when usual problem-solving methods fail. Everyone experiences periods of
crisis. If you reflect on your own history, you can probably identify one or
more periods of crisis that you, your family, or your community experienced.
People respond to crises differently, including crises resulting from acts
of violence. Some people approach a crisis as a challenge, an event to be
reckoned with, whereas others may feel overwhelmed and defeated or give
up. Some survivors of violence seek help and many experience minimal
disruptions, perhaps perceiving themselves as even stronger than before the
crisis occurred. Some people may have difficulty coping with the crisis,
experience severe psychological distress, or express their feelings of rage,
frustration, or powerlessness to others.
Regardless of their responses, people who are in crisis after experiencing
violence need support, and C/PHNs have a unique opportunity and
responsibility to provide support in a variety of situations and settings. For
example, a nurse assisting a 15-year-old transgender patient at a free
community-based sexually transmitted infection clinic refers to the patient
using the patient's preferred name and pronoun and asks the patient when she
last ate and whether she has a safe place to sleep that night. By being
respectful and genuinely showing interest in the teen's well-being, the nurse
gains the teen's trust and learns she is homeless and a victim of sex
trafficking. Or, a pregnant woman reschedules her appointment at a
community clinic twice and then arrives at the appointment with multiple
faded bruises on her face and arms. The clinic nurse uses sensitivity and
caring while screening for intimate partner violence (IPV) and identifying
opportunities for appropriate referrals to community-based agencies.
Primary and secondary prevention measures used by C/PHNs that help
prevent crises include teaching families communication skills and coping
strategies and connecting them with community resources. In addition to
assessment and education, C/PHNs provide tertiary responses with direct
assistance during times of crisis or in the immediate aftermath of
experiencing violence. This chapter discusses the knowledge and skills

1497
C/PHNs use in their practice of crisis prevention and intervention aimed at
promoting improved health for individuals and communities who may be
affected by acts of violence.
Throughout this chapter, difficult topics are discussed. Some topics may
bring up unwanted memories, feelings of anger related to abuse, assault,
implicit bias, compassion fatigue, or/and secondary trauma. Nurses are at
risk for compassion fatigue when placed in stressful situations and the
continuous offering of themselves (Peters, 2018). Compassion fatigue and
secondary traumatic stress were closely related (Mottaghi, Poursheikhali, &
Shameli, 2020). Health care providers that work with the abusers need to be
aware of the higher level of vicarious trauma, the higher the risk for
posttraumatic stress disorder (PTSD) (Newman, Eason, & Kinghorn, 2019).
Implicit bias, or the “unconsciously held set of associations (or stereotypes)
about a social group,” can affect the quality of care C/PHNs provide their
patients (Berghoef, 2019, para. 1). The Joint Commission's material on
implicit bias can be found at
https://www.jointcommission.org/-/media/deprecated-unorganized/imported-
assets/tjc/system-folders/jointcommission-
online/quick_safety_issue_23_apr_2016pdf.pdf?
db=web&hash=A5852411BCA02D1A918284EBAA775988.

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DYNAMICS AND
CHARACTERISTICS OF A CRISIS
Each person is a dynamic system living within a given environment under
the circumstances unique to that person alone. A person's conscious and
subconscious behavior is gauged to maintain a balance within oneself and in
one's relations with others. When an internal or external force disrupts one's
balance and alters functioning, a loss of equilibrium occurs. The individual
then attempts to restore equilibrium by using whatever resources are
available to the individual, attempting to cope with the situation.
Coping refers to those actions and ways of thinking that assist people in
dealing with and surviving difficult situations. If a person cannot readily
cope with a stressful event, the person experiences a crisis (Boyd, 2018).
Crises are usually resolved, either positively or negatively, within 4 to 8
weeks (Kanel, 2019). However, there may be long-term biopsychosocial
health consequences related to experiences of violence and other adverse
events. People's strong need to regain homeostasis and the intense nature of
crises contribute to making the crisis itself a temporary condition.
Crises may be precipitated by a specific identifiable event that becomes
too much for the problem-solving skills of those involved, may result from
sudden unexpected or traumatic events, or may be related a person's
perception of an event. Box 18-1 summarizes three common types of crisis.

BOX 18-1 Major Differences Between

Types of Crisis
Developmental Crisis
Part of normal growth and development that can upset normalcy
Precipitated by a life transition point
Gradual onset
Response to development demands and society's expectations

Situational Crisis
Unexpected period of upset in normalcy
Event jeopardizes an individual's physical and psychological well-
being

1499
 Event may be internal (e.g., cancer) or external (being laid off)

Traumatic Crisis
Unexpected, overwhelming and unusual event (e.g., disasters or
acts of violence)
Occurs to an individual or a group
Events cause death, destruction, injury, or sacrifice
Source: Wheeler and Boyd (2018).

When a community crisis occurs on a large scale or is so unexpected that

it also involves people who are hundreds of miles away, it can affect distant
friends and relatives. Examples include an arson fire at an apartment building
killing 12 people and injuring dozens of others; the terrorist attack in San
Bernardino in 2015; the mass shooting at the Route 91 Harvest Music
Festival in Las Vegas on October 1, 2017; and the terrorist attacks in New
York City on September 11th, which indirectly affected people hundreds of
miles away.

A traumatic crisis is a stressful, unexpected, disruptive event arising

from external circumstances that occur suddenly to a person, group,
aggregate, or community. Typically, the external event requires
behavioral changes and coping mechanisms beyond the abilities of the
people involved (Wheeler & Boyd, 2018).
The crisis occurs to people because of where they are in time and space.
These events, which involve loss or the threat of loss, represent life
hazards to those affected.
C/PHNs may assist in a variety of traumatic crises, including those
arising from acts of violence. In each situation, people feel
overwhelmed and need help to cope. Skilled intervention can make the
difference between a healthy and an unhealthy response to the crisis.

1500
OVERVIEW OF VIOLENCE
ACROSS THE LIFE CYCLE
Violence affects people across the life cycle, from birth through death. It may
involve chronic or long-term acts of abuse, neglect, or maltreatment or
situational acts of violence that may be unexpected and sudden. C/PHNs
encounter many different types of violence, including child abuse and
neglect, youth violence, gang violence, bullying, IPV, dating violence, sexual
violence, and elder abuse and maltreatment. Multiple types of violence can
occur within a single household, community, or neighborhood, affecting
people at different stages in life.
As mentioned in the introduction, there is no single factor that can
explain a specific act of violence. However, decades of research reveal that
different types of violence are interconnected. For example:

People who experience one form of violence are likely to experience

other forms of violence.
People who use violence in one context are likely to use violence in
another context.
Different types of violence share common short-and long-term
biopsychosocial health effects that may contribute to chronic health
conditions such as cancer, cardiovascular disease, lung disease, and
diabetes.
Different types of violence have shared risk factors and protective
factors (CDC, 2016).

Violence is a complex phenomenon. Understanding the neurobiological

effects, potential subsequent health effects, and overlapping causes of
violence can help community health nurses to enhance protective factors and
reduce risk factors and can help inform violence intervention and prevention
activities.

1501
Neurobiology of Trauma
Over the past few decades, neuroscience research has clarified the
neurobiological response to trauma. This body of research has provided
professionals responding to acts of violence a better understanding of human
behavior and how people respond to trauma, contributed to trauma-informed
practices, and enhanced the capacity of multidisciplinary responders to serve
victims of violence. This knowledge is critical because many victims have
been disregarded, not believed, dismissed, or revictimized through victim-
blaming practices because well-intended professionals misunderstood what
was normal human behavior after experiencing traumatic experiences.
An expanded definition of trauma includes all the events and experiences
that are subjectively traumatic to an individual, which are different from
person to person. Just as the brain is complex, so are a person's potential
reactions and behaviors in response to an experience. This complexity is
further compounded by many potential extraneous factors, such as substance
use, past trauma, underlying pathologies, and established neural patterns.
Although there are common responses, there are no absolute responses for all
people; this is a fundamental concept behind trauma-informed care. Trauma-
informed practices are improving how nurses interview victims, anticipate
the support they need for coping with the physiological and psychological
impact of traumatic experiences, and link them with community agencies
(Wilson, Lonsway, & Archambault, 2016).

1502
Protective Factors and Risk Factors
Many factors contribute to increasing or decreasing the occurrence of
violence. Risk factors are factors known to increase the likelihood of
experiencing violence. Protective factors are factors known to reduce the
likelihood of experiencing violence or increase one's resilience when
violence is experienced. Individual lived experiences and a person's own
characteristics may also be risk factors or protective factors. For example,
growing up in a high crime area and witnessing violence is a risk factor,
whereas having communication and problem-solving skills that allow one to
address conflict without using violence is a protective factor. The CDC
(2020c) recognized the following protective factors and risk factors related to
youth violence.
Protective factors:

Community protective factors include coordinated resources and

services among community agencies; access to mental health and
substance abuse services; and community support and connectedness.
Relationship protective factors include family support and
connectedness; caring relationships between youth and adults;
association with prosocial peers; and a commitment to or connection
with one's school.
Individual protective factors include skills that support solving
problems nonviolently.

Risk factors:

Societal risk factors include cultural norms supporting aggression

toward others; depiction of violence in the media; societal income
inequity; poor health, educational, economic, and social policies or
laws; and harmful norms related to the concepts of masculinity and
femininity.
Community risk factors include neighborhood poverty; a high number
of locations selling or providing alcohol; community violence;
diminished economic opportunities and high unemployment rates; and
poor neighborhood support and cohesion among residents.
Relationship risk factors include social isolation and lack of social
support; a poor parent–child relationship; family conflict; economic
stress; associating with delinquent peers; and gang involvement.
Individual risk factors include low educational achievement; lack of
nonviolent problem-solving skills; poor behavioral control or
impulsivity; history of violent victimization; witnessing violence;
psychological and mental health problems; and substance use.

1503
 Community windshield surveys and other community-based learning
opportunities often reveal community-level risk factors and protective
factors. For example, the level of safety described by residents can greatly
vary from one neighborhood to the next. There are neighborhoods in all
cities where residents describe feeling unsafe and witnessing crimes. Such
neighborhoods or communities are often referred to as high poverty or high
crime areas. In these communities, residents experience an overwhelming
number of community risk factors compared with protective factors. The
CDC (2016) publication Connecting the Dots reveals the following:

In neighborhoods where residents do not support or trust each other,

residents are more likely to experience child maltreatment, IPV, and
youth violence.
People who are socially isolated and do not have supportive
relationships with family, friends, or neighbors are at greater risk for
using violence, including acts of child maltreatment, IPV, and elder
abuse.
A lack of economic and employment opportunities is associated with an
increased risk for using violence, including acts of child maltreatment,
IPV, self-directed violence, sexual violence, and youth violence.
Communities in which societal norms support aggressive or coercive
behaviors have an increased risk for violent acts such as physical assault
of children, IPV, sexual violence, youth violence, and elder
maltreatment.
Witnessing community violence increases one's vulnerability for being
bullied and the risk of using sexual violence against others.

To counteract community risk factors, residents need support to enhance

their protective factors. For example, communities having coordinated
resources and services among the different community agencies experience
greater protective factors. Access to mental health and substance abuse
services increases protective factors. Receiving community support and
having connections within the community and with the family, prosocial
peers, and school can also increase community protective factors and
decrease individual vulnerability. What are some of the protective factors in
your community?

1504
HISTORY OF VIOLENCE AGAINST
WOMEN AND CHILDREN
Violence against women and children is not new. For centuries, children
were considered the property of their parents and most countries had animal
welfare laws long before child welfare laws were adopted. The first
documented case of child abuse occurred in 1874, involving Mary Ellen
Wilson. However, due to the lack of child abuse laws of the period, her case
was filed under the Animal Welfare Agency. This 9-year-old was so badly
beaten and neglected by her foster mother that the public was shocked during
the trial in the New York Supreme Court. This case changed public opinion
on society's role in the protection of children and resulted in the forming of
the Society for Prevention of Cruelty to Children in New York, the first
organization of its kind (Smithfield, 2016). In the early 1900s, leaders
concerned with child welfare issues promoted the development of
international agencies focused on factors affecting the health of children. In
1924, the League of Nations adopted the Declaration of the Rights of the
Child, which later informed the United Nation's Declaration of the Rights of
the Child (1959) and the Convention on the Rights of the Child (1989). This
committee meets three times yearly to address global concerns related to
children's rights, including violence against children (Office of the United
Nations High Commissioner for Human Rights, 2020).
Historically, women were also treated as property and often experienced
gender-based violence resulting in biopsychosocial injuries. Recent global
prevalence figures indicate that 35% of women worldwide have experienced
IPV or nonpartner sexual violence in their lifetime (WHO, 2017). In 2010,
the United Nation's Entity for Gender Equality and the Empowerment of
Women was established and prioritized the prevention of and response to
violence against women. The first global and regional estimates of violence
against women were published in 2013, resulting in clinical and policy
guidelines that have been widely disseminated, and 35 countries have
participated in programs to build community capacity (WHO, 2016).

1505
Public Laws and Protection in the United States
In the 1960s, the Children's Bureau began to focus on child abuse and
supported the development of a mandatory child abuse reporting law that
could be used as a model for state laws. The law required health
professionals and childcare workers to report suspected child abuse to
appropriate officials. In 1974, the Child Abuse Prevention and Treatment Act
(CAPTA) was passed, becoming Public Law 93-247 (PL 93-247). This law
served to reinforce the earlier mandatory reporting law model and was aimed
at solving the growing problem of child abuse in the country. PL 93-247 has
been amended several times since 1974. The CAPTA Reform Act of 1978
preceded the Family Violence Prevention and Services Act of 1984. Later, all
three acts were consolidated into the Child Abuse Prevention, Adoption, and
Family Services Act of 1988 (PL 100-294), and most recently, the Act (PL
108-36) was amended and reauthorized as the Keeping Children and
Families Safe Act of 2003 (Child Welfare Information Gateway, 2019a). The
Administration on Aging supports similar programs including the National
Center on Elder Abuse (n.d.b) that works to educate and assist families,
seniors, health care, and legal providers regarding elder abuse.

1506
Myths and Truths About Violence and Abuse
Many myths about violence and abuse need to be dispelled. Strongly held
myths by members of society, including C/PHNs and other health care
providers, may interfere with their ability to help people in crisis get the help
they need. Table 18-1 displays some common myths and truths about
violence and abuse.

TABLE 18-1 Common Myths and Truths About Abuse in

Families

Source: Arizona Law (n.d.); Paisner (2018).

1507
VIOLENCE AGAINST CHILDREN
Child abuse is defined by the federal CAPTA (42 USCA, 5106g) as
“any recent act or failure to act on the part of a parent or caretaker
which results in death, serious physical or emotional harm, sexual abuse
or exploitation; or an act or failure to act which presents an imminent
risk of serious harm” (Child Welfare Information Gateway, 2019b, para.
1).
Child maltreatment is defined as abuse and neglect toward a child
under age 18 including “physical and/or emotional ill-treatment, sexual
abuse, neglect, negligence and commercial or other exploitation, which
results in actual or potential harm to the child's health, survival,
development or dignity in the context of a relationship of responsibility,
trust or power” (WHO, 2020c, para. 1).

Identifying and gathering worldwide data about child abuse is difficult

because many cases are not investigated, death reports may not be classified
as a result of abuse or homicide, and definitions of maltreatment may vary.
Despite, this, the following global statistics reveal a concerning reality:

A total of 25% of adults reported being physically abused during

childhood, over 36% reported emotional abuse, and 16.3% reported
neglect.
Health effects of maltreatment include long-term physical and mental
health impairments.
Child maltreatment results in adverse social and occupational
community outcomes (WHO, 2020c).

The National Child Abuse and Neglect Data System reported that 3.5
million referrals were investigated or had alternative responses by Child
Protective Service departments in 2017 and 1,720 child fatalities due to
abuse and neglect. Infants had the highest victimization rate at 25.3 per
1,000. Neglect (74.9%) continued as the category of highest occurrence
followed by physical abuse (18.3%). Either one or both parents were
responsible for almost 92% of all child maltreatment (Children's Bureau,
2019). Polyvictimization, experiencing two different types of maltreatment in
a single report or different types of maltreatment across several reports, was
reported in 14% of the cases of child maltreatment (Children's Bureau,
2019).
Nationally, measures have been taken to improve data gathering and
information about violence toward children, as well as outcomes for these

1508
children. One of the largest investigations ever conducted to assess
associations between childhood maltreatment and adult health and well-being
is the Adverse Childhood Experiences (ACE) Study. The seminal 1998 study
conducted by Felitti et al. (1998) has led to new research on the long-term
consequences of maltreatment in children. Further information can be found
on
https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/abo
ut.html.

1509
Neglect
Neglect occurs when the physical, emotional, medical, or educational
resources necessary for healthy growth and development are withheld or
unavailable. Neglect is obvious to an observer if a very young child is
playing unattended outside, is not dressed appropriately for the weather, or
has an unkempt appearance (Box 18-2). However, neglect is not always so
obvious (Psychology Today, 2019):

BOX 18-2 Signs and Symptoms of Neglect

and Emotional Abuse
Signs and Symptoms of Neglect Neglect may be
suspected if one or more of the following conditions
exist:
Lacks adequate medical (including immunizations), vision, or dental
care.
Often sleepy or hungry.
Consistently dirty, demonstrates poor personal hygiene, or is
inadequately dressed for weather conditions.
There is evidence of poor or inadequate supervision for the child's age.
The conditions in the home are unsafe or unsanitary.
Malnourished, failure to thrive, poor weight gain.
Substance abuse.

Parents may refuse to buy eyeglasses for a child who needs them or to
access dental care for severely decayed teeth (medical neglect).
An 8-year-old may get to school only 3 days a week, possibly without
breakfast and no lunch money or packed lunch (educational neglect).
A family with three children may live in a sparsely furnished apartment
with very little food available and only intermittent heat and multiple
people coming and going in the residence, while the children may
appear at school unwashed and without coats in winter weather (general
neglect).
Emotional neglect may be seen when demands placed on a child are
excessive or inappropriate for his or her development, or the caretaker
berates or verbally humiliates a child frequently and without reason.

Signs and Symptoms of Emotional Abuse

Emotional abuse may be suspected if the child

1510
displays the following behavioral indicators:
Shows extremes in behavior such as extremely demanding, passive, or
compliant
Inappropriately takes on parent role or infantile in behavior
Physical or emotional development is delayed
Depression or suicidal thoughts
Unable to develop emotional bonds with others
Source: Child Welfare (2019); Stanford Medicine (2019).
C/PHNs need to assess if the neglect is due to lack of knowledge of child
development, lack of finances, or lack of health care. Providing services such
as WIC, education developed for health literacy level, and assisting parents
to enroll children in a Child Health Insurance Program may provide the
needed support for many families with children. Because of the invisibility of
neglect, its prevalence is hard to estimate. Often, cases of neglect are brought
to the attention of the proper authority only during the investigation of other
forms of abuse or family issues.

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Physical Abuse
Physical abuse is intentional harm to a child by another person that results in
pain, physical injury, or death (Fig. 18-1). The abuse may include striking,
biting, poking, burning, shaking, or throwing the child (Box 18-3). Some
parents cannot control the degree of physical punishment they give their
child (Child Welfare Information Gateway, 2019b). In one case, a mother
repeatedly physically assaulted her young daughter while getting her into the
car. The mother's behavior was recorded by the store's parking lot
surveillance camera. Intervention and follow-up occurred, including
incarceration and counseling for the mother and foster home placement for
the child. If physical punishment is administered in anger, while the parent is
under the influence of mind-altering substances or out of a sense of
frustration, the punishment may cross over to become battering of the child.
A parent or caregiver may claim the injuries are the fault of the child, such as
a 2-week-old rolling off the bed and hitting their head. C/PHNs need to be
knowledgeable about the stages of developmental growth to understand if a
child is capable of performing such a skill.

FIGURE 18-1 Young girl with signs of physical abuse.

BOX 18-3 Signs and Symptoms of

Physical Abuse
Does the Child or Caregiver…Important
Questions to Ask Yourself
Frequent emergency department visits

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 Caregiver blames child for injuries
Delay in seeking health/medical care or changes provider
frequently
Explanation changes, doesn't match the child's developmental
ability, or contradicts injuries

Signs of Physical Abuse The most common

systems affected are the integumentary,
skeletal, and central nervous system.
Health care providers including C/PHNs must consider language
and cultural differences when interviewing a child and parent.
Interviewing with a translator is important with these cases.

Has unexplained injuries, explanation does not match the injury, or

injuries are inconsistent with medical diagnosis. such as
Injuries may include bruises, bite marks, abrasions, lacerations,
head injuries, internal injuries, and fractures
Bruising from defensive injuries to forearms
Burns from cigarettes, ropes, or immersion into hot water or hot
grid
Traumatic alopecia with possible hematoma area and is tender to
touch
Trauma to ear
Appears depressed, withdrawn, anxious, or aggressive
Appears scared of parent and does not want to go home

Behavioral Indicators of Physical Abuse These

behaviors are often exhibited by physically
abused children:
Attempts to hide injuries; child wears excessive layers of clothing,
especially in hot weather.
Frequently absent from school or misses physical education
classes.
Fearful, clingy, anxious, withdrawn, hypervigilant, or aggressive.
The child is apprehensive when other children cry.
Wary of physical contact with adults.
Exhibits drastic behavioral changes in and out of parental/caretaker
presence.
The child suffers from seizures or vomiting.

1513
 Exhibits depression, self-mutilation, suicide attempts, substance
abuse, or sleeping and eating disorders.
Fearful of going home.

Other indicators of physical abuse may include the following:

A statement by the child that the injury was caused by abuse

(chronically abused children may deny abuse).
Knowledge that the child's injury is unusual for the child's specific
age group (e.g., any fracture in an infant).
Knowledge of the child's history of previous or recurrent injuries.
Parent or caregiver shows little concern for the child or seeking or
fails to seek medical care for the child's injury.
Source: Child Welfare (2019); Stanford Medicine (2019).

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Sexual Abuse
Sexual abuse of children includes acts of sexual assault or sexual
exploitation of a minor and may consist of a single incident or many
acts over a long period. Sexual abuse is considered “The employment,
use, persuasion, inducement, enticement, or coercion of any child to
engage in, or assist any other person to engage in, any sexually explicit
conduct or simulation of such conduct for the purpose of producing a
visual depiction of such conduct” (Legal Information Institute, n.d.,
para. 1).
Rape, molestation, prostitution, and human trafficking of minors are
included in the definition.

In a behavioral analysis of perpetrators, grooming is often used to gain

access to child. Depending on the age of the child either the child or the
parents are groomed. If these tactics do not work, the perpetrator may
become more aggressive (Bryce, Robinson, & Petherick, 2019).

Incest is sexual abuse among family members who are related by blood
(e.g., parents, grandparents, older sibling). Intrafamilial sexual abuse
refers to sexual activity involving family members who are not related
by blood (e.g., stepparents, partner of a parent).

Child sexual abuse accounts for 6.7% of all maltreatments against

children (Children's Bureau, 2019). The child may blame himself or herself
for tempting or provoking the abuser. Indicators of sexual abuse are
expressed in various ways, and attention should be given to a history of
sexual abuse, sexual behavior indicators, behavioral indicators in younger
children and behavioral indicators of sexual abuse in older children and
adolescents, and physical symptoms of sexual abuse (Box 18-4). As
mandated reporters, C/PHNs should be aware that sexual abuse of a child
may surface through a broad range of physical, behavioral, and social
symptoms. Some of these indicators, taken separately, may not be
symptomatic of sexual abuse and should be examined in the context of other
behaviors or situational factors (Box 18-5).

BOX 18-4 Indicators of Sexual Abuse

Physical Signs
Sexually transmitted infections.

1515
 Trauma to the perineal area including bleeding, bruising, or pain.
Blood may be seen on sheets or undergarments.
Discharge from genitals or anus.
Pain during bowel movements or urination.

Behavioral Signs
Enuresis and/or fecal soiling in bed when behavior has been
outgrown
Inappropriate sexual behavior for age
Not wanting to be left alone with certain people or fearful to leave
parent or caregiver
Refuses to remove clothing
Has money, gifts, or toys unexpectedly
Self-injury/suicide attempts
Sexually promiscuity in teens
Substance use

Emotional Signs
Nightmares or fear of being left alone at night
Extreme worry or fear
Sexually explicit language or explicit knowledge about sexual
topics beyond age of child
Mood changes

Nursing students are encouraged to research the topic to learn more.

Source: RAINN (2019); Stop It Now! (2019).

BOX 18-5 PERSPECTIVES

A School Nurse's Viewpoint on Child Sexual

Abuse—Emily's Secret I am a school nurse at the
only K-3 school in a small, rural town. Every child
in those grades attends this school (1,000
children). I have a busy school nurse office, but I

1516
try to be observant to subtle cues. Sadly,
sometimes it's so busy that I worry I miss things.
Emily, a third grader, came to my office with
stomachaches and vague complaints off and on for
several months. Thinking back, this usually
happened within the last hour of school. After
school, she walked to her aunt's house and stayed
there for a few hours until her mother picked her
up after work. Emily was a petite child, well
behaved, very quiet, and usually only responded
with a few words when I asked about her
ailments.
One day Emily came in with another stomachache and wanted to lie down.
When I asked what was going on, she shrugged her shoulders and didn't
really respond. When the final bell rang, I told her if she didn't feel well
enough to walk home, I could call her aunt. The aunt was the emergency
contact, so the procedure was to start there. She just seemed to really be
avoiding going to her aunt's house and wanted me to call her mom at work.
I had a feeling something was wrong. I remembered from a recent
workshop on child sexual abuse that sometimes the hardest thing was to
break through the guilt and shame for the child to open up. I told Emily she
“could tell me anything, and I wouldn't think she was bad.” She began
talking. Well, it was more like “verbal vomiting”—the words just came
spilling out. She told me her uncle had been “touching her” and she “didn't
want to go back there.” She began crying, and I told her we would call her
mom and someone from CPS to help her. I also sent someone to get her
teacher, a person she felt comfortable and safe with, who stayed with Emily
through the lengthy process.
Later, as I thought about the constant stream of children coming into my
office every day, I wondered how many of those kids with subtle, vague
complaints might have something going on that is as serious as Emily's
secret. Now I try to be even more vigilant and open to their concerns—
whatever they may be.

Zoey, school nurse

1517
 Care for children who have been sexually abused varies, as the duration
of the molestation, the age, and symptoms of the child will influence their
care measures. Long-term consequences of CSA have been well
documented. A recent study found adolescent males who had been sexually
abused were at a greater risk of substance use; while, girls were more likely
to be suicidal and depressed (Gray & Rarick, 2018). Parents may also need
counseling and support following the investigation and proceedings
involving their child's victimization.

1518
Commercial Sexual Exploitation
Commercial sexual exploitation of children (CSEC) is “a range of
crimes and activities involving the sexual abuse or exploitation of a
child for the financial benefit of any person or in exchange for anything
of value (including monetary and nonmonetary benefits) given or
received by any persons” (Office of Juvenile Justice and Delinquency
Prevention [OJJDP], n.d. para.1).
Nonmonetary items may include food, shelter, clothing, drugs,
transportation, or protection from another person. Forms of CSEC
include child sex trafficking (prostitution of children), child sex tourism,
production of child pornography, and transmission of live video of a
child engaged in sexual acts in exchange for something of value.
Internet-based marriage brokering, early age marriages, and performing
in sex-related venues are also forms of CSEC (OJJDP, n.d.).

1519
Emotional or Psychological Abuse
Emotional abuse of children involves psychological mistreatment or
neglect, which impairs a child's self-worth and sense of security and
being loved. Types of psychological abuse includes rejection, scorn,
terrorism, isolation, exploitation, lack of emotional response, exposure
to domestic violence, and verbal threats or void of loving comments
(Gluck, 2019).
Emotional abuse alone is rarely reported because it is another hidden
form of abuse. However, mandated reporters are required by law to
report suspected cases of severe emotional neglect or abuse or
deprivation in addition to suspected neglect and physical or sexual
abuse (Child Welfare Information Gateway, 2019b).

1520
Specific Abusive Situations
The previous information addressed the major types of child abuse in
families, yet other patterns of abuse against children need to be discussed.
Abusive head trauma, Munchausen syndrome by proxy, and parental filicide
are uncommon, but by the time the symptoms are recognized, it is often too
late. Diagnoses may be made at autopsy or after resulting comorbidities have
developed. Technology-facilitated crimes against children are an increasingly
common fear of parents. Technology-related crimes against children are
occurring more often as children and adolescents have increased time, and
access to computers such as when both parents (or a single parent) are at
work and children are alone or with sitters. Another area of growing concern
for parents and communities is school violence (Bryce et al., 2019).

Abusive Head Trauma

Abusive head trauma (AHT), sometimes called shaken baby
syndrome, is the intentional action of violently shaking a child, usually
2 years of age or younger; children 1 year of age and younger are at the
greatest risk. AHT is the leading cause of death related to physical child
abuse (CDC, 2020b).
Injuries related to shaking, blunt impact, or a combination of both may
result in neurological injury to the child (Vinchon, 2017). These types of
injury very seldom occur through play, as in minor falls or as a result of
being tossed into the air.
Symptoms of AHT may include bilateral retinal hemorrhage, subdural
or subarachnoid hematomas, the absence of other external signs of
abuse, breathing difficulties, seizures, dilated pupils, lethargy, and
unconsciousness (American Association of Neurological Surgeons
[AANS], 2020).

The National Center on Shaken Baby Syndrome at

https://www.dontshake.org offers resources for parents and health care
providers. Explanations for injuries are often vague such as stating the baby
was “fine” and then suddenly went into respiratory arrest or began having
seizures—both common symptoms of AHT—or they may attribute the
injuries to falling out the crib or off of the sofa. In the United States,
approximately 1,300 children annually are injured or die due to AHT
(National Center on Shaken Baby Syndrome [NCSBS], 2020). Children who
survive AHT may require lifelong care, with approximately 80% having
learning, physical, visual, and speech disabilities; hearing impairment;
cerebral palsy; cognitive impairment; and seizures (NCSBS, 2020).
Considering perpetrators of AHT are most often a parent or caregiver,

1521
C/PHNs can play a critical role in caregiver education and preventative
mental health referrals.

Munchausen Syndrome by Proxy

Munchausen syndrome by proxy is a mental illness in which the parent or
caregiver attempts to bring attention to self by injuring or inducing illness in
their child. About 85% to 98% of perpetrators are the child's biological
mother, who often forms close bonds with health care providers. Many of
these abusers have a mental health illness or a history of abuse as a child
(Boyd, 2018). The following scenarios can be typical of these cases:

Serious medical problems or conditions that have no medical basis.

The child experiences “seizures” or “respiratory arrest” only when the
parent or caretaker is present.
While the child is hospitalized, the parent or caretaker shuts off
intravenous tubes or life-support equipment, causing the child distress,
and then turns everything back on and summons help.
The parent or caretaker induces illness by introducing a mild irritant or
poison into the child's body.
The child may have many school absences and a complicated medical
history according to the child's mother or father who may seem
overinvolved or demanding.

Child Murder by Mother or Father

Filicide is a rare yet concerning type of child death, defined as child
murder by a parent. Infanticide is defined as the murder of a child
during the first year of life, whereas neonaticide is the murder of an
infant within the first 24 hours of life. Maternal filicide is known to
occur in all areas of the world. The United States has the highest rate of
child murders than any developed country with the parent being the
main perpetrator (Resnick, 2016).
Risks factors include the maternal age of 19 or younger, lack of prenatal
care, less than a high school diploma poverty, social isolation,
depression, or suicidality (Debowska, Boduszek, & Dhingra, 2015;
Resnick, 2016).
In 2017, homicide was among the top 15 leading causes of death for
children from birth to 18 years. In the United States, the child homicide
rate is 7.2 deaths per 100,000 infants under the age of 5. Infants are
most likely to be killed by their mother during the first week of life, but
thereafter are more likely to be killed by a male perpetrator (Kochanek,
Murphy, Xu, & Arias, 2019).

1522
 Measures for prevention and support to mothers include parenting
classes, emotional support, providing emergency numbers for support, as
well as treating maternal substance abuse and postpartum depression. Safe
haven laws are in place to prevent infant abandonment, leading to potential
injury or death, by denoting safe places to relinquish a newborn infant, such
as a fire or police station (Child Welfare Information Gateway, 2017). See
Box 18-6 for two examples of neonaticide.

BOX 18-6 STORIES FROM THE

FIELD
Neonaticide
Case 1
After realizing she was pregnant, a 17-year-old honor student chose not
to tell her parents, friends, or boyfriend. She kept her pregnancy a secret
by wearing loose clothing and complaining about “gaining weight” over
the holidays. While home alone after school, she went into labor sitting
on the toilet. She lay down on the bathroom floor and labored for
several hours, experiencing significant blood loss. After delivering the
newborn, she used scissors to cut the umbilical cord. She was afraid
because she had not stopped bleeding. Blood was everywhere. She got
the keys to the car and drove herself to a local hospital. On the way, she
became dizzy and felt like she passed out. Coming to, she continued to
drive to the hospital. Upon admission, she was treated to control the
hemorrhaging. Later, an emergency department nurse asked about the
newborn and the girl said, “I left it, It's on the bathroom floor.” Police
located the dead newborn as described and no formal charges were
filed.

Case 2
A 16-year-old girl became pregnant after having sex with her boyfriend.
She thought she was having stomach or GI problems and her mother
took her to the pediatrician's office. The doctor prescribed medication
for her symptoms, but she still felt ill. Concerned about being pregnant,
she took an over-the-counter pregnancy test. The result was negative. A
friend encouraged her to go to a walk-in clinic for a pregnancy test, the
test result was inconclusive, and she began spotting. She continued to
take her birth control pills, thinking she was not pregnant. A few months
later during a family barbeque, she felt like she is getting the “stomach
flu” and told her mother she was going to bed. Before going to bed, she

1523
 tried to have a bowel movement, but nothing happened. She thought she
might be in labor and lay down on the floor of the bathroom. To her
shock and horror, she gave birth, quickly stabbed the newborn, and hid
it in a trash bin where the body was later discovered. A court
psychiatrist examined the girl, and she described “watching the birth
and the stabbing from a vantage point above her body.” Her defense was
limited to testimony about whether she noticed the newborn's fingers
moving and trying to counter the pathologist's findings that the lungs
had inflated. Her attorney was not allowed to bring up issues
surrounding her pregnancy and neonaticidal syndrome. The jury found
her guilty of murder, and she was sentenced to prison for a life term.

1. What are your thoughts about the two cases?

2. Have you seen examples like these in your local or regional
newspapers or online news sources?
3. What preventive programs and policies might be helpful in
addressing this issue? Are there EBP population-focused
interventions available to address this problem?
Source: Malmquist (2013).

Internet Crimes Against Children

Internet and technology-facilitated crimes are insidious because they come
right into the home (Fig. 18-2). Children may unintentionally or intentionally
access a chat room or Web site developed or used by perpetrators. The
perpetrator establishes contact, usually pretending to be a teenager or young
man who has similar interests and is affectionate and understanding about the
youth's “problems.” After gaining the child's trust, the perpetrator may
engage in sexually explicit dialogue with the minor. Many minors find the
attention from this stranger inviting or exciting and make plans to meet the
person. When this happens, the minor falls victim to this individual, putting
the child/adolescent at great risk for harm. Technology-enabled child abuse
has led to the U.S. Attorney General authorizing a national awareness and
justice program focusing solely on technology-facilitated sexual exploitation
and abuse against children, named Project Safe Childhood (USDOJ, 2020)
and the creation of Internet Crimes Against Children (ICAC) task forces.
ICAC task forces assist federal, state, and local law enforcement agencies by
enhancing their ability to investigate technology-facilitated crimes against
children.

1524
 FIGURE 18-2 Children and youth can be victims of Internet
crimes.

C/PHNs can assist families to prevent technology-facilitated crimes by

the following:

Encouraging parents to openly discuss with their children the dangers of

online friendships that seek face-to-face meetings; downloading photos
or uploading/posting photos to people they do not know; giving
identifiable information about themselves (name, phone number, school
they attend, home address); responding to e-mails, instant messages, or
tweets that are suggestive or harassing; and, being aware of phishing
and other forms of attempted identity theft.
Establishing parent–child contracts for devices that can connect to web-
based applications (e.g., computer, tablet, smartphone, gaming systems).
Blocking or only permitting specific phone numbers for smartphone and
web-based application calls and regularly checking for deleted phone
calls and texts.
Monitoring the amount of time that a child uses Internet accessible
devices and reviewing user history for applications used and Web sites
visited.
Placing computer and gaming consoles in a high-traffic area in the
home, affording easy observation of usage by the child.
Using available parental controls or blocking software on all devices
with Internet connectivity.
Installing a firewall, antivirus, and malware/spyware programs that
increase privacy and restrict usage.
Discouraging downloading of apps, games, and other media that might
contain hidden applications or programs that enable remote access by
unauthorized users.
Having access to their child's e-mail and other web-based accounts;
randomly checking e-mails and text messages. Being aware of
safeguards in place at their child's school, public areas the child

1525
 frequents, and homes of their friends (Federal Bureau of Investigation
[FBI], n.d.a).

There is a constant stream of news around cyberbullying and

cyberstalking incidents. Cyberstalking is “the use of electronic
communication to harass or threaten someone with physical harm”
(Merriam-Webster, 2020, para. 1). Nationwide nearly 15% of all students
have been cyberbullied including with slightly <20% of high school girls and
10% of boys being victims (CDC, 2018d). Effects of cyberbullying can be
more far-reaching than those of traditional schoolyard bullying. Nurses can
ensure families are prepared to identify and appropriately respond to
cyberbullying, sexting, and threats from online predators.

The destructive effects of cyberbullying were highlighted in the news

when a 12-year girl committed suicide after receiving texts saying she
was fat, had no friends, and that she should kill herself (Gillis, 2019).
In 2019, a 21-year-old young man jumped from a parking structure at
the university he was to graduate from in 20 hours. His girlfriend is
being charged with manslaughter for sending him tens of thousands text
messages telling him to kill himself (Boston25News, 2019).
These stories put a face on a recent study that found that being a victim
of cyberbullying increases the risk of suicidality (Chang, Xing, Ho, &
Yip, 2019).

Parents can contact the Cyber Tip Line at (800) 843-5678 or access their
Web site (www.cybertipline.com) if they suspect an online predator has
contacted their child (National Center for Missing and Exploited Children,
2020).

Child Abduction
Although child abduction by a stranger happens infrequently, it remains one
of the greatest fears for parents. Intense media coverage gives the impression
that such crimes occur frequently, and this causes great stress among parents
and community members. Child abduction by family members or intimate
partners is more common. Nationally, the Amber Alert program and the
Child Abduction Response Teams (CART) were established to provide an
informed, prompt, and professional response to child abduction. Amber
Alerts are sent through the radio, television, road signs, and the Wireless
Emergency Alerts (WEA) system to millions of cell phone users. The goal of
the Amber Alert is to provide instant collaboration and partnership in the
community to assist in the search and safe recovery of the child and, as of
May 2020, a total of 988 children have been rescued (USDOJ, n.d.a).

1526
 Prevention of child abduction is difficult, and at times, parents who think
they have taught their children well may have a false sense of security.
C/PHNs can help parents improve their child's safety by promoting close
supervision of young children and practicing behaviors to promote
anonymity, such as:

Placing the child in the seat of a shopping cart and holding their hand
when in malls or stores
Keeping a young child in sight always when playing outside
Sharing parental supervision with another parent when children play
Do not put the child's name or initials on clothing or backpacks
Teaching the child a “password,” which only the parents and child
know, to use when a different person is picking them up from an activity
Teaching children to recognize when they feel unsafe and to go get help
Involving children in making safety plans and having them practice
getting help
Helping children understand when it is okay to give personal
information (e.g., at school, medical office, lost in a store) and when it
is not (e.g., a stranger they don't know)
Practicing “think first” and “keep walking” activities with their children
(Kidpower, 2020)

Older children and teens who go outside the home unattended by parents
should be encouraged to use the following behaviors that promote safety:
staying with groups of other children or teens, having a cell phone, leaving
an itinerary with the parents, and not changing their plans without contacting
parents.

Crimes Against Children by Babysitters

Abuse by caretakers is a fear of parents who work and leave their children
with others. The C/PHN can help parents assess childcare settings by
providing them descriptors for finding good childcare providers. Parents who
use neighbors as babysitters should get references and drop by the home or
childcare setting at various times during the day. They should assess their
infants and follow up on any bruises, rashes, burns, conditions, or behaviors
they observe that are not normal for their child. Parents need to listen to their
children and ask about their day and activities. Parents must not ignore signs,
such as a child's fear of going to the babysitter or reports of spankings, being
shouted at, or other inappropriate treatment.
Childcare centers and many home childcare programs are licensed by the
state. When parent complaints have been filed with licensing agencies, those
programs are monitored more closely and the state is mandated to make
changes or close the facility if necessary. Parents need to know that their

1527
child is safe and cared for when they leave them to pursue their employment
or educational activities. A daycare owner was recently arrested for hiding 26
toddlers behind a fake wall in the basement of her home; there were only 2
care providers, and the business was only licensed for 6 children. When
notified by law enforcement to pick up their children, parents were shocked
to find their children in filthy conditions in the basement. One mother told
reporters when she dropped off her child the home was clean; she had no
idea the owner cared for children in the basement. The owner had previously
lost her license to operate daycare centers in California for similar violations
(Jensen, 2019).

School Violence
Violence in the school setting is an area of growing concern for parents and
communities. Violence in schools may range from bullying, slapping, or
punching to weapon use (CDC, 2019h). Random shootings and hostage
situations in schools over the past decades have fueled fears about the safety
of students and promoted research on how to prevent this type of community
violence affecting children.

Since the 1999 shootings at Columbine High School in Colorado where

13 students died, a total of 11 mass shootings in which 4 or more
persons were killed has resulted in 127 student deaths through 2014
(Keneally, 2019).
Seventeen more died during a mass shooting at the high school in
Parkland, Florida in 2018 (Andone, 2020).
The largest mass shooting event occurred in 2017 at an outdoor concert
in Las Vegas where 58 people were killed and almost 1,000 injured
(Romo, 2019).

Shootings have occurred at large universities, small community colleges,

high schools, and elementary schools. They have taken place throughout the
country and no segment of the population is immune. The mass shootings
have occurred in public and private schools, including the killing of 5 young
girls at an Amish one room schoolhouse in Pennsylvania (Walters, 2016).

Bullying is defined as “any unwanted aggressive behavior(s) by another

youth or group of youths, who are not siblings or current dating
partners, involving an observed or perceived power imbalance and is
repeated multiple times or is highly likely to be repeated” (CDC, 2019b,
p. 1).
Bullying can be verbal, social, or physical or happen through electronic
communication (cyberbullying).
Children at high risk of being bullied may have delayed puberty, be
gender nonconforming, have a unique physical appearance, or be

1528
 socially rejected and isolated (Simms, Bushman, & Pederson, 2020).
Gay, lesbian, bisexual, and transgender youth were more likely than
were heterosexual youth to report high levels of bullying (CDC, 2017a).
Bullying is interconnected with other types of youth violence including
gang violence (Simms, Bushman, & Pederson, 2020).

The Youth Risk Behavior Survey collects information about health and
prevention issues among adolescents. Included in the survey are questions
about violence risks such as fighting, use of illegal drugs, carrying a weapon,
and being threatened or injured with a weapon on school property. In 2017,
of a national representative sample of youth in grades 9 to 12 found the
following:

8.5% of 9th through 12th graders reported being in a physical fight on

school property in the 12 months before the survey.
19% reported being bullied on school property and 14.9% reported
being bullied electronically.
6.7% missed 1 or more days of school because they felt unsafe at school
or on their way to and from school.
3.8% reported carrying a weapon on school property in the 30 days
before the survey.
6.0% reported being threatened or injured with a weapon on school
property (Kann et al., 2018).

School violence has immediate and long-term effects on students

demonstrated by an increase in depression, anxiety, psychological problems,
and fear (CDC, 2016). See Chapter 20 for more on school-age children and
adolescents.
The U.S. Department of Education, the Department of Health and
Human Services, and the Department of Justice have collaborated to provide
funding, programs, and training that improve school safety through the Safe
Schools Healthy Students Framework. Five elements identified for attention
in building safe school climates are as follows:

Create a safe and violence free school environment.

Prevent behavioral health problems.
Promote emotional, mental, and behavioral health.
Provide early childhood psychosocial and emotional development
programs.
Connect communities, schools, and families (National Center for
Healthy Safe Children, 2019).

Similar to community risk factors, those factors surrounding youth

violence can be categorized as individual risks, relationship risks, and

1529
community or societal risks. Individual risks for perpetrating youth violence
may include a history of violent victimization; a history of early aggressive
behaviors, attention deficit, hyperactivity, or learning disorders; an
association with delinquent peers; gang involvement; high emotional
distress; social rejection; family violence and conflict; or poor behavioral
control (CDC, 2020c). Low parental involvement, parental substance abuse
or criminality, poor supervision, low emotional attachment to the parent, and
harsh, lax, or inconsistent forms of discipline increase a child/adolescent's
risk for violence. Community and societal risk factors for youth violence are
associated with diminished economic opportunities, a high concentration of
poverty, transiency, and family disruption, with low levels of community
participation (CDC, 2020c).
Youth development programs address these risk factors in schools and
communities, as well as promoting activities to help students in meeting
individual needs. Mentoring programs are beneficial for at-risk teens when
the mentors are appropriately trained and supported. Social skills, conflict
resolution, and programs supporting student sports, arts, and extracurricular
interests decrease an individual's risk of being involved in violence. School
and societal strategies include surveillance, maintenance of facilities, and
consistent classroom management techniques, along with adequate student
supervision (USDHHS, n.d.). Parent involvement and education are
expanding through programs such as Healthy Start and parent-participation
preschools, Loving Solutions for elementary age students, and the Parent
Project for parents of difficult adolescents (The Parent Project, 2019).

1530
INTIMATE PARTNER VIOLENCE
Intimate partner violence (IPV) is the abuse or aggression that occurs
within close relationships that are either current or previous. There are four
types of IPV: physical violence, sexual violence, stalking, and psychological
aggression (CDC, 2019d).

1 in 4 women and 1 in 10 men have experienced physical and/or sexual

violence and/or stalking.
1 in 5 women and 1 in 7 men have been victims of severe physical
violence.
1 in 5 women and 1 in 12 men have experienced sexual violence.
16% of all homicides have been committed by an intimate partner.
10% of women and 2% or men have been stalked.
43 million women and 38 million men have experienced psychological
aggression (CDC, 2019f).

According to the WHO (2017), global prevalence figures for women

indicate the following:

IPV is a leading cause of morbidity and mortality in women worldwide,

as well as a public health and human rights issue 35% of women have
experienced either IPV or nonpartner sexual violence in their lifetime.
30% of women report being physically abused by an intimate partner at
some point in their lives.
38% of all women who were murdered were murdered by their intimate
partner.

While research related to IPV against members of the LGBTQ

community is limited (Rollè, Giardina, Caldarera, Gerino, & Brustia, 2018),
the most recent in-depth study conducted by the CDC (2010) found the
following:

A total of 26% of gay men and 37% of bisexual men experienced rape,
physical violence, and/or stalking by an intimate partner at some point
in their lifetime.
Individuals who self-identify as lesbian, gay, and bisexual have an equal
or higher prevalence of experiencing IPV, SV, and stalking as compared
to self-identified heterosexuals.
A total of 44% of lesbian women and 61% of bisexual women
experienced rape, physical violence, and/or stalking by an intimate
partner in their lifetime.

1531
 Approximately 1 in 8 lesbian women (13%) and nearly half of bisexual
women (46%) have been raped in their lifetime.
A total of 40% of gay men and nearly half of bisexual men (47%) have
experienced SV other than rape in their lifetime. The Human Rights
Campaign (2020, para. 1) found that approximately 47% of transgender
people are sexually assaulted “at some point in their lifetime.”

Researchers often describe domestic violence, a form of IPV, as

punching, grabbing, shoving, slapping, choking, kicking, biting, hitting with
a fist or some other object, being beaten, or being threatened with a knife or
gun by a spouse or cohabiting partner. The USDOJ (n.d.b, para. 2) defines
domestic violence as “a pattern of abusive behavior in any relationship that is
used by one partner to gain or maintain power and control over another
intimate partner”; it may be emotional, economic, physical, psychological, or
sexual in nature (Box 18-7).

BOX 18-7 PERSPECTIVES

Viewpoint of a Victim of Intimate Partner

Violence My family was always shouting at each
other. The hitting wasn't nearly as bad as all the
yelling. Now here I am in the same boat all over
again—the yelling, the hitting, but now I've got
this new baby to take care of. I'm just so tired.
When the nurse showed up today to check on me and the baby, I swore to
myself that I wouldn't tell her about last night. Then she looked at me and
asked if I felt safe and that triggered me…I said “NO!” before I realized my
mouth was even open. I told her how he punched me here in my side when I
was changing the baby's diaper. That nurse was so nice. She helped me look
at my options. Because I was holding the baby when he hit me, she said she
was required to make a report of child abuse.
That was just awful news and I started crying; but like she said, I could
have dropped my baby, or he could have missed me and hit her. I knew he'd
be furious when he found out and I really started to panic. Then she told me
about this place, a place downtown where I can stay with my baby. Then

1532
she helped me make arrangements. I'm so tired and scared, but I know now
that I have to keep my baby safe. I still don't know what made me tell that
nurse—I guess it was because she asked.

Angie

Because of the nature of IPV, the problems are difficult to study and
believed to be underreported. Much remains unknown about factors that
increase or decrease the likelihood that one person will use violence against
another person within an intimate relationship or in the course of seeking that
relationship. However, models have been developed to aid in the
understanding of the repetitive cycles often seen in intimate partner and
domestic violence.

1533
Cycle of Violence
The cycle of violence is a repetitive, cyclic pattern of abuse seen in domestic
violence situations (Box 18-8). Developed by Walker in 1979, the cycle is
still in use today. The cycle includes the tension-building phase, the
explosion (acute battering incident), and the honeymoon phase (SexInfo
Online, 2017; White Ribbon, 2019). For more information, refer to
https://sexinfo.soc.ucsb.edu/article/cycle-domestic-violence. The
psychological dynamics of these three phases help explain why the person
experiencing abuse feels guilty and ashamed of their partner's violence
toward them, and why they find it so difficult to leave, even when their lives
are in danger.

BOX 18-8 The Cycle of Violence

Tension-Building Phase
Considered the longest of the phases—up to several weeks.
Victim may feel they are “walking on eggshells.”
Abuser is edgy, negative mood, verbally abusive, and controlling.
Minor augments occur.
Victim attempts to appease partner in hopes calming situation and to
avoid the acute explosion phase.

Acute Explosion Phase

Shortest phase usually lasting 1 to 2 days.

1534
 Most violent phase as tension is released.
Violence may take many forms such as sexual, physical, verbal,
psychological, and emotional abuse.
Phase is triggered by an external event or the abuser's state of mind.
Abuser may blame victim for the abuse.
Victim may fight back, leave the person, or try and placate the abuser.

Honeymoon Phase
Abuser may feel embarrassed and become withdrawn or attempt to
justify actions.
Abuser expresses remorse and pledges it will not happen again.
Abuser promises to make behavioral changes such as work less, stop
drinking, and be more attentive to victim.
Abuser is excessively romantic to victim such as giving expensive gifts,
flowers, candy.
Victim forgives abuser.
Intimacy may increase.
Tension-building phase begins again.

Denial
Common in each phase.
Used to minimize seriousness of behavior.
Creates a false sense of reality in victim.
Family and friends use denial to lessen their responsibility.
Abuser uses denial to diminish the abuse is their fault, that it wasn't
abusive behavior, or the behavior was deserved.
Source: White Ribbon Australia (2019); SexInfo Online (2017). Figure reprinted with permission from
Hatfield, N. T., & Kincheloe, C. (2018). Introductory maternity and pediatric nursing (4th ed., Fig. 16-
3). Philadelphia, PA: Wolters Kluwer.

Often, as the cycle of violence continues, the frequency of the cycle

increases, with the tension-building phase and the acute battering incident
occurring more often and diminishment or elimination of the loving
reconciliation phase. Without intervention, this shorter, more violent cycle
becomes increasingly risk-filled for outcomes that may lead to injury or
maiming of a partner, incarceration, or death. Although early research
focused on women who experience violence by men, the same descriptive
cycle holds true regardless of the victim's or the aggressor's gender (Hinsliff-
Smith & McGarry, 2017).
The Domestic Abuse Intervention Project in Duluth, Minnesota,
developed a wheel of violence, identifying power and control at the center
and citing eight categories of perpetrator behaviors (Fig. 18-3). This model is

1535
a useful tool for visualizing the multidimensional nature of abuse in which
threats, coercion, isolation, blaming, intimidation, and use of children, male
privilege, and economics convene to control the victim.

FIGURE 18-3 Wheel of violence.

Reducing violence and its effects happens strategically at all three levels
of prevention.

Primary prevention efforts attempt to identify risk factors, reduce risks,

and increase social support to prevent violence from occurring.
Secondary prevention effort involves developing an immediate response
to violence that addresses the short-term consequences through
emergency response and medical care.
Tertiary prevention interventions work to address the long-term effect of
trauma through counseling and rehabilitation (CDC, 2019a).

1536
 Health care providers have a responsibility and opportunity to assess and
initiate a safety plan when these patients report experiencing violence. A
compendium of assessment tools for IPV can be found on the CDC Web site.

1537
Teen Dating Violence
Teen dating violence includes physical violence, sexual violence,
psychological aggression, and stalking between teenagers who are or have
been in a casual or serious dating relationship. It can be electronic or in
person and might occur between a current or former partner (CDC, 2019f).

The 2017 National Youth Risk Behavior Study revealed that 8% of high
school students reported physical dating violence and 7% reported
sexual dating violence in the past 12 months; furthermore, people who
experience dating violence in adolescence are at higher risk for dating
violence in college (CDC, 2018d).
Documented risk factors include poverty, limited education, substance
abuse, poor family functioning, child maltreatment, and childhood
exposure to IPV (Stewart, Vigod, & Riazantseva, 2016).
Research on male aggressors found that those who exhibited physical
and psychological dating aggression often had a history of suicide
attempts, reports of past physical aggression, and low relationship
satisfaction/instability and jealousy (Collibee & Furman, 2016).

Teens, regardless of gender, who experience dating violence in

adolescence, are more at risk for binge drinking, suicide attempts, doing
poorly in school, physical fighting, and sexual activity (CDC, 2018a).
Programs through schools and communities, such as Dating Matters, are part
of a national effort to address harmful beliefs about dating violence and
promote healthy and respectful dating relationships (CDC, 2018a). Dating
violence in adolescent relationships is a serious problem and because of its
prevalence, community health nurses should include screening for dating
violence in all encounters with teens.

1538
Stalking
Stalking may occur by either partner in a relationship, demonstrated as a
“pattern of repeated and unwanted attention, harassment, contact, or any
other course of conduct directed at a specific person that would cause a
reasonable person to feel fear” (USDOJ, n.d.d, para. 2). Approximately, 17%
of women report a lifetime prevalence of being a victim of stalking behavior,
and 5.9% of men (CDC, 2018b). Cyberstalking, a technology-based attack,
can also take many forms that can involve harassment, embarrassment, and
humiliation of the victim. Twenty-five percent of those stalked were
cyberstalked as well (Bureau of Justice Statistics [BJS], n.d.)

1539
Violence During Pregnancy
IPV during pregnancy increases the vulnerability of the woman and the fetus.
For example, when abusive partners target a woman's abdomen, not only are
they hurting the women but also potentially jeopardizing the pregnancy
(WHO, 2017).

Worldwide the exact number of women abused during pregnancy may

never be known. While a U.S. study of more than 36,500 pregnant
women found <2% experienced IPV, the consequences of IPV during
pregnancy are grave (CDC, 2017b).
Victims of physical abuse and sexual abuse during childhood increases
the risk of IPV during pregnancy. Violence during pregnancy increases
risk of depression, anxiety, and negative self-image (Hrelic, 2019).
Additionally, abuse during pregnancy results in higher rates of
intrauterine growth retardation and preterm labor that can lead to low
birth weight and neonatal risks (WHO, 2017). See Chapter 19 for more
on maternal–child health issues.
Pregnant teens are at a greater risk of IPV. One study found that among
teenage couples 64% had no IPV, while the remaining couples
experienced either the males, mutual, or females as the perpetrators of
the violence (Lewis et al., 2017).

The prenatal care visit is one of the few times when providers have an
important opportunity to identify women who are abused and therefore at
risk for homicide. It is imperative that nurses conduct an assessment for
danger and lethality so that the women can be aware of their level of risk and
take safety precautions as needed. A series of questions requiring a “yes” or
“no” response and inquiries about occurrences of abuse, escalation of abuse,
frequency, severity, weapons, drugs or alcohol use by the perpetrator, and
safety of other children should be incorporated into prenatal home visit
assessments. All health care providers, including C/PHNs, should have
regular training on IPV. According to The American College of Obstetricians
and Gynecologist (ACOG) (2019), when choosing a tool to assess for IPV,
avoid ones that include words such as “abuse,” “rape,” or “violence” as they
may cause the person to feel stigmatized. The ACOG offers sample of a tool
on their Web site. Numerous tools can also be located in Intimate Partner
Violence and Sexual Violence Victimization Assessment Instruments for Use
in Healthcare Settings
(https://www.cdc.gov/violenceprevention/pdf/ipv/ipvandsvscreening.pdf).
Annual screenings for IPV and providing interventions and referrals are part
of the Women's Preventive Services Guidelines (HRSA, 2019). These are
especially important for women who have not followed through with prenatal

1540
care, thereby allowing health care professionals to monitor the progress of
their pregnancies. C/PHNs are uniquely situated to screen for IPV during
pregnancy, particularly through Healthy Start and Nurse Family Partnership
Programs.

1541
Batterer Characteristics
Although a person of any gender may become a batterer, many studies and
statistics are specific to male aggressors. The following attributes represent
personal characteristics often seen in male aggressors of IPV:

Poor sense of self-worth

Low earnings or unemployed
Not doing well in academics or dropping out of school
Conduct disorders as a child
Heavy substance use
Mood disorders such as depression
Exhibiting angry and hostile behavior
Personality disorders (PD) such as borderline and antisocial PDs
Physically abusive to others
A loner with few or no friends
Emotional immaturity
“Belief in strict gender roles (e.g., male dominance and aggression in
relationships)
A desire for power and control in relationships”
Being a prior “victim of physical or psychological abuse—this is
consistently one of the strongest predictors of perpetration” (CDC,
2019i, para. 4)

Relationship, community, and societal factors may also affect a

perpetrator's risk for aggressive IPV behaviors.

Relationship factors include marital fights and tension, divorce and

separations, money problems, issues with jealousy/being possessive,
and problematic and difficult family relationships, as well as the male's
need for dominance and control in the relationship.
Community factors involve a lack of resources in the community,
failure or unwillingness of others to intervene or contact authorities
when they are aware of the abuse, and factors associated with poverty,
such as overcrowding and unemployment.
Societal factors include strict role stereotyping about male and female
roles in marriage (CDC, 2019i).

1542
Victim Characteristics
Increasing the victim's abilities to manage and improve their behaviors and
understanding of relationship patterns and abuse allows victims to change
their risk of being further victimized. Individual risk factors for IPV victims
include the following:

A prior history of IPV

Being female
Young age, especially if pregnant
From low-income household
Witnessing or experiencing violence as a child
Lower education level
Unemployment
Being a single parent with children or separated/divorced/previously
widowed
For men, having a different ethnicity from their partner
For women, having a greater education level than their partner
For women, being American Indian/Alaska Native or African American
For women, being disabled
Childhood sexual and/or physical violence
For women, having a verbally abusive, jealous, or possessive partner
Veterans and active-duty military
Some research indicates higher levels of IPV (especially emotional
victimization) in same-sex couples (Ludermir, Barreto de Araújo,
Valongueiro, Muniz, & Silva, 2017; Yakubovich et al., 2018)

Marked differences between partner's incomes, levels of education, or

job status place a victim more at risk for IPV. Community characteristics are
similar to those of the perpetrator, revealing that those communities with
fewer available resources, in areas of poverty, and having a lack of sanctions
against violent behaviors increase one's risk; there is some indication that
rates of IPV are higher in rural versus urban areas. Traditional gender roles,
such as a belief that men work and women are submissive and should stay
home, are societal risk factors associated with higher IPV risk (Zapata-
Calvente, Megías, Moya, & Schoebi, 2019).

1543
Effects of Violence on Children
A national study found that over 40% of children were physically assaulted
within the last year (Finkelhor, Turner, & Shattuck, 2013). The consequences
of exposure to violence and abuse hinder children's health and development
and can have a lifelong impact, negatively affecting health and increasing the
risks of further victimization and becoming a perpetrator of violence (Box
18-9; WHO, 2020c).

BOX 18-9 Evidence-Based Practice

Generational Transmission of Intimate Partner
Violence About one quarter of women will
experience intimate partner violence (IPV) or
domestic violence during their lifetime (CDC,
2019d), and research has linked child exposure
to IPV and later adult domestic violence
behavior (CDC, 2019i). Some posit that
children adopt behaviors that have been role
modeled by parents; however, most children
who have witnessed IPV do not abuse their
partners in adulthood.
Others found that abused children, compared to IPV-exposed
children, have a similar or even higher risk of becoming perpetrators of
IPV as adults. Research has also indicated that there may be an even
greater effect for those children who are both abused and who witness
interparental violence.
Eriksson and Mazerolle (2015) wanted to know if examining gender
role–specific behavior would give a clearer indication of generational
transmission. Their research revealed a possible gender-specific
connection to male IPV perpetration (e.g., male children who observe
their fathers beating their mothers are more likely to do the same as
adults).

Given this evidence and after examining other research on this

topic, what interventions might you consider when working with
families dealing with domestic violence?

1544
 Source: Center for Disease Control and Prevention (CDC) (2019d); Eriksson and Mazerolle
(2015).

Literature reviews consistently suggest that a positive correlation exists

between children's witnessing IPV and some aspects of impaired child
development. Young children are particularly vulnerable to the effects of
violence, as they lack the ability to understand the trauma and are likely to
exhibit somatic complaints (e.g., headaches, eating or sleep problems) and/or
behavior regression, such as clinging, whining, or becoming nonverbal
(National Child Traumatic Stress Network, n.d.). Meanwhile, school-age
children and adolescents are more likely to either act out with delinquent
behaviors or withdraw. Children in families with domestic violence are at
risk for depression, negative mental health effects, and consequences that last
far into their adult lives. These maladjustments may be behavioral
(aggression and conduct problems), emotional (withdrawal, anxiousness,
fearfulness), social, cognitive (learning disabilities), and/or physical.

Researchers have linked physical alterations in the child's brain (e.g.,

cerebral cortex, limbic system, corpus callosum, hypothalamus) with
PTSD following child exposure to domestic violence (Tsavoussis,
Stawicki, Stoicea, & Papadimos, 2014).
For some children, high cortisol and other hormonal responses may lead
to chronic levels of arousal, aggression, anxiety, depression, eating
disorders, and other problems (e.g., self-harm, general irritability). In
others, during adulthood, attempts to adjust to new stressors may lead to
down-regulation of receptors and the ability to only respond minimally
to stress hormones (Tsavoussis et al., 2014).

Providers who work with children need to listen in a sincere,

nonjudgmental manner and provide ongoing support when assisting the child
and family with resources, such as counseling, education, or community
violence prevention programs.

1545
ELDER ABUSE AND
MALTREATMENT OF OLDER
ADULTS
Elder abuse is the “intentional act, or failure to act, by a caregiver or another
person in a relationship involving an expectation of trust that causes or
creates a risk of harm to an older adult” (CDC, 2019c, para. 1). Examples
include physical, sexual or abusive sexual contact, emotional or
psychological abuse, neglect, financial or material exploitation, confinement,
passive neglect, and willful deprivation (CDC, 2019c; National Council on
Aging, n.d). As with other types of abuses against vulnerable populations,
the true incidence and prevalence of elder abuse is not known.

A total of 90% of adults over the age of 65 live in the community on

their own or with family (USDOJ, 2018b).
It is estimated that 1 in 10 older adults experience some type of abuse
(USDOJ, 2018a). Worldwide estimates are as high as 1 in 6 adults over
age 60 experience abuse (WHO, 2020b).
Approximately two thirds of elder abuse victims are women, often
about half of individuals have dementia (USDOJ, 2018a).
Risk factors include low social support, dementia, poor physical health,
and functional impairment (NCEA, n.d.b).
Perpetrators are often adult children or spouses, male, history of
substance disorders, or mental health issues (NCEA, n.d.b).
The most reported abuse includes neglect, followed by financial
exploitation and emotional abuse (USDOJ, 2018a).
Two thirds of staff employed in skilled or assisted nursing facilities
admitted to abusing residents within the past year (WHO, 2020b).

Forms of physical abuse include rough handling during caregiving,

pinching, hitting, and slapping. Emotional abuse, which can take many
forms, included being shouted at or threatened and having needed care
withheld. Older adults may also be sexually assaulted or sexually abused.
Some elders are neglected by those they depend on to meet their caregiving
needs. Elders with dementia and those requiring assistance for all activities
of daily living are more vulnerable to experiencing maltreatment due to
caregiver stress or burnout, factors known to increase risk for maltreating
older adults. A neglected older adult may appear unwashed and unkempt, be
malnourished or dehydrated, or have pressure sores. Financial exploitation

1546
includes theft of Social Security or retirement money, savings or investments,
and the use of these funds by the abuser. Criminals often approach elders
with get-rich-quick schemes, sham investment opportunities, overpriced
home repairs, or pose as collectors for illegitimate charities, thereby preying
on the trusting nature of older adults (USDOJ, 2018a; NCEA, n.d.b). See
Chapter 22 for more on older adults.

1547
Vulnerability Factors
Individual characteristics associated with vulnerability of abuse include poor
health, increased age, and disability. Lesbian, gay, bisexual, and transgender
older adults and those who are residents of an assisted living facility are also
more vulnerable to experiencing maltreatment (NCEA, n.d.a). The older
LGBT community experiences discrimination due to age and sexual
orientation leading to social isolation. This population may experience abuse
and discrimination from medical providers and law enforcement (Bloemen et
al., 2019). Dementia and newly diagnosed cognitive impairment correlate
with occurrences of abuse. If violence or threats of violence by the elder
toward the caregiver accompany dementia, this contributes to the elder's risk
for abuse. Harmful effects of abuse for this vulnerable population include
longer convalescence period, permanent damage, premature death,
depression, and anxiety (WHO, 2020b).
The invisibility of elders in general, and abused elders specifically,
increases an older adult's vulnerability of being abused. Reasons for
invisibility among the elderly are multifaceted. Older adults may have less
contact with the community, they are no longer in the workforce or in public
on a regular basis, which keeps their problems hidden longer. Older adults
are reticent to admit to being abused or neglected. Because the abuser is
often a family member, the elder attempts to protect the abuser to avoid
being entirely alone. On the other hand, the elder may fear reprisal from the
abuser for coming forward with a self-report of abuse or telling someone
about the home situation. Cultural and societal values also contribute to
keeping “family matters” private, while shame and embarrassment make it
difficult for many elders to tell others of the abuse (New York City Elder
Abuse Center, 2013).

Older adults may be considered a vulnerable population for several

reasons. Individuals may experience a diminished capacity in self-
determination, impaired cognitive ability, decreased physical strength,
lack of or inadequate education including low health literacy, and lack
of resources (Barbosa et al., 2017).
Many elders who are frail are dependent on others for some aspect of
their day-to-day survival. The degree to which an older adult needs
assistance is often kept hidden from others because the elder fears being
removed from his present living situation and being placed in a more
restrictive environment.
Additionally, vulnerability in elders is increased when any of the
following characteristics are present: (1) being female, (2) 85 years and
older, (3) widowers, (4) a decrease in health, (5) low income, and (6)
lack of education and low health literacy (Barbosa et al., 2017).

1548
Prevention of Elder Abuse
Elders who are dependent on others for their care often do not report abuse
for fear of being abandoned. They feel powerless and at a loss about how to
attain help. They often fear reprisal from the perpetrator if they tell others
about the abuse. Awareness of elder abuse and education about the types of
abuse via public and professional media campaigns has improved community
recognition of the problem. C/PHNs need knowledge in screening procedures
and risk factors for abuse and perpetrators. Respite care can provide valuable
relief to family members. Training for caregivers as well as health care and
social service providers that focus on recognizing stress and initiating
intervention measures has developed a new understanding of effective
interventions. Statutory requirements for reporting abuse and providing crisis
hotlines for reporting elder abuse are also integral aspects of a community's
response to the problem of elder abuse (WHO, 2020b). World Elder Abuse
Awareness Day has been designated as an annual observance on June 15th to
promote public awareness and prevention education regarding elder abuse
(United Nations, n.d.).

1549
OTHER FORMS OF VIOLENCE
Additional forms of violence include self-directed violence (including
suicide), homicide, sexual assault, and human trafficking.

1550
Self-Directed Violence
Self-directed violence (SDV), an intentional act to cause injury to one's self,
is a public health issue worldwide. SDV is considered a range of behaviors
involving fatal and nonfatal self-harm. Examples of self-harm include
cutting, head banging or hitting, self-scratching, self-biting, burning self,
attempted suicide, and suicide. Suicidal ideation, although not a behavior, is
often included due to an association with SDV (CDC, 2019e).
Suicide is taking action that causes one's own death. According to the
CDC, suicide rates are rising in every state in the United States. In 2017
alone, more than 47,000 people committed suicide in the United States. It
touches all age groups; it is

Second leading cause of death among 10-to 34-year-olds

Fourth leading cause of death among 35-to 54-year-olds
Eighth leading cause of death among 55-to 64-year-olds (CDC, 2019e)

In 2017, 10.6 million individuals in the United States considered suicide,

of those 3.2 million had a plan and 1.4 million attempted suicide (CDC,
2019e).
It is important to be aware of warning signs of potential suicide when
working with people in crisis. The strongest risk for suicide is a previous
suicide attempt (WHO, 2019a). Warning signs fall into three categories: what
the person talks about, types of behaviors, and mood. The more warning
signs, the greater the risk (American Foundation for Suicide Prevention
[AFSP], 2020). An individual may talk about not having a reason to live,
feeling trapped, or suicide. Threats or comments that indicate a plan or
giving personal items away are potential indicators of a person contemplating
suicide. Isolation, sleeping too much, acting recklessly, and increased use of
alcohol or drugs are high-risk behaviors for suicide. Moods that may reflect
increased risk are depression, irritability, rage, humiliation, and anxiety.
Community awareness campaigns and education programs are needed to
help a person recognize the risks and the importance of initiating prevention
for someone who is suicidal (Box 18-10). Crisis hotlines with 24-hour access
are a vital resource for a distraught individual, friend, or loved one to contact
and find help during a crisis and to learn about local resources to contact.

BOX 18-10 STORIES FROM THE

FIELD

1551
Helping Youth Build the Strength to Prevent
Suicide Mark LoMurray is the founder and
Executive Director of Sources of Strength, a
youth suicide prevention program that address
bullying, violence, and substance abuse. The
program uses peer leaders with adult advisors
in the school setting. The peer leaders help their
classmates address emotions they're grappling
with and cultivate strengths to use to change.
The goal is to remove suicide intervention from
the crisis mode and focus on development of
appropriate coping skills. The main focus is
positivity; instead of dwelling on negative
emotions, strengths are emphasized. There are
8 strengths students can use to help develop
coping skills. Arranged in a wheel the 8 sources
of strength include mentors, positive friends,
family support, mental health, medical access,
spirituality, generosity, and healthy activities.
Students are taught to reframe stressful
situations to what will help the situation using
the 8 strengths as a guide. A variety of
modalities are used, for instance, playing
games, talking, use of social media, and art.
More information can be found at
https://sourcesofstrength.org/.
1. As you read this chapter, how might this program decrease
violence in our communities?
2. Examine the 8 strengths and identity 3 to 4 that may have helped
you in a stressful situation.
3. The Sources of Strength address several Healthy People 2030
objectives. After examining the topic areas of Health Behavior,

1552
 Populations, and Social Determinants of Health, reflect on how
Sources of Strength addresses these objectives.
Source: ODPHP (2020a).

1553
Homicide
Homicide is any non–war-related action taken to cause the death of another
person. In 2017, globally, intentional homicide took the lives of 464,000
people (United Nations Office on Drugs and Crime, 2019). In 2017, there
were 19,510 homicides reported in the United States alone. It was the 16th
leading cause of death among all age groups and the 3rd leading cause of
death of young people between the ages of 15 and 24 years (Kochanek,
Murphy, Xu, & Arias, 2019).
Evidence suggests that violence can be prevented by measures aimed at
individuals, families, relationships, community, and society. The Guide to
Community Preventive Services (Community Guide) provides evidence-
based recommendations and interventions for 22 health topics including or
violence prevention for each level of prevention (USDHHS, n.d.). Although
biologic and personal factors may influence one's predisposition to violence,
an interaction between one's family, community, cultural, and other factors
combine to create violence (WHO, 2019b). The WHO cites four key steps in
developing a public health approach to violence. These steps include the
following:

Define the problem

Discover the causes and risk factors
Develop and test interventions
Implement and scale effective interventions (WHO, 2019b)

Prevention methods include education programs for preschool, school-

aged children, and adolescents to decrease bullying and improve social skills;
parent education courses and parent resources such as advice lines, support
groups, or a crisis nursery; and community measures that improve firearm
safety and reduce firearm injuries.

1554
Sexual Assault
Sexual assault is defined as “any nonconsensual sexual act proscribed by
Federal, tribal, or State law, including when the victim lacks capacity to
consent” (USDOJ, n.d.c, para. 2). According to the U.S. Department of
Justice (USDOJ) (2016), this definition includes threats of sexual violence,
attempted rape, and rape. The percent of sexual assaults are staggering:

30% of sexual assault victims were raped.

23% experienced attempted rape.
24% were sexually assaulted.
18% of victims received threats of sexual assault.
6% experienced “unwanted sexual contact without force.”
19% of women and 1.5% of men… “have been victims of rape or
attempted rape.”
For close to 78% of females who were raped, the assault was recorded
before they turned 25.
Over 67% of males who were sexually assaulted, victimization occurred
before age 25 (USDOJ, 2016, p. 17).

The majority of perpetrators were either current or former intimate

partners or acquaintances.
Community measures useful in preventing sexual assault involve
education and prevention provided through state sexual assault coalitions,
sexual assault programs for adolescents and college students, dating violence
education, hotlines staffed to provide help for victims of sexual assault and
interpersonal violence, and having trained professionals, such as Sexual
Assault Response Team (SART) members, on hand (CDC, 2019g). Rape
crisis centers and state sexual assault coalitions work together with law
enforcement, health care providers, and community-based organizations
(CBOs) to provide community education and care and support to victims.
SART (Sexual Assault Response Team) consists of multidisciplinary
members that are trained to understand the psychological and physical
assessment needs of the victim, as well as the legal requirements for an
investigation and court proceeding (National Sexual Violence Resource
Center [NSVRC], 2018). The CDC's Rape Prevention and Education
program provides current tools, training, and support works (CDC, 2019g).
Unfortunately, only 33% of sexual assaults are reported to law enforcement
(USDOJ, 2016).
A common role in the SART is a sexual assault nurse examiner (SANE).
A SANE's role is more explicit than that of the C/PHN in assisting people
who are affected by sexual violence, including victims, suspects, and the
accused. For people who have experienced sexual assault, SANEs provide

1555
forensic medical exams and appropriate follow-up referrals based on the
patient's individual needs. SANEs may specialize in pediatrics, adolescents,
adults, or a combination of all three. A SANE represents one subspecialty of
forensic nursing practice; forensic nurses work in a variety of community
settings and specialize in many different types of patient populations affected
by violence including elder abuse, IPV, homicide, human trafficking, and
more (Adams & Hulton, 2016; DailyNurse®, 2019).

1556
Human Trafficking
Human trafficking of adults and children on a national and international scale
is recognized by the United States in the Trafficking Victims Protection Act
(TVPA) of 2000.

This federal law defined human trafficking as the “recruitment,

harboring, transportation, provision, or obtaining of a person” for
compelled labor or commercial sex or for labor or services through the
“use of force, fraud, or coercion” (National Human Trafficking Hotline,
n.d., para. 5). The law specifically identified any child <18 years who
engaged in commercial sex as a victim of trafficking when coerced or
forced.
Since 2000, a total of 11 laws, revisions, and reauthorizations of the
TVPA have been implemented; the most recent in 2018 (USDOS,
2019). Victims of human trafficking are not associated with any one
specific demographical factor. Victims can be anyone of any age,
ethnicity, economic status, or gender and are trafficked into various
forms of human abuse such as commercial sex, medically assisted
reproduction, many types of physical labor, and more.

In February 2020, during a weeklong investigation, federal, state, and

county officials in California made over 500 arrests in a human trafficking
sting operation. Twenty-seven suspects and 270 customers were arrested for
sex trafficking. A total of 11 children and 76 adults were rescued (City News
Service, 2020). Despite the significant number of known cases, the actual
prevalence of human trafficking is not known. This, combined with the well-
established negative health consequences, have made this into a public health
problem, and one that is difficult to mitigate. Research shows that the
majority of victims have encounters with health care providers. However,
victims of human trafficking most often do not self-identify as victims during
the health care encounter and health care providers do not readily recognize
them as potential victims of human trafficking (Chisolm-Straker et al., 2016).
This places nurses at the forefront of screening for human trafficking victims
and also facilitating effective response protocols. A major response measure
implemented by the USDHHS was the establishment of the National Human
Trafficking Hotline (n.d.) at https://humantraffickinghotline.org/. The center
is responsible for the 24-hour crisis line available in over 200 languages, plus
additional texting (233733), live chat, and online resources to assist in the
recognition and response to victims.

1557
Gang Violence
According to the FBI (n.d.b), there are 33,000 violent gangs in the United
States, consisting of street, motorcycle, and prison gangs. Violent activities
involve prostitution, human trafficking, drug sales, robberies, and gun
trafficking. Los Angeles City and County combined are considered the gang
capital of the world with a total of 450 violent gangs comprising 45,000
individuals (Los Angeles Police Department [LAPD], 2019). Since 2016,
there have been 491 homicides, 5,510 robberies, 98 rapes, and 7,050 felony
assaults (LAPD, 2019). Teens join gangs for several reasons:

Identity or recognition
Fellowship
Intimidation
Protection
Criminal activity (Office of Justice Programs [OJP], n.d.)

Teens involved in gangs are at higher risk of not graduating from high
school, teen parenthood, and unemployment (OJP, n.d.).

1558
Gun Violence
A Pew Research Center Survey discovered 30% of Americans own a
firearm, 11% live with someone that owns a firearm, nearly 60% have
friends that own guns, and 72% of those that responded to the survey
have fired a gun (Gramlich & Schaeffer, 2019).
Most gun owners cite the Second Amendment to the Constitution as
their right to own a firearm. Reasons for owning a firearm include
protection (67%), followed by hunting, sport shooting, collector, and
requirement of job (Gramlich & Schaeffer, 2019).
In 2016, death from firearms was estimated to be 251,000 worldwide
(Naghavi, 2018). The countries that account for 50% of these deaths
include Brazil, the United States, Mexico, Colombia, Venezuela, and
Guatemala. Homicide was the leading cause of firearm deaths at 64%,
with suicides at 27%, and unintentional deaths by guns at 9% (Naghavi,
2018).
In 2017, the United States had 39,800 deaths due to firearms; the
highest number since 1993 (Gramlich & Schaeffer, 2019).

Of the 7,639 bills introduced in Congress from January to August 2019,

110 related to guns (Desjardins, 2019). The two bills with the most support
were the Bipartisan Background Checks Act and the Concealed Carry
Reciprocity Act. Grassroots movements include Moms Demand Action
(https://momsdemandaction.org/), a movement to protect against gun
violence by public safety measures; Everytown For Gun Safety
(https://everytown.org/), a group that advocates for changes in gun laws; and
March For Our Lives (https://marchforourlives.com/), whose Web site opens
to voter registration and was started by the students of Marjory Stoneman
Douglas high school in Parkland, Florida, after a mass shooting there that
killed 17 and injured 17 in 2018 (Marjory Stoneman Douglas High School
Public Safety Commission, 2019).

1559
Workplace Violence
Workplace violence is defined as “any act or threat of physical violence,
harassment, intimidation, or other threatening disruptive behavior that occurs
at the work site” (OSHA, n.d., para. 2). The violence can take the form of
threats, verbal abuse, physical assaults, or homicide. According to the U.S.
Department of Labor, those at greatest risk include health care providers,
customer service workers, employees working in small groups or alone,
public service employees, and law enforcement officers (OSHA, n.d.).
Workplace injuries due to violence account for 12% of injuries among
registered nurses. While this figure may appear low, it is three times greater
than injuries due to violence when compared to any other occupation. Nurses
employed in nursing and residential care are at greater risk, followed by
hospitals and ambulatory care clinics (U.S. Bureau of Labor Statistics, 2018).
In hospitals, those nurses working in emergency departments and in-patient
psychiatric units have the highest risk of injuries due to violence. Health care
workers underreport workplace violence by patients because of unclear
definitions of workplace violence, feeling that the patient was not responsible
for actions due to mental status, or believing violence is part of the job
(JCAHO, 2018). The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) standards and recommendations related to
workplace violence are located at
https://www.jointcommission.org/resources/patient-safety-topics/sentinel-
event/sentinel-event-alert-newsletters/sentinel-event-alert-59-physical-and-
verbal-violence-against-health-care-workers/.
The phrase “nurses eat their young” has long been a lament of novice
nurses (Colduvell, 2017). Bullying or incivility among nurses is a common
occurrence. It is estimated 44% of nurses have been bullied within the health
care setting (JCAHO, 2016). In a CINAHL search of “bullying” and “nurses”
between 2017 and 2019, a total of 375 results were found. Several countries
were represented including the United States, Russia, Iran, Korea, and
Australia demonstrating this is an epidemic in health care. While, incivility is
considered part of the job by some, it has a negative impact on health care.
Horizontal and vertical bullying increases burnout, turnover rate, patient care
errors (e.g., medication errors and higher infection rates), and costs (JCAHO,
2016). However, the bullying can have fatal consequences. In 2018, a
registered nurse in Wales committed suicide related to workplace bullying
(Stephenson, 2018).

1560
C/PHN Self-Care
The American Nurses Association (ANA) announced 2017 as the Year of the
Healthy Nurse. Each month focused on a different topic of health such as
sleep, happiness, mental health wellness, physical activity, and healthy eating
(ANA, n.d.). Practicing these health promotion themes throughout our
careers place us a better position to handle individual, family, community,
and global violence. These topics should be a part of every C/PHN daily
routine. Unfortunately, due to work requirements and family commitments
nurses may not practice self-care techniques even though we teach these
practices to our communities (Ross, Bevans, Brooks, Gibbons, & Wallen,
2017). Nurse leaders need to highlight and encourage self-care practices in
the workplace (Ross et al. 2017); for instance mediation lunches, walking
groups, or infographics on self-care.

1561
HEALTHY PEOPLE 2030 AND
VIOLENCE PREVENTION
The problem of violence is pervasive, affecting the people who experience
violence directly and family members and society indirectly. Progress on
selected violence and abuse objectives for Healthy People 2030 include the
following (Office of Disease Prevention and Health Promotion [ODPHP],
2020b):

Reduce homicides: In 2018, the baseline for homicides was

5.9/100,000. The target for 2030 is to decrease this to 5.5/100,000.
Reduce emergency department visits for nonfatal self-harm injuries:
Reduce these emergency department visits from 182.7/100,000 in 2017
to 144.7/1,000 for person 10 years and older.
Reduce gun carrying among adolescents: In 2017, 4.8% of students in
grades 9 through 12 carried an firearm at least 1 day within the past
year. The target for 2030 is 3.7%.

See Box 18-11 for selected Healthy People 2030 violence-related

objectives.

BOX 18-11 HEALTHY PEOPLE 2030

Selected Violence-Related Objectives

1562
Reprinted from Office of Disease Prevention and Health Promotion (ODPHP). (2020a). Healthy
People 2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives.

1563
LEVELS OF PREVENTION: CRISIS
INTERVENTION AND FAMILY AND
INTIMATE PARTNER (IP)
VIOLENCE
C/PHNs are in a unique position to prevent, identify, and intervene during
crisis situations involving family violence. Because C/PHNs encounter
people in their own settings, a more accurate assessment with direct
observation, discussion, and intervention can occur. The nurse's assessment
skills, familiarity with the community, and access to resources enhance his
ability to help families in crisis. By using the three levels of prevention, the
nurse can assist families in a variety of ways to counter problems arising
from family and IP violence (Box 18-12).

BOX 18-12 Levels of Prevention Pyramid

Promoting Crisis Resolution SITUATION:
Traumatic crisis due to act of violence regarding
a mass shooting GOAL: To use the three levels of
prevention, to avoid promptly diagnose and treat
the community's negative health conditions, and
to restore the fullest possible potential.

1564
1565
Primary Prevention
The cycle of violence can be interrupted. Primary prevention is the most
effective level of intervention in terms of promoting clients' health and
containing costs. Primary prevention reflects a fundamental human concern
for well-being and includes planned activities undertaken by the nurse to
prevent an unwanted event from occurring, to protect current health and
healthy functioning, and to promote improved states of health for all
members of a community. For the C/PHN, any activity that fosters healthful
practices will counteract unhealthful influences, thereby empowering an
individual or family to avoid or better respond to a crisis. Health promotion
considerations include the biopsychosocial and spiritual needs of the
individual and family.
Opportunities for interventions include promoting positive relationships
and parenting practices, improving communication skills, and developing
positive self-esteem. Healthy self-esteem also improves education and
occupational success. If poverty is a contributing factor to the violence being
experienced, adequate educational preparation and having a successful
employee role may help to eliminate this stressor. Parenting influences
children's coping strategies, decision-making, and sense of self-confidence.
Parenting classes are an important resource, particularly for parents who are
at high risk, such as teens, people with no exposure to children in their
upbringing, and people raised in violent and abusive families. Parenting
classes offer an opportunity for parents to discuss challenges, while learning
new strategies for managing their children's behaviors and appropriate
physical, emotional, and developmental expectations for their children's ages
(Dutton, James, & Kelley, 2015).
Home visiting has been formalized into community/ public health
nursing model programs around the country, based on two decades of work
by David Olds (NurseFamily Partnership, 2020) and others. This evidenced-
based program has shown that nurse follow-up and interventions during the
pregnancy and for the first 2 years of the child's life was effective in
preventing child abuse, decreasing the mother's reliance on government
assistance, having mothers with longer spacing between their children and
fewer subsequent pregnancies, and improving health habits, such as less
smoking by mothers (USDHHS, 2019). To date, the NFP has served over
309,000 families in the United States (NurseFamily Partnership, 2019). See
Chapter 4. For more information on this unique partnership, refer to
https://www.nursefamilypartnership.org. The effectiveness of home visit
programs to pregnant women and families with a child from birth to 5 years
are evaluated yearly by the Office of Planning, Research, and Evaluation
(Sama-Miller, Akers, Mraz-Esposito, Coughlin, & Zukiewicz, 2019). This

1566
report provides an in-depth evaluation of home visit programs across the
United States and is a valuable tool when starting a home visit program.
The interrelatedness between families and communities cannot be
overlooked or underestimated. Neighborhoods need to be enfranchised,
developed, and attentive to the needs for health and safety for all community
members. Empowered families and communities can take back their
neighborhoods from criminals, and their empowerment acts as a source of
growth for other families.

1567
Secondary Prevention
Early diagnosis and prompt treatment of the effects of family crisis or
violence is the focus of secondary level prevention strategies. Secondary
prevention seeks to reduce the intensity and duration of a crisis and to
promote adaptive behavior. By creating a positive relationship with family
members in their homes, the C/PHN can often uncover and intervene in a
crisis or stop abusive situations.
Those affected by a violence-related crisis is rendered temporarily
helpless and unable to cope on their own and are especially receptive to
outside influence. C/PHNs can implement crisis resolution models to assist
clients at the secondary level. The following process outlines a proven crisis
intervention process (James & Gilliland, 2017):
1. Establish rapport.
2. Assess the individual and the problem for lethality.
3. Identify major problems and intervene.
4. Deal with feelings.
5. Explore alternatives and coping mechanisms.
6. Develop an action plan.
7. Follow up, including anticipatory planning for coping with future crises.
People in crisis will seek and generally receive some kind of help, but the
nature of that help may act in favor of or against a healthy outcome from
which the participants can grow and evolve. A client's desire for assistance
gives the helping professional a prime opportunity to intervene; this
opportunity also presents a challenge to make the intervention as effective as
possible. Behaviors found to be helpful in these interventions include the
following:

Respect the client's confidentiality.

Listen to the client and validate the client's experiences.
Acknowledge any violation and oppression.
Allow clients to make their own decisions.
Assist the client and the client's family to plan for future safety.
Promote access to community services (James & Gilliland, 2017).

The Quality and Safety Education for Nurses Project [QSEN] provides a
guide for preparing future nurses to improve the quality and safety of the
health care system in which they work (QSEN Institute, 2020). Knowledge,
skills, and attitudes are delineated for the domain of safety. Although framed
specifically for acute care settings, the domain of safety identifies factors that
create a culture of safety such as communication and reporting systems (i.e.,
mandatory reporting). Effective use of strategies to assess and reduce harm is

1568
important when working with families in crisis. Valuing safety, vigilance,
monitoring, and reporting are skills necessary for community/public health
nursing practice.

One goal of crisis intervention should be to help clients reestablish a

sense of safety and security while allowing them to share their feelings
and have those feelings validated. This process helps reestablish
equilibrium at as healthy a level as possible and can result in client
change and growth.
Minimally, the goal is to resolve the immediate crisis and restore clients
to their precrisis level of functioning. Overall, intervention seeks to
improve their functioning to a healthier, more mature level that will
enable them to cope with and prevent future crises.
As discussed earlier, crises tend to be self-limited; intervention time
generally lasts from 4 to 8 weeks, with resolution within 2 or 3 months
(James & Gilliland, 2017).
The urgency of the situation represents a window of opportunity that
invites prompt, focused attention by the client and nurse in working
together to achieve intervention goals.

At times, the nurse may be responding to a referral regarding suspected

abuse; at other times, an abusive or neglectful situation may be uncovered on
a home visit made for another reason. In any case, the C/PHN has an
important role in reporting suspected abuse and encouraging the child,
partner/spouse, or elder to go to the appropriate facility to seek care and to
file required documentation about the abuse (Box 18-13).

BOX 18-13 STORIES FROM THE

FIELD
Community/Public Health Nursing and a
Potential Family in Crisis You are a PHN
employed be the Smithville Health Department.
You are following up on a referral from a
community clinic's family planning clinic
involving a 19-year-old woman, Sarah, who
exhibited inappropriate behaviors with her 6-
month-old daughter during a clinic visit. Per
the referral, staff observed the mother shouting

1569
at the child, accusing her of “being spoiled
rotten,” the mother appeared quite anxious,
and seemed to have difficulty waiting the 15
minutes for her examination. Although the
behaviors described were insufficient to
warrant a report to social services, the staff felt
that this young mother would benefit from
intervention on the part of the nurse.
In preparation for the home visit, you review the medical records of
Sarah and her child to determine whether the family has had previous
involvement with social service agencies such as Child Protective
Services (CPS). You find that the maternal grandparents made a referral
to child welfare staff on behalf of Sarah when she was 15. The
grandparents were concerned about a sexual relationship between Sarah
and her stepfather. The findings of the investigation were inconclusive,
and the charges were never pursued.
You discuss the case with family planning and immunization clinic
staff, because the family receives services at both clinics. The staff are
familiar with Sarah and her husband Jacob. Their only interaction with
Jacob was during a family planning clinic visit 2 months ago. They
report Sarah appeared anxious and rushed, stating, “I really need to
hurry, Jacob is waiting in the car, and he gets impatient.” Shortly after
that, the staff tell you, Jacob came running into the clinic shouting,
“What the hell is taking you people so long?” He reportedly glared at
Sarah, and the two quickly exited the clinic.
You phone the client and introduce yourself as a nurse with the local
health department, explaining that nurses often visit new mothers to
assist them in finding resources. You add that as a PHN, you will be
available to talk with her about her child's growth and development. The
client expresses interest in the visit and states, “I want you to show me
some things about feeding her and stuff. I need help figuring out what to
do at night, she still isn't sleeping much and it's driving me crazy.” You
advise the client that you will be happy to discuss those issues with her
and that you will bring information to review together. Noting that the
father of the baby is living in the home, you assure her that she may
involve other family members, including the father of the baby, in the
home visit. You jointly decide that the visit will occur the following day
at 10:30 AM and that the father of the baby will be present if his work
schedule allows.

1570
 On the day of the visit, as you walk up the stairs toward the
apartment, you notice someone looking at you through the curtains. As
you near the apartment door, the curtains close. Your repeated knocking
on the door is met with no response. You call the client's name but there
is no answer.

1. Does this scenario provoke anxiety for you? How would you deal
with your reaction?
2. How is this different from being in a hospital setting where a
supervisor is readily available?
3. Given this scenario, what actions will you take?
4. If you had been working in the family planning clinic on the day
that Jacob came in, what, if anything, would you have done
differently?
5. As young parents, Jacob and Sarah are part of an aggregate that
has unique risk factors for parenting. List as many of these risk
factors as you can think of and brainstorm about possible
community/public health nursing interventions for each.
6. What methods would you suggest the clinic staff utilize to detect
signs and symptoms of physical, sexual, or emotional abuse
among this aggregate?

Reporting Abuse
All states have reporting laws for suspected abuse, although states differ on
aspects of the timeline for reporting, who to notify, and the sequence of
events. The following steps represent one state's guidelines for reporting
suspected child abuse (California Department of Education, 2020):
1. All mandated reporters must report known or suspected abuse or neglect.
2. Immediately, or as soon as practically possible, the designated agency
such as the local child protective agency (police department after
normal working hours) must be contacted by telephoned and given a
verbal report. During this verbal report, mandated reporters must give
their name—which is kept confidential and may be revealed only in
court or if the reporter waives confidentiality (others can give
information anonymously)—the name and age of the child, the present
location of the child, the nature and characteristics of the injury, and any
other facts that led the reporter to suspect abuse or that would be helpful
to the investigator.
3. The mandated reporter must notify the appropriate agency immediately
or as soon as possible, followed by a written report within 36 hours. It is
imperative that nurses know their state laws for reporting. If a mandated
reporter fails to report known or suspected instances of child abuse, they

1571
 may be subject to criminal liability, punishable by up to 6 months in jail
or/and a fine of $1,000.
Similar steps are required for nurses when reporting elder abuse and
other vulnerable adults. Such cases of suspected maltreatment are reported to
a local area agency on aging, Adult Protective Services, or to the police, and
a screening/documentation form is used to gather and record pertinent
information. Guidelines for filing the report and agency notification are
specific within each state. In cases of partner/spousal abuse, adults who are
mentally competent cannot be removed involuntarily from the abusive
situation. The C/PHN can communicate concern for the client's safety,
emphasize the importance being in a safe environment, and provide
information regarding community resources, such as a shelter (Fig. 18-4). If
the adult has a life-threatening injury or illness, medical follow-up must be
encouraged; however, the victim may still be reluctant to seek help.

FIGURE 18-4 Public health nursing client in a homeless shelter.

Tools
Assessment of suspected abuse cannot be overemphasized. The C/PHN may
be the only person entering the home of a family in crisis where abuse is
occurring. Asking the right questions, being a careful observer, and following
the correct reporting process and recording procedures may mean the
difference between life and death for a person or family experiencing
violence. (See http://thepoint.lww.com/Rector10e for the following sample
tools: a Suspected Child Abuse Report, a two-page Medical Report of
Suspected Child Abuse, and a Domestic Violence Screening/Documentation
Form.) C/PHNs must be observant for hazards and personal safety. Follow
agency policy if ever feel in harm's way. Some agencies assign nurses to go

1572
in pairs or with law enforcement to ensure safety. If the batterer is in the
home, meet the victim in a public place and not in the home.

1573
Tertiary Prevention
Tertiary prevention focuses on the rehabilitation of the person or family from
the violence and crisis they have experienced. They may be alone, such as a
trafficked teenager estranged from his family. Or, they may never again have
the same relationships because partners may separate—by choice, motivated
by fear or hatred; by court order, if the perpetrator is incarcerated; or due to a
death. Regardless of an individual, or a couple or a family, long-term
intervention may be needed to establish a climate more conducive to
normalcy. Many of the services discussed as part of the secondary level of
prevention are continued into the tertiary prevention phase to promote
healing and to restore and promote family growth.
If incarceration is a part of tertiary prevention, the effects of having one
person living in this environment must be factored into the services and
support provided by the C/PHN to the other people involved (see Chapter 28
for information on working in correctional facilities). If children are
involved, even if the partner/spouse has separated from the perpetrator, the
perpetrator usually has legal rights to see the children. This may mean that
other family members, usually from the abuser's side of the family, can bring
the children to the prison to visit their parent. Making arrangements for these
visits can create stress for adult survivors, children, and the visitors. The
C/PHN needs to be aware of the complicated dynamics and emotional stress
such difficult situations can produce for all family members. The victim–
perpetrator relationship is as complex as the forces that created the violence
and abuse (NCADV, n.d.b).

1574
VIOLENCE FROM OUTSIDE THE
HOME
There has always been some degree of violence that affects people in their
homes, such as burglaries, murder, or abduction (Fig. 18-5). Home invasion,
the purposeful and sudden entry into a home by force while people are home
and awake, is a form of terror that relies on surprise. Confrontation is often
sought, and offenders are often younger (under age 30) and male, working in
small groups. They often look for victims who may be more vulnerable and
are believed to have money or desired goods that they can pawn or sell
(Heinonen & Eck, 2012). Motivation may be material or thrill; household
belongings are frequently stolen while members of the home are
incapacitated by being bound, blindfolded, and/or gagged. In some cases,
people are murdered. Often, the perpetrators are under the influence of drugs
or alcohol, and at times, the violence may be gang related.

FIGURE 18-5 Crime is a type of community violence that can

affect families.

Other forms of violence include the potential for terrorist activities

through planned community violence (e.g., 9/11 attacks, Sandy Hook school
shooting, Route 91 Harvest Music Festival) and biologic, chemical, or
radioactive actions (see Chapter 17). Communities have developed resources
such as the National Organization for Victim Assistance (NOVA) and crisis
response teams (CRT), to assist individuals and groups experiencing a
disaster or violent event (e.g., child murder or school shootings).

1575
 The Global Study on Homicide 2019 provides an in-depth investigation
into crime. Lethal violence can create a climate of fear and uncertainty.
Intentional homicide victimizes individuals, families, and the community of
the victim (United Nations Office on Drugs and Crime, 2019). Fear of
violence can create psychological and physiologic stress reactions. These
fears should not be ignored.
Historically, society has depended on the criminal justice system to
respond to community violence with emphasis on deterrence and
incarceration, which has limited prevention capacity. Today, violence is
considered a public health issue requiring more than a criminal justice action.
To put primary prevention into practice, an integrated multifaceted approach
is required.

The spectrum of prevention offers a systematic framework for

developing effective and sustainable primary prevention programs.
Developed by Larry Cohen, the spectrum of prevention identifies
multiple levels for community intervention: strengthening individual
knowledge and skills; promoting community education; educating
providers; fostering coalitions and networks; changing organizational
practices; and influencing policy and legislation.
When used together, these levels are complementary and create synergy
that results in greater effectiveness (Prevention Institute, n.d.).

Nurses may work at each level of the spectrum, by educating individuals

and high-risk target populations, working on coalitions to foster increased
awareness and use of screening tools by health care providers, and working
with multisector partnerships to foster change in workplace, organizational,
and community policy. Nurses may work with extended family members of
the victims or families who have reported such an incident in their
neighborhood and are now fearful of a reoccurrence. See Chapters 11 and 12.

1576
THE NURSING PROCESS
Assessment and Nursing Diagnosis
Initially, the nurse must assess the nature of the crisis and the client's or
community's response to it in a focused community assessment. How severe
is the problem, and what are the risks? Who is at risk? Assessment must be
rapid but thorough and focused on specific areas.

First, the nurse concentrates on the immediate problem during the

assessment. Why have clients asked for help right now? What are the
injuries? How do they define the problem? What precipitated the crisis?
When did it occur?
Next, the nurse focuses on the clients' perceptions of the event. What
does the crisis mean to them, and how do they think it will affect their
future? Are they viewing the situation realistically? When a crisis
occurs to a family or group, some members see the situation differently
from others.
Determine who is available to offer support to the individual or family.
Consider family, friends, clergy, other professionals, community
members, and agencies. Who are the clients close to, and whom do they
trust?
Finally, the nurse assesses the clients' or community's coping abilities
and resources. Have they had similar kinds of experiences in the past?
What techniques have they tried in this situation, and if they did not
work, why not? Clients should be encouraged to think of other stress-
relieving techniques, perhaps ones they have used in the past, and to try
them.

After the assessment, a nursing diagnosis is developed. Nursing

diagnosis priorities should focus on Maslow's (1971) Hierarchy of Needs at
the Physiological and Safety levels related to the act of violence. Ineffective
coping related to the client's or community's traumatic event provides a
means to increase coping skills. When the violence problem is more
community centered, the Omaha System of documentation and information
management may be useful as a nomenclature as it comprehensively includes
the family and community as clients or modifiers. The system consists of
three relational, reliable, and valid components used together: The Problem
Classification Scheme, Intervention Scheme, and the Problem Rating Scale
for Outcomes (Omaha System, 2019). The Problem Classification Scheme

1577
includes neighborhood/workplace safety in the environmental domain. See
Chapters 12 and 15.

1578
Planning Interventions
Several factors influence clients' reaction to crises. Nurses should try to
determine what factors are affecting clients before making intervention plans.
The major balancing factors—clients' perceptions of the event, social
supports, human resources, and clients' coping skills—have been assessed in
the first step (James & Gilliland, 2017). While continuing to explore these,
the nurse now also considers the clients' age, past experiences with similar
types of situations, sociocultural and religious influences, general health
status, and the actual assets and liabilities of the situation. This assessment
helps clarify the situation and gives the nurse an opportunity to further
encourage the clients' participation in the resolution process. If clients are
defensive, resistant, and rigid, they are not processing clearly and can
complete only simple tasks. It will take time before these clients can begin to
solve problems related to the effects of the crisis on themselves and the loss
they are experiencing, but the nurse will want to encourage them to reach this
level.
A plan is based on multiple factors:

The crisis
The effect the crisis is having on clients' lives
Where they are in coming to resolution of the crisis
The ways in which significant others are affected and respond
Their level of preparation for such a crisis
The clients' strengths and available resources

1579
Implementation of Interventions
During implementation, the partnership between the nurse and clients is
important. Discussions about what is happening, reviewing the family's plan
and rationale for this approach, and making appropriate changes are
necessary. Know the resources in the community so as to make referrals as
needed. Referrals may include social workers, mental health practitioners,
clergy, law enforcement, or support groups. The C/PHN needs to:

Demonstrate acceptance of clients. Clients need to feel the support of a

positive, caring person who does not judge their feelings or behavior.
Use therapeutic communication. Verbal and nonverbal therapeutic
communication allows clients to feel safe in expressing their feelings of
fear, anger, guilt, or other negative emotions.
Assist client in making and reaching achievable goals by using
strengths.
Communicate changes with client prior to making them.
Do not offer false reassurance. Clients need to face reality, not avoid it.
A statement such as “Don't worry, it will all work out” is demeaning
and meaningless.
Discourage clients from blaming others. Clients often blame others as a
way to avoid reality and the responsibility for problem solving.
Help clients learn new coping skills by providing alternatives. Explore
and test old and new techniques to reduce stress and anxiety. Ask
questions.
Encourage clients to accept help from their social support system and
spiritual resources as needed. Denial in the early phases of crisis cuts
off help. Encouraging clients to acknowledge the problem is a first step
toward acceptance of help.
Promote development of new positive relationships. Clients who have
lost significant others through unintentional or intentional death,
divorce, incarceration, or an act of perpetrated violence should be
encouraged to find new connections, purpose, and people to fill the void
and provide needed supports and satisfactions (Ackley, Ladwig, &
Makic, 2017).

1580
Evaluation
In the final step, clients and the nurse evaluate, stabilize, and plan for the
future. Evaluating the outcome of the intervention might address the
following:

Are the clients using effective coping skills and exhibiting appropriate
behavior?
Are adequate resources and support persons available?
Is the diagnosed problem solved?
Have the desired outcomes been met?
Are modifications needed in the assessment, outcomes, or
interventions?

Analysis of these outcomes will provide a greater understanding for

coping with future crises.
Clients' plans for the future should include setting realistic goals and
means to implement them. Review with clients how their handling of the
present crisis can help them cope with, minimize, or preferably prevent
future crises.

1581
SUMMARY
Violence affects individuals, families, groups, communities, and all of
society. Experiencing violence may result in a crisis, a temporary state
of severe disequilibrium for persons who face a threatening situation.
A crisis is a state that individuals can neither avoid nor solve with their
usual coping abilities and occurs when some force disrupts normal
functioning, thereby causing a loss of balance or normalcy in life. Crises
create tension; subsequently, efforts are made to solve the problem and
reduce the tension. If such efforts meet with failure, people feel upset,
redefine the situation, and try other solutions, and if failure continues,
the person eventually reaches the breaking point.
Violence is a global public health issue. It is not limited by
sociodemographic or geographic factors—anyone may experience
violence or abuse at any point in their lifetime.
Acts of violence can result in a crisis—a crisis is a stressful and
disruptive event (or series of events) that comes with or without
warning and disturbs the equilibrium of the individual, family, or
community.
Understanding the neurobiological effects, potential subsequent health
effects, and the overlapping causes of violence can help community
nurses to enhance protective factors, reduce risk factors, and inform
violence intervention and prevention activities.
Child abuse occurs among children of all ages, from infancy through the
teen years, and may be physical, emotional, and/or sexual. Neglect and
sexual exploitation are additional forms of child abuse.
Community violence creates fear and uncertainty and impacts
individuals and families that may live, work, play, and pray in close
proximity.
Maltreatment of older adults, often called elder abuse, may involve
physical, sexual, emotional or psychological abuse; neglect;
abandonment; financial or material exploitation; or self-neglect or any
combination of these mistreatments.
Community health nurses use three levels of prevention when working
with families.
Primary prevention focuses on providing people with the skills and
resources to prevent violent situations.
Secondary prevention involves immediate intervention at the time
of the violent episode. Secondary level prevention may include
medical attention, emotional support, police, and social services
involvement.

1582
 Tertiary prevention offers rebuilding services and helps establish
equilibrium with a structure that may be different, but healthier.
The spectrum of prevention offers a multidimensional approach to
building community capacity to address issues of violence.
People in crisis need and often seek help.
Crisis intervention builds on these two phenomena to achieve its
primary goal—reestablishment of equilibrium. Crisis intervention
begins with assessment of the situation, followed by planning a
therapeutic intervention. The nurse then implements and carries out
the intervention, building on the strengths and self-care ability of
clients. Crisis intervention concludes with resolution and
anticipatory planning to avert possible future crises.
Regardless of the method of intervention used by the C/PHN, the steps
of the nursing process provide an intervention framework. Assessing the
assets and liabilities, a person's willingness to change, and the nature of
the violence help the nurse form a nursing diagnosis. With this
diagnosis, the nurse can begin to plan appropriate interventions and
implement plans. Evaluation of the intervention techniques provides the
nurse with new data to assist with ongoing assessment of the progress
and additional anticipatory guidance needs.

1583
ACTIVE LEARNING EXERCISES
Some activities may be uncomfortable to participate in, please give yourself
the freedom to decline on any that cause undue stress.

1. Acts of violence affect the individual, the family, and the community.
C/PHNs may practice or live in the area affected by the violence. As
registered nurses, it is imperative that we engage in self-care so as to
care for our clients. What are some successful self-care methods you
have practiced? Is there research that confirms your self-care
practice? How might you use that research to help your clients?
2. Gun violence in schools and social events have become part of
society. Research legislative bills dealing with gun violence in your
community or state. Write a letter in favor of or against the bill based
in current statistics and facts.
3. Research “Assess and Monitor Population Health” and “Investigate,
Diagnose, and Address Health Hazards and Root Causes” (2 of the 10
essential public health services; see Box 2-2) in relationship to racism
and inequity in your community. As a C/PHN, what other essential
public health services might you use to make changes?
4. A classmate comes to class with a black eye and upper arm bruising.
Describe what you would, or would not, do and why. Role play with a
classmate if possible. Although, gender was not mentioned did you
assume the classmate was female? Do your actions differ if your
classmate is a male? Research what your local community offers on
the three levels of prevention of IPV. Where do you see the gaps and
how might you correct them?
5. After reviewing your state's child abuse reporting form what do you
think would be the most difficult about the process?

Research what your state and county laws are regarding filing.
What is the policy at your clinical agency?
Does your agency follow state law?
Self-care is important when working with children abuse cases. Does
your agency use debriefing methods?

thePoint: Everything You Need to Make the

Grade!

1584
 Visit http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, study aids for
all learning styles, and more!

1585
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 UNIT 5
Aggregate Populations

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1601
CHAPTER 19
Maternal–Child Health
“Be gentle with the young.”

—Juvenal (55–127 AD)

KEY TERMS
Abusive head trauma Alcohol-related birth defects Alcohol-related
neurodevelopmental disorder Child abuse Environmental tobacco smoke
(ETS) Fetal alcohol effects Fetal alcohol spectrum disorders (FASDs) Fetal
alcohol syndrome (FAS) Gestational diabetes mellitus (GDM) Head Start
High-risk families Infant
Low birth weight (LBW) Preschooler Shaken baby syndrome Sudden infant
death syndrome (SIDS) Toddler
Very low birth weight (VLBW)

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Identify major health problems and concerns for childbearing women,
infants, toddlers, and preschoolers globally and in the United States.
2. Discuss major risk factors and special complications for childbearing
families.
3. Describe the important considerations in developing effective health
promotion programs to fit the needs of diverse maternal–child
populations.
4. Describe various roles of a public and community/public health nurse
(C/PHN) in serving the maternal–child population.
5. Recognize resources available regarding recommended immunization
schedules for infants and children.
6. Discuss methods and interventions the C/PHN might use in working
with infants, toddlers, and preschoolers to help promote their health.
7. Give examples of methods and interventions the C/PHN might use in
working with infants, toddlers, and preschoolers to help promote their
health.

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INTRODUCTION
Maternal and child populations have always been priorities for public health
and community and public health nurses (C/PHNs). These populations
consist of childbearing women (including pregnant adolescents), infants,
children, and adolescents. In this chapter, the focus is specifically on
childbearing women (including adolescents) and children from birth through
age 4 years. Often, more than half of the practice of C/PHNs in official
public health agencies involves primary prevention work with mothers, such
as family planning, preconception care, provision of prenatal care, and
monitoring infant health. Why should maternal–infant populations require
this amount of attention from C/PHNs? Despite advanced technology and
availability of excellent perinatal services in the United States, we often have
less than optimal birth outcomes—for instance, 318,847 low birth weight and
381,321 preterm infants were born in 2014 (Centers for Disease Control and
Prevention [CDC], 2016d). Also, certain segments of the maternal and infant
populations, such as adolescent mothers, those who are economically
disadvantaged, and women and children of color, remain at high risk for
disparities in regard to maternal deaths and complications and child risk and
illness. Although some women receive excellent prenatal care and benefit
from diagnostic and technological resources, many others lack access to
prenatal care.
This chapter addresses major areas of concern regarding population
health for maternal–infant clients. It also explores the global needs of and
related services available to the youngest and thus most vulnerable of
society's members. Health services that are commonly available in the United
States for pregnant and postpartum women, infants, toddlers, and
preschoolers are examined, and the role of the C/PHN in providing those
services is explored.

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HEALTH STATUS AND NEEDS OF
PREGNANT WOMEN AND
INFANTS
C/PHNs constitute a key group of health professionals involved in both
program planning and the actual delivery of services to mothers and babies in
the community. In the public health sector, these nurses are the largest group
of professionals practicing public health. A solid understanding of vital
statistics and other data regarding mothers and infants is important to
determine the appropriateness and the effectiveness of programs and
services. A review of some global and national vital statistics provides
insight into the major problems facing maternal and child populations.

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Global Overview
Maternal and newborn health has been thrust into the global community
spotlight since the publication of the Sustainable Development Goals in 2015
(Global Burden of Disease 2015 Maternal Mortality Collaborators, 2016).
The goal was to improve women's and children's health on a global scale
through 17 sustainable development goals. The main key to decreasing
maternal mortality is to increase prenatal care benefits and coverage.

Maternal Mortality Rate

One of the major indicators of population health is maternal health, which is
often measured by the maternal mortality rate (MMR). The MMR is a
measure of obstetric risk and is determined by dividing the number of
maternal deaths by the number of live births per 100,000. Most maternal
deaths are the result of direct causes (complications of pregnancy, labor, and
delivery), hypertensive disorders, intervention omissions or incorrect
treatment, the chain of events resulting from any one of these, and unsafe
abortions. In developing countries, the MMR is 239 per 100,000 live births,
compared with developed countries, where the MMR is around 12 per
100,000 live births—a very wide disparity (World Health Organization
[WHO], 2018a). The U.S.'s MMR has risen from 7.2 per 100,000 live births
in 1987 to 16.9 per 100,000 live births in 2016, although it has fluctuated
between a low of 14.1 and a high of 17.8 per 100,000 live births since 2002
(CDC, 2018j). Although worldwide the MMR has decreased since 1990 by
44%, the worldwide goal is to eliminate preventable maternal death by 2030
(WHO, 2018a). This goal is achievable because most countries have
implemented successful policies to eliminate maternal–child inequities (Box
19-1).

BOX 19-1 Evidence-Based Practice

Reducing Child Mortality in Bangladesh Child
mortality rates have declined significantly in
Bangladesh over the last 25 years. Bangladesh
has experienced a 76% reduction in the under-
five mortality rate from 144 per 1,000 in 1990 to
34 per 1,000 in 2016. Additionally, the neonatal
mortality rate was decreased by 68% from 64
per 1,000 in 1990 to 20 per 1,000 in 2016 (World

1605
 Bank Group, 2018). Routine childhood
immunizations, oral rehydration therapy, and
supplementation of vitamin A are inventions
that have significantly influenced this reduction
in child mortality rates. Full vaccination of
children 12 to 23 months increased from 60% in
2000 to 84% in 2014. Children receiving oral
rehydration therapy for diarrhea increased
from 74% in 2000 to 84% in 2014 (Ministry of
Health & Family Welfare, 2015). Vitamin A
supplementation increased from 49% in 1994 to
62% in 2014. Furthermore, the government of
Bangladesh implemented a nutrition plan in its
National Health Strategy. Children who were
underweight decreased from 43% in 2004 to
33% in 2014. Although these improvements are
dramatic, additional developments in
sustainable trends and equity are essential
(Baruah et al., 2013).
Source: Baruah et al. (2013); Ministry of Health and Family Welfare, Bangladesh, Partnership
for Maternal, Newborn, & Child, WHO, World Bank and Alliance for Health Policy and
Systems Research (2015); World Bank Group (2018).

Infant Mortality Rate

Another critical population health indicator is the infant mortality rate (IMR).
Globally, 4.2 million children under 5 years of age died in 2016, which is a
significant decrease from the 8.8 million who died in 1990 (WHO, 2018b).
Of these 4.2 million deaths, 44% took place during the neonatal period and
were primarily caused by preterm birth, birth asphyxia, and infection. More
than half of the deaths for children under 5 years of age are preventable and
the interventions are affordable (WHO, 2018b). In the United States, the
IMR was 5.9 per 1,000 live births in 2016 (CDC, 2018j). Although this is a
decrease from years past, 23,000 infants still died in 2016 in the United
States. See Figure 19-1 for U.S. IMR ethnic comparison data.

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FIGURE 19-1 Infant mortality rates by race and ethnicity, 2016.
(Reprinted from Centers for Disease Control and Prevention. (n.d.).
User guide to the 2016 Period Linked Birth/Infant Death Public
Use File (p. 80). Retrieved from
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infan
tmortality.htm)

1607
National Overview
In the United States, the birth rate has decreased each year since 2007; in
2018, nearly 3.8 million women gave birth, a decline in the birth rate of 2%
from the previous year (Martin, Hamilton, Osterman, & Driscoll, 2019). The
general fertility rate declined to a total of 59.1 births per 1,000 women aged
15 to 44 years. Birth rates declined for non-Hispanic White, Hispanic, and
African American women. Just over 40% of births were to unmarried women
(Martin et al., 2019). When unmarried women rely on a single income,
financial resources are more limited, and many of these women raise their
children at poverty or near-poverty income levels, which impacts their health
and their children's health over the life course of both (Fig. 19-2).

FIGURE 19-2 Support for mothers and children helps ensure

healthier families.

Child Health USA (U.S. Department of Health and Human Services

[USDHHS], Health Resources and Services Administration [HRSA],
Maternal and Child Health Bureau [MCHB], 2014) reports that adequate
prenatal care is associated with adequate health insurance. In 2012, 88% of
privately insured women and 83% of Medicaid-insured women received
adequate prenatal care (defined as four or more provider visits during
pregnancy). Seventy-two percent of those who were uninsured were least
likely to receive adequate prenatal care. This correlates with health inequity
characteristics such as race and ethnicity, poverty, and low maternal
education levels (less than high school education).
Historically, the health of U.S. women and children has largely fallen
under the umbrella of Title V of the Social Security Act, enacted in 1935.
(For more on the Social Security Act, see Chapter 6.) Funding for state

1608
Maternal and Child Health and Crippled Children programs was part of this
original legislation, as was some provision for child welfare services. Title V
is “the longest-standing public health legislation in American history” and
came to fruition after other legislation established a National Birth Registry;
provided Infant Care, the first educational pamphlet; established the
Children's Bureau; and provided protection against child labor practices (i.e.,
the first Child Labor Law of 1916; MCHB, n.d.b, para. 4). For an illustration
of MCHB functions and programs, see Box 19-2.

BOX 19-2 Types of Services Offered

Through Federal Maternal–Child
Health Funding
Direct Health Care Services (Gap Filling)
Examples: Basic Health Services and Health
Services for Children with Special Health Care
Needs (CSHCN)
Enabling Services Examples: Transportation,
Translation, Outreach, Respite Care, Health
Education, Family Support Services, Purchase
of Health Insurance, Case Management,
Coordination with Medicaid, WIC, and
Education
Population-Based Services Examples: Newborn
Screening, Lead Screening, Immunization,
Sudden Infant Death Syndrome Counseling,
Oral Health, and Injury Prevention
Infrastructure Building Services Examples:
Needs Assessment, Evaluation, Planning, Policy
Development, Coordination, Quality Assurance,
Standards Development, Monitoring, Training,

1609
 Applied Research, Systems of Care, and
Information Systems
Source: U.S. Department of Health and Human Services (2008).

In 1909, formal prenatal care was first provided in Boston by the

Instructive District Nursing Association and spread across the country to
outpatient clinics (MCHB, n.d.a). Since the inception of Title V, many
programs have been developed with the goal of improving the health of
women of childbearing age, as well as infants and children. Research areas
have included prenatal and pregnancy health, child development and
parenting, and improving health care systems and delivery of care, as well as
obesity, nutrition, medical homes, school services and outcomes, and
behavioral health (MCHB, n.d.b). Healthy Start grants were first awarded in
1991 to 15 agencies, with the goal of reducing rates of infant mortality, low
birth weight, premature births, and maternal deaths (MCHB, n.d.c).
Evaluation of Healthy Start programs reveals that almost all programs
provide home visitation to prenatal clients, and most continued these visits to
infants and toddlers. Health education, smoking cessation counseling,
services for perinatal depression, and involvement of male partners are
hallmarks of most programs.
In 2017, $374.4 million in grants were awarded to expand the Maternal,
Infant, and Early Childhood Home Visiting Program (Home Visiting
Program). This program provides C/PHN visits, assistance from social
workers, teaching from early childhood educators, and services from other
professionals to expectant families, much like the program designed by
David Olds (HRSA, 2018). Early improvements in six benchmark areas were
noted (MCHB, n.d.d, p. 3):

Maternal and newborn health

Child injuries, child maltreatment, and emergency department visits
School readiness and achievement
Crime or domestic violence
Family economic self-sufficiency
Service coordination/referrals for other community resources/support

Birth Weight and Preterm Birth

Birth weight is one of the most important predictors of infant mortality. Low
birth weight (LBW) refers to babies who weigh <2,500 g (or <5.5 lb) at
birth; very low birth weight (VLBW) refers to babies who weigh <1,500 g
(or <3 lb 4 oz) at birth. An estimated 15 million infants are born prior to 37
weeks of gestation, making them preterm, and this number is still on the rise
(Fig. 19-3; WHO, 2018b). Complications from infants born preterm led to 1

1610
million deaths in 2015 and are the number-one cause of death under the age
of 5 years.

FIGURE 19-3 Infant in the neonatal intensive care unit.

Infant complications of preterm birth include hearing and vision

problems; acute respiratory, gastrointestinal, and immunologic problems; and
central nervous system (CNS), motor, cognitive, behavioral, and
socioemotional disorders. A variety of growth concerns as well as acute and
chronic health and developmental problems often occur, and the families of
these infants are burdened with additional economic and emotional costs. In
a study of children from birth to age 2 years who were preterm as infants,
those with feeding difficulties or at risk for feeding difficulties had
significant neurodevelopmental problems, such as impaired cognition and
impaired language, motor, and socioemotional skills, that led to increased
parental stress, poorer maternal mental health, or increased family stressors
compared with those preterm infants who did not have feeding difficulties.
Maternal mortality, LBW, and VLBW are three areas requiring attention by
health care providers and the public health system. Nurses can contribute to
reducing these rates and societal costs through outreach, surveillance, health
teaching, counseling, and referral (Save the Children, n.d.).
In addition to infant deaths and LBW, the effects of pregnancy and
childbirth on women are other important indicators of health and reflect
discrepancies in access to reproductive health care. The United States is not
ranked among the top 10 countries in maternal–child health in the 2015
Mother's Index. It is ranked 33rd out of the more developed countries. The
U.S. ranking is largely due to poorer scores on the indices of maternal and
child health. The Eastern European countries of Slovakia, the Czech
Republic, Belarus, and Croatia and the developing countries of Peru and
Ethiopia rank higher than the United States (Save the Children, n.d.).

1611
 In the United States, the MMR is higher than in other developed
countries, mostly because of the disparities found among women of color.
The MMR for Blacks (42.4 per 100,000 live births) is between three and four
times greater than that for Whites (13.0), and the gap has continued to widen
since 1986, when the MMR surveillance was initiated (CDC, 2020e).
Pregnancy-related death risk increases with age and with lack of prenatal
care for women of every race, but the risk of pregnancy-related death for
U.S. Black women is three to four times greater than for White women. Even
though the rate of maternal deaths is low, most maternal deaths are
preventable.
One of the maternal–child objectives for Healthy People 2030 is to
improve the proportion of infants who are breastfed. Breastfeeding is
beneficial to both mother and infant, and recently, 79.2% of mothers reported
ever breastfeeding. Only 49.4% of U.S. infants were breastfed for the
recommended 6-month period, and 18.8% were breastfed exclusively for this
6-month period. It is estimated that if 90% of U.S. families would comply
with the recommended American Academy of Pediatrics guidelines
regarding exclusive breastfeeding, $3.7 billion in direct and indirect pediatric
health costs and $10.1 billion in costs related to premature death resulting
from pediatric disease would be saved (AmericanPregnancy.org, 2018). See
Box 19-3 for Healthy People 2030 maternal, infant, and child health
objectives.

BOX 19-3 HEALTHY PEOPLE 2030

Objectives for Maternal, Infant, and Child Health
Improve the health and safety of infants; prevent
pregnancy complications and maternal deaths;
improve women's health before, during, and after
pregnancy; and improve the health and well-being
of children.

1612
Reprinted from U.S. Department of Health & Human Services (USDHHS). (2020). Healthy People
2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

Adolescent Mothers
In 1991, after a steady 5-year upward trend, the United States reached a 20-
year high in the number of children born to teen mothers (aged 15 to 19
years) of 61.8 per 1,000. That trend then reversed, with 2007 marking a
decline in teen birth rates to 41.5 per 1,000. In 2018, the trend continued,
with 17.4 births per 1,000 females aged 15 to 19 years (Martin et al., 2019).
Furthermore, 38 states saw a decrease in birth rates among this age group
(Martin et al., 2019). The decrease in teen birth rate can be attributed to
several behavioral changes, such as decreased sexual activity, increased use
of contraception at first sex and at most recent sex, and the increased use of
contraception methods. Although the United States has seen a decrease in
teen births, the country continues to have much higher teen birth rates
compared with other developed countries, including Canada with a birth rate
of 6.6 per 1,000 (Elflien, 2019). See Chapter 20 for more on adolescent
pregnancy.
The Healthy People 2030 (USDHHS, 2020) document encompasses
specific goals and objectives for the maternal–child population, based on the
previous achievements in the same or similar areas. After years of working

1613
toward improving maternal–child health, the United States has made limited
progress. One objective, however, has been met; 70% of infants are now
sleeping on their backs, up from a 35% baseline. The rate for sudden infant
death syndrome had dropped by over 50% since 1994. This can be attributed
to the national public health education campaign known as “Back to Sleep”
(Eunice Kennedy Shriver National Institute of Child Development and
Health, 2016).

1614
Risk Factors for Pregnant Women and Infants
Most pregnant women in the United States are healthy; they have normal
pregnancies and produce healthy babies. Many factors contribute to the
health problems of those mothers and babies who figure in the statistics on
infant mortality and LBW. The factors associated with LBW and infant
mortality can be grouped into three categories (CDC, 2017b):
1. Lifestyle: Smoking, secondhand smoke exposure, inadequate nutrition,
alcohol consumption, substance abuse, late prenatal care, environmental
toxins, stress, violence, and lack of social support 2. Sociodemographic:
Maternal age below 15 or above 35 years, low educational level,
poverty, domestic violence, and unmarried status 3. Medical and
gestational history: Primiparity, multiple gestation, short interpregnancy
intervals, premature rupture of the membranes, uterine abnormality,
febrile illness during pregnancy, spontaneous abortion, genetic factors,
gestation-induced hypertension, less-than-ideal weight gain during
pregnancy, and diabetes
It is in the area of lifestyle choices that nurses can have the most
significant impact on pregnancy outcomes such as LBW, preterm birth, and
infant mortality. Programs that provide access to and funding for C/PHNs are
available through federal, state, and local funding (Box 19-4).

BOX 19-4 Evidence-Based Practice

Home Visiting There are many ways C/PHNs
can help moms and babies. One of the
programs in which a nurse can do this, in a
very fundamental way, is through the
NurseFamily Partnership (NFP) program. The
program was created by Dr. David Olds and
came out of his experience working in a
daycare. He quickly realized that to make an
impact, he needed to reach families earlier in
life. Thus, the NFP was born. Dr. Olds has done
research to test and improve the program in
Elmira, NY; Memphis, TN; and Denver, CO.
The results have been consistent; NFP improves

1615
 the lives of both moms and babies through the
tenacious work of a registered nurse (RN). The
program is guided by a robust theoretical
framework that includes; self-efficacy, human
ecology, and attachment theories. Nurses follow
a curriculum based on these theories from the
time the client finds out she is pregnant until
the baby turns 2 years old. NFP nurses go
through a rigorous and well-planned training
curriculum. This training includes courses in
Denver, Colorado at the National Service
Office, in a way that ensures fidelity to the NFP
model.
Previous research has been completed in 2002, 2004, and 2014
examining both paraprofessionals and nurses visiting clients. The
studies showed that RNs had a more significant impact on varying
outcomes of the program. The relationship that is formed between the
RN and the client is one based on trust and support. The client begins to
see the nurse as part of the family, and someone that she can go to with
any concern. The NFP nurse home visitor becomes a life coach, lifting
the client up in one of the toughest parts of a women's life pregnancy
and the first 2 years of motherhood. NFP nurses offer praise and screen
the baby to make sure milestones are being met. Parenting skills are
taught, references are made, if needed, and encouragement is given.
Clients can contact their NFP nurse with questions about their bodies,
their babies, future plans, relationships, and so much more. The program
provides the kind of consistency and advocacy that many of the clients
have never experienced. The NFP nurse is a true ally and fierce
advocate for both mom and baby in the critical early years of
motherhood.
Source: NurseFamily Partnership (2018a, 2018b); Olds et al. (2002, 2004, 2013).

Substance Use and Abuse

Another area of concern is substance use and abuse among the childbearing
population. The range of adverse consequences associated with the use of
tobacco, alcohol, and illicit drugs during pregnancy is wide and includes
preterm birth, LBW, and fetal alcohol spectrum disorders (described later in

1616
this chapter). This puts these women and their unborn children in double
jeopardy; not only are they at risk from the consequences of alcohol or drug
use, but also they do not receive the preventive prenatal care that can
eliminate or reduce other obstetric complications. This is most often related
to the pregnant woman's concerns about legal ramifications of substance use
while pregnant if they do seek care.
Substance abuse during pregnancy is a problem with staggering social
and medical implications, such as preterm births, LBW, miscarriage,
placental abruption, developmental delays, and child behavior and learning
problems later in life (American Pregnancy Association, 2016). The precise
rate of substance abuse among pregnant women is difficult to determine. In a
large study (n = 27,874) of substance abuse and pregnancy, 26.3% of the
women reported previous use and 2.6% current use. Adverse outcomes of
these pregnancies included LBW, preterm birth, babies born small for
gestational age, and admissions to neonatal intensive care units (NICUs).
The United States has seen an increased incidence of neonatal abstinence
syndrome (NAS) as a result of heroin or other opioid use in pregnancy, with
a NAS diagnosis every 25 minutes (Anbalagan & Mendez, 2020). The U.S.
Agency for Healthcare Research and Quality (2019) reports 7 per 1,000
newborns are hospitalized for NAS. Between 1999 and 2014, there was a
333% increase in NAS (Anbalagan & Mendez, 2020). The states with the
highest numbers of newborns hospitalized include West Virginia (48.1),
Maine (33.1), Delaware (26.4), and Kentucky (22.9), with South Dakota at
the lowest with 1.5 (U.S. Agency for Healthcare Research and Quality,
2019). Yet, not all states mandate the reporting of NAS, and/or states may
differ in the NAS definition, which causes problems in determining rates
(Anbalagan & Mendez, 2020). NAS occurs as a result of the sudden
discontinuation of fetal exposure to substances such as heroin or other
opioids during pregnancy. Withdrawal symptoms experienced by these
infants include irritability, excessive or high-pitched crying, tremors, and
gastrointestinal problems such as diarrhea. In the event that
nonpharmacologic care does not alleviate these symptoms, morphine is the
most commonly used pharmacologic treatment for withdrawal symptoms
related to NAS. The long-term effects of NAS are not fully understood
known due to socioeconomic and environmental factors of the mother, but
these children may have poor school performance, vision problems,
cognitive disabilities, neurodevelopmental delays, and higher mortality rates
(Anbalagan & Mendez, 2020). It is clear more research needs to be done on
this vulnerable population.
A lifestyle choice that includes the use of drugs during pregnancy and
results in maternal addiction has placed millions of children at risk. These
children are seen in NICUs, foster care, special education programs in the
public schools, and later in the juvenile court system. Family structure

1617
patterns are altered because grandparents may find themselves primary
caregivers for their grandchildren. A woman who uses alcohol or drugs may
lose her inhibitions and engage in high-risk sexual behaviors, which can
introduce other public health problems, such as acquisition of sexually
transmitted infections (STIs), including HIV, and possible spread of the
infection to the fetus or others (CDC, 2019g). The primary, secondary, and
tertiary prevention interventions of the C/PHN cannot be underestimated
when drug use takes such a high toll on every aspect of society.

Alcohol Use
Another societal problem is the use of and addiction to alcohol. It is difficult
to establish accurate statistics on the number of women who drink during
pregnancy, but results from the 2011 to 2013 Behavioral Risk Factor
Surveillance System indicate that roughly 1 in 10 pregnant women drank
alcohol within the past 30 days, compared with 53.6% of nonpregnant
women. Prevalence of binge drinking was 18.2% for nonpregnant women
and 3.1% for pregnant women, with a 4.6-times greater rate for unmarried
pregnant women (CDC, 2015b).
The conditions that can occur in a child due to maternal drinking of
alcohol during pregnancy are collectively known as fetal alcohol spectrum
disorders (FASDs). The most severe type of FASD is fetal alcohol
syndrome (FAS), which can result in facial abnormalities, delayed growth
and development, neurologic defects, learning and sensory problems, and
even death. What was once termed fetal alcohol effects, characterized as
causing some but not all of the symptoms of FAS, is now separated into the
more descriptive categories of alcohol-related birth defects, indicating
problems with hearing, bones, heart, and kidneys, and alcohol-related
neurodevelopmental disorder, represented by mental or functional
problems, including cognitive and/or behavioral abnormalities (CDC,
2020b). Physical signs of FASDs are often much more subtle than in cases of
FAS. However, those with FASD may have one or more of the following
behaviors or characteristics (CDC, 2020c):

Small size for gestational age or small stature in relation to peers

Facial abnormalities (e.g., smooth philtrum)
Poor coordination
Hyperactivity, attention problems, and learning disabilities
Difficulties in school, especially with math
Developmental disabilities (e.g., speech and language delays)
Intellectual disability or low intelligence quotient (IQ)
Vision and hearing problems; problems with heart, kidneys, and bones
Poor reasoning and judgment skills
Sleep and sucking disturbances in infancy

1618
 It is important to provide evidence-based primary prevention before
pregnancy and to reach women before drinking becomes such a part of their
lives that they are unable or unwilling to abstain during pregnancy. For
example, the Pregnancy Risk Assessment Monitoring System (PRAMS) is a
surveillance system developed by the CDC and state health departments to
collect population-based information on maternal preconception, prenatal,
pregnancy, and postpartum behaviors and experiences. Data collected from
2016 revealed that <10% of women used tobacco 3 months prior to
conception, and 7.1% continued to smoke while in the first trimester. This
percent dropped in each trimester, with a decrease to 5.7% in the third
trimester (Kondracki, 2019). Children are also at risk based on maternal
alcohol use during child-rearing, especially for adolescent mothers aged 15
to 19 years.
Working with women of childbearing age to improve their general health
behaviors and promote better preparation for pregnancy is essential. For
those pregnant women and mothers already using substances, maternal drug
and alcohol treatment programs that focus on supportive parent–child
attachment, enhancement of parenting and child-rearing capabilities, and
encouragement of the use of support systems that can improve child health
and cognitive development are needed. In-home family skills training and
parenting education programs that are evidence based and promote C/PHN
and client rapport can be effective methods of working with substance-
abusing mothers and their at-risk children; however, more studies are
recommended. In a systematic review of home visitation with alcohol-and
drug-using mothers, there was no significant reduction of substance abuse
among mothers entering drug and alcohol rehabilitation programs compared
with those receiving home visitation. However, individual studies showed
significance of home visitation in reducing these mothers' involvement with
Child Protective Services, indicating a positive effect on parenting and
childcare practices even if it did not effectively diminish the addictive
behavior (Dauber et al., 2017).

Tobacco Use
Tobacco use has increased dramatically among women, especially since the
women's movement of the 1970s, inevitably affecting maternal and newborn
health. The nicotine in tobacco is a major addictive substance, and smoking
is an addiction that many people find difficult to stop. Although the risk
factors of smoking are well documented, many pregnant women continue to
smoke. Smoking during pregnancy is one of the most studied risk factors in
obstetric assessment. Women, who may have started smoking as adolescents,
often continue to smoke in response to life stressors. From a population and
C/PHN perspective, one study found that the higher the density of tobacco
stores in a neighborhood, the higher the prevalence of smoking among

1619
pregnant women (Galiatsatos et al., 2020). The use of e-cigarettes, or vaping,
is considered to be a health danger for pregnant women and developing
fetuses. This nicotine delivery system poses threats to the baby. Also, the
exhaled aerosol that is advertised to be “water vapor” actually contains
nicotine and other chemicals such as metals, nitrosamines, and volatile
organic compounds (CDC, 2016b).
Passive smoking or environmental tobacco smoke (ETS)—exposure to
tobacco smoke from other people smoking in one's environment—also puts a
person at risk for smoking-related disease. The Surgeon General has outlined
major conclusions related to ETS based on years of research findings. One
conclusion is that there is no risk-free level of secondhand smoke. Related to
children and ETS, there is an increased risk of SIDS, more acute respiratory
infection, ear disease, worse asthma, and risk for poor lung growth (Dede &
Cinar, 2016). If a pregnant woman lives with a smoker, she and her fetus can
be negatively affected by the other person's addiction. An initial health
history of a pregnant woman should always include the assessment of
tobacco use, smoking status, and exposure to smoke in the personal
environment.
C/PHNs and other health care professionals must be involved in the
control of tobacco products on many levels, especially in health policy
development, community outreach, education, and advocacy. It is very
common to see smoking incentives and advertisements in poorer
neighborhoods and communities of color. It is also important to have skills in
smoking risk assessment, cessation options, and symptom management
interventions for smoking withdrawal. Nurses should serve as positive
nonsmoking role models and to be active in research implementation using
clinical guidelines and evidence-based practices. In the case of tobacco
control, health policy development has made important strides at the
grassroots level (see Chapter 13).
The C/PHN must not only advise clients to quit smoking but also offer
supportive and empathetic approaches to stress reduction during smoking
cessation, including methods or interventions that can help other symptom
management that is associated with smoking cessation. For example, the
C/PHN may counsel clients individually, refer for behavioral therapy,
provide self-help manuals, or recommend nicotine replacement therapy or
medication. Other approaches, such as support groups, can be helpful. Any
permanent reduction in the number of cigarettes smoked, amount of
secondhand smoke inhaled, or amount of smokeless tobacco products used is
helpful in improving the health of the mother and her fetus. Particular
attention should be paid to adolescent mothers (15 to 19 years), as their rates
of smoking are much higher than for adolescents of similar age who are not
mothers (Substance Abuse & Mental Health Services Administration, 2014).

1620
Intimate Partner Violence
Intimate partner violence (IPV) is any sexual, physical, economic, and/or
psychological abuse taken by someone against an intimate partner or ex-
partner (New York City Department of Health and Mental Hygiene, 2020).
Pregnancy is a vulnerable period for women and can increase their risk for
IPV. It is estimated that 1 in 6 pregnant women from all walks of life
experience IPV per year (March of Dimes, n.d.). Reasons for increased IPV
during pregnancy can be an unintended pregnancy, increased stress related to
supporting a child, and jealousy. These women may also avoid prenatal care
services for a variety of reasons such as injuries, control by their partners,
and a lack of resources such as transportation or money for mass transit.
Pregnant women who experience psychological IPV have a 1-fold increase in
the risk of suicidal ideation (Tabb et al., 2018). IPV can also have effects on
the newborn and infant. In a longitudinal study of women who had
experienced IPV, posttraumatic effects were found to have negative effects
on the infants' and toddlers' language and neurologic development (Udo,
Sharps, Bronner, & Hossain, 2016; see Chapter 18).

Sexually Transmitted Infections and Sexually

Transmitted Diseases
Although STI and STD have been used interchangeably for some time, there
are differences between the two terms. STIs refer to a person being infected
but asymptotic, and sexually transmitted disease (STD) is used when
symptoms are present (Rudderown, 2019). The CDC estimates the
prevalence of all STI cases in the general population to be 110 million, with
an annual incidence of 20 million, and health care costs of $16 billion. The
CDC (2016e) has recommended STD screening of all pregnant women at the
initial prenatal visit for Chlamydia, hepatitis B (and hepatitis C for high-risk
mothers), HIV, and syphilis. Further, they recommend screening high-risk
pregnant women for gonorrhea.
STIs can pass from mother to baby. Syphilis can cross the placenta and
infect the fetus, as can HIV—which can also be passed to the infant through
breastfeeding (CDC, 2016e). Congenital syphilis (CS) is on the rise at
alarming rates. Between 2012 and 2017, the rate of CS increased 750% in
California (California Department of Public Health, 2019). This increase is
seen across the United States, where there has been a 153% increase from
2013 to 2017 to 918 cases (Schmidt, Carson, & Jansen, 2019). Other STIs
(e.g., gonorrhea, hepatitis B, Chlamydia, genital herpes) can infect the baby
as it passes through the birth canal during delivery. LBW, stillbirth,
conjunctivitis, blindness, deafness, neurologic damage, chronic liver disease,
and cirrhosis, along with neonatal sepsis and pneumonia, are possible infant
complications of maternal STIs. Mothers may have premature rupture of

1621
membranes and resultant infection or may have a premature onset of labor.
Some STIs can lead to cervical and other cancers, pelvic inflammatory
disease, infertility, chronic hepatitis, and many other health problems (CDC,
2019f).
A pregnant woman who discovers she has an STI often feels ashamed,
betrayed, embarrassed, and angry. Those who are asymptomatic may not
realize they are infected or deny the existence of the disease and fail to carry
out the treatment plan after diagnosis. Although educating the pregnant client
about the effects of STIs is critical, providing information alone is not
enough. The C/PHN has a pivotal role in enhancing the empowerment of
women so they can act on the information they receive. The C/PHN engages
with pregnant clients and helps them understand that they have control over
their bodies. Usually, STIs are first discovered in pregnancy during routine
prenatal screening, which places the clinic nurse and the nurse who may
make home visits in the position to take an affirmative approach to treatment
and follow-up.

HIV and AIDS

There are 36.9 million individuals living with human immunodeficiency
virus (HIV). Almost 70% of all cases are found in sub-Saharan Africa
(WHO, 2016). Most children with acquired immunodeficiency syndrome
(AIDS) are children of HIV-positive mothers (WHO, 2020). Mother-to-child
transmission (MTCT) of HIV can be almost fully prevented with
antiretroviral treatment for mother and infant (WHO, 2020). To reduce
MTCT, women must seek prenatal care early enough in their pregnancies for
the antiretroviral drug to be effective. Antiretroviral therapy was provided to
an estimated 20.9 million persons in 2017 (HIV.gov, 2018).
Early detection of HIV/AIDs and antiviral therapy has shown decline in
the number of infants born with HIV since the height of the epidemic. A
large-scale study conducted from 2005 to 2012 examining the association
between mother and child HIV transmission in 15 jurisdictions of the United
States found that 2% were diagnosed with HIV. It was concluded that there
was an increased risk of having an HIV-infected infant among those mothers
who received late testing/prenatal care or no prenatal antiretroviral therapy
(Camacho-Gonzalez et al., 2015). An HIV-positive woman who is pregnant
or who has delivered a baby requires special nursing management of the
pregnancy and of the family after the birth of the newborn. There are many
teaching opportunities for the C/PHN during a high-risk pregnancy, such as
helping the client identify, change, or curtail high-risk behaviors and
promoting adherence to prenatal and HIV care. Success in changing
behaviors often requires an interdisciplinary approach of health care, social,

1622
emotional, and financial resources (Bungay, Massaro, & Gilbert, 2014; CDC,
2015a).
In the United States and other developed nations, HIV-infected women
are advised not to breastfeed their infants because there is a chance that the
infants will become infected with HIV from breast milk (CDC, 2020d). The
C/PHN focuses teaching on providing a safe, available, and low-cost form of
infant formula. In developing countries, the lack of clean water still makes
formula feeding dangerous, and breastfeeding is usually recommended. The
infection rate for HIV from breastfeeding and the mortality rate from formula
made with impure water are about the same, resulting in a dilemma for
women and health care providers in developing countries.

Poor Nutrition, Weight Gain, and Oral Health

Research has demonstrated a positive correlation between weight gain during
pregnancy and normal birth weight in the babies. In 2009, the Institute of
Medicine (IOM) released new guidelines for weight gain during pregnancy
based on body mass indices (BMIs). Weight gain between 25 and 35 lb
during pregnancy is recommended for women with BMIs ranging from 18.5
to 24.9, and the recommendation is 28 to 40 lb for underweight women with
a BMI under 18.5, whereas overweight women with a BMI between 25 and
29 should gain 15 to 25 lb, and obese women with a BMI over 30.0 should
hold their weight gain to between 11 and 20 lb (IOM, 2009). The American
College of Obstetricians and Gynecologists (ACOG) reaffirmed in 2016 that
the 2009 IOM gestational weight gain guidelines are important for clinicians
to use. It is recommended that clinicians determine a woman's BMI at the
initial prenatal visit and discuss weight gain, diet, and exercise goals initially
and throughout the pregnancy (Fig. 19-4; ACOG, 2013 and reaffirmed in
2016).

1623
 FIGURE 19-4 Weight gain during pregnancy should be monitored
regularly.

Obesity currently affects about 39.8% of all adults (CDC, 2018a).

Studies have shown that about 48% of pregnant women in the United States
gain more than the recommended amount of weight (CDC, 2016f).
Gestational diabetes poses the greatest risk to obese pregnant women and
increases the risk for preterm birth (CDC, 2017c). C/PHNs who work with
morbidly obese pregnant women can help them most by emphasizing good
nutrition and by encouraging them to maintain their pre-pregnant weight
without drastically reducing caloric intake. This can be accomplished
primarily by a marked decrease in consumption of “empty calories” from
junk food and replacing with increased intake of fruits, vegetables, and low-
fat sources of calcium. Pregnancy is never a time for dieting. Nutritional
counseling can have an additional benefit in that it may ultimately decrease
the risk of obesity or eating disorders in the client's children. For women who

1624
are prone to gaining too much weight, nutrition-rich, low-calorie foods are
recommended.
Exercise during pregnancy is essential and can moderate maternal weight
gain and improve overall fitness that is desirable for the labor and delivery
process. After assessment, the C/PHN can determine whether the unwanted
weight gain is related to the consumption of additional calories, to limited
activity, or to fluid retention. Each cause must be managed differently.
Underweight women have twice as many LBW babies as women whose
weight is within normal range. Nutritional teaching is part of the C/PHN's
role when working with a pregnant woman who has difficulty gaining the
recommended weight during pregnancy. Finding ways to add calories to
foods and increasing the woman's desire to eat are effective methods to
improve maternal weight gain. Insufficient caloric intake in pregnant
adolescents (who themselves are still growing) is an additional concern for
their future health and health of the infant over the life course.
Periodontal infection may affect around 40% of women of childbearing
age and is especially common among disadvantaged and ethnic or racial
minorities who may not have adequate access to dental health care. Maternal
periodontal disease has been linked to preterm birth, LBW, preeclampsia, and
early fetal loss; however, recent studies have not shown the reduction of
preterm birth or LBW among those infants whose mothers received
periodontal therapy in pregnancy. Although the research is conflicting, it is
evident that dental health procedures have generally been found to be
effective and safe for pregnant women, especially during the second
trimester (because of possible nausea during the first trimester and being
uncomfortable in the third trimester) (Mark, 2018). Not only is dental health
important during pregnancy, but poor dental hygiene and disease have been
linked to health conditions, such as cardiovascular disease and diabetes. High
maternal levels of the bacteria that cause cavities have been associated with a
greater chance of subsequent dental caries in the infant (CDC, 2019d).
C/PHNs should teach women of childbearing age the importance of
regular dental health checkups and proper dental hygiene, along with making
referrals for dental treatment when needed. Because there is frequently a
shortage of dental providers to see vulnerable or low-income women, the
nurse sometimes has to advocate for pregnant women who have major oral
health treatment problems, such as gingivitis or dental caries or infections.
Dental health should be a part of general primary preventive education for all
childbearing-age women and a major teaching and screening element of
prenatal care.

Socioeconomic Status and Social Inequality

1625
As noted earlier, poverty plays a role in pregnancy and birth outcomes.
Social and economic disparities are factors in preterm birth in both
developed and developing nations and reflect some of the social determinants
of health (SDOH). These relationships may be more indirect, as poorer
women often lack health insurance, have less access to quality prenatal care
services, have poorer nutrition, and are exposed to more situational and
psychological stressors. In the United Kingdom, a retrospective study with a
very large sample (n = 59,487) was done that focused on the poorly
understood factors that delay seeking antenatal care and engagement in that
care. Findings indicated that higher parity, pregnancy during the teenage
years, non-White ethnic background, unemployment, unmarried, poor social
support, and smoking were significantly associated with late access to
antenatal services and poor fetal outcomes (Kapaya et al., 2015). Prenatal
stress is difficult to research because of the multiple variables that can affect
prenatal stress. All areas of perceived stressors should be assessed (e.g.,
unintended pregnancy; nutrition; chronic stress and daily hassles; levels of
social support; mental health issues, such as depression or anxiety, work
stressors, racism, or discrimination; and any significant life events, such as
death or other significant losses).
A systematic review of literature looked at SDOH and pregnancy of
young people. Within the review, 17 of the studies found a link between at
least one SDOH and pregnancy among young people with the area of poverty
and family structure most represented (Maness & Buhi, 2016). Other critical
areas identified within the SDOH include neighborhood-built environment
(crime and violence and environmental conditions), social and community
context (family structure and incarceration/institutionalization), economic
stability (poverty and housing stability), and education (high school
graduation rates) (Maness & Buhi, 2016). The American College of
Obstetricians and Gynecologist identify the role of SDOH and the impact it
has on outcomes of health (ACOG, 2019). Social, economic, political, and
cultural structures contribute to reproductive health issues. Practices that
address inequalities are necessary for improving health outcomes while
addressing national morbidity and mortality inequalities. Consider the
following example. A C/PHN discovers during the interview that a pregnant
patient with gestational diabetes has not been checking her blood sugar
routinely. Rather than labeling the patient noncompliant, the nurse asks the
patient what challenges she has encountered that prevent her from
completing this task and discovers that the woman lacks a stable living
environment in which to keep her supplies. The C/PHN makes arrangements
with social services to address the housing concerns (ACOG, 2019).
The C/PHN can play a role in reproductive health care and equity.
Nurses can inquire regarding structural determinants such as access to food
and safe water. Does the client have utility needs, and is the home and

1626
community environment safe? Nurses can ensure access to social services
and other services to support needs (ACOG, 2019).
Prenatal care is crucial to ensure good outcomes of pregnancy. Studies
continue to reiterate the need for regular care visits, showing an association
between regular and early care and fewer preterm deliveries and higher
infant birth weights. Significant disparities in prenatal care are present
among Black, Hispanic, and American Indian/Native American women
(HRSA, n.d.). Access to obstetrical and gynecologic health care is difficult in
many areas of the country. It is at crisis levels in some rural areas. Lack of
adequate access to prenatal care leaves many pregnant women in danger
(Box 19-5). Other factors, outlined in more detail in Chapter 25, may also
affect the health of both mothers and babies.

BOX 19-5 PERSPECTIVES

A Nursing Student's Viewpoint on the Dangers of

Childbirth I began working as a nurse's aide at
our local hospital when I started nursing school. I
learned firsthand the dangers of childbirth and
the consequences that can result. One night, a
female reported to the emergency room in labor
and was admitted to the labor and delivery
department. The young mother-to-be was very
excited. Her contractions continued, though she
did not progress with the labor process, so she was
to be started on oxytocin (Pitocin) to increase the
effectiveness of her labor. The nurse midwife
checked on her patient frequently, but problems
began after the first 8 hours of labor. As the
dosage was increased, the fetus reacted with
bradycardia, and the nurse midwife did not notify

1627
the physician. The Pitocin dosage was decreased
and then the heart rate stabilized; this process
continued for three cycles. The nurse midwife
signed off her 12-hour shift and handed care of
the patient over to the nurse midwife coming on
shift. Again, whenever the Pitocin dosage was
increased to the point of becoming effective, the
fetus would respond with bradycardia. The
physician in charge was still not notified. After 24
hours of a failed labor process and at this point
severe bradycardia, and the fetus was in
irreversible distress. The physician was finally
notified of an emergency and reported to the
bedside within 5 minutes. An emergency cesarean
section was performed. The Apgar scores at
delivery were 0, 0, 0, and 3 after 15 minutes of
resuscitative effort. The infant was severely
neurologically damaged. I found out later that the
infant was diagnosed with severe cerebral palsy
and will never walk, talk, or feed normally. She
cannot swallow and will require suctioning,
gastrostomy tube feeding, and total care
throughout her lifetime. She is also cortically
blind. A multimillion-dollar award was given, and
the nurses and nurse midwives employed by the
hospital were fired due to negligence. It is sad to
think that this tragedy could have been avoided
with prudent nurse–patient advocacy, reporting,
and appropriate documentation—the things our
nursing instructors are always drumming into our
heads. I know that as a new graduate, I am now in

1628
a position of responsibility to make decisions to
notify the physician or not. I have decided that the
choice should always be to notify the physician.
Even though it may seem inconvenient, it really
should be done. I will never forget this case and its
long-reaching consequences for the child and
family, as well as for the nursing staff and nurse
midwives.
Lyndsay, student nurse

Adolescent Pregnancy
Pregnancy during the adolescent years (13 to 19 years old) is considered a
health risk because of the ongoing physical growth and the demands of
psychosocial development during these years. The United States leads most
developed nations in the rates of teenage pregnancy, abortion, and
childbearing. Young maternal age at time of pregnancy and birth creates
several medical risks for the mother and baby. Teen pregnancy is discussed
further in Chapter 20.

Maternal Developmental Disability

For couples that are developmentally disabled, having a child puts increased
stress on a system that is already burdened. Parenting requires attending to
not just the child's physical care but socialization and developmental
stimulation, well-child and illness health care, emotional nurturing, and age-
appropriate supervision. Depending on the social support, and coping skills
of the developmentally delayed parent, the stress and need for emotional
control and positive decision-making can be monumental. Evidence from a
seminal cohort study in Britain found that, for 4-to 6-year-olds, there was “no
association of parental IQ with conduct or emotional problems” in the
children; however, for children age 7 into adolescence, “strong evidence was
observed” between lower parental IQ and child “conduct, emotional, and
attention problems” (Whitley, Gale, Deary, Kivimaki, & Batty, 2011, p.
1032). Confounding variables included the environment of the home,
parental affect, and child IQ. Even though there may not be strong evidence
for these problems, children are still at risk for under-stimulation and
environmental insecurity. Parent training/childcare skills programs, peer-to-
peer support groups, community agencies, and careful home monitoring can

1629
reduce the risk of child abuse and neglect and promote more effective
parenting (Promising Practices Network, n.d.).
How does the C/PHN work with developmentally disabled parents
effectively? Most importantly, nursing support must enhance the natural
resilience of the family.
The establishment of a trusting relationship between the nurse and the
family is of foremost importance. Teaching by demonstration with many
visual aids and prompts, along with games and creative approaches to engage
and sustain attention, can challenge the nurse's creativity. Modeling of
appropriate parenting behavior needs to occur on each visit. Supervision and
monitoring of family functioning must continue until the child reaches
adulthood. As part of the transition to other systems of care, C/PHNs often
advocates for families with maternal developmental disability regarding the
plan of care, interpreting it for other professionals and multiple disciplines.
Many agencies employing nurses cannot provide the intensive follow-up that
such a family requires. It is then necessary to make referrals to organizations
that can provide support, such as the American Association of Retarded
Citizens or Exceptional Parents Unlimited. The nurse may stay involved as a
consultant to the paraprofessionals or make periodic home visits at times of
developmental or situational crisis.

1630
Complications of Childbearing
Some maternal deaths are not preventable (e.g., amniotic fluid embolism).
Morbidity is also a factor, and although some major risk factors among
pregnant women and infants have been discussed, several common medical
complications of childbearing bear mentioning. The effects of hypertensive
disease in pregnancy, gestational diabetes, postpartum depression, and grief
in families who have lost a child are important areas in which the C/PHN can
intervene effectively.

Hypertensive Disease in Pregnancy

Hypertension in pregnancy may be chronic or related specifically to
pregnancy. Chronic is diagnosed prior to 20 weeks of gestation, and
gestational (pregnancy related) is diagnosed after 20 weeks but goes away by
6 weeks postpartum. Chronic hypertension affects 1% to 5% of pregnancies
and gestational about 5% to 10% (Friel, 2017).
Preeclampsia results in new-onset high blood pressure and protein in the
urine, along with nondependent edema, and can result in eclampsia
(characterized by convulsions and/or coma), pulmonary edema, liver rupture,
renal failure, disseminated intravascular coagulopathy, and cortical blindness,
as well as maternal death. The effects from pregnancy-induced hypertension
on infants are often serious because placental health is associated with fetal
growth (Dulay, 2017). Preeclampsia occurs in about 3% to 7% of
pregnancies, with 25% of cases developing in the postpartum period (Dulay,
2017). Various methods are employed to attempt to prevent and control
hypertension during pregnancy, namely, careful and constant monitoring of
blood pressure, use of blood pressure medications if needed, frequent
prenatal visits with monitoring of lab tests, a diet rich in fresh fruits and
vegetables, lower sodium food choices, adequate fluid intake, weight gain
limitations, rest, and regular exercise. Intermittent fetal monitoring may be
required. These remain the most common preventive suggestions that
C/PHNs, in collaboration with the clients' primary health care providers, can
give to their pregnant clients. A calm environment, periods of rest, and the
pregnant woman either elevating her feet or reclining in a left side lying
position are also recommended. Additional assessment data may guide the
nurse to focus teaching on stress reduction techniques and modification or
elimination of smoking. As care providers C/PHNs can provide frequent
monitoring of blood pressure and other symptoms and encourage the client to
be vigilant in keeping prenatal appointments. However, medication or even
hospitalization may be necessary. The C/PHN can offer support and
understanding while continuing to be a resource for the client as the
pregnancy progresses and the infant is born.

1631
Gestational Diabetes
Gestational diabetes mellitus (GDM) occurs in pregnant women who have
never had a problem with high blood glucose but do during pregnancy. The
average onset for GDM is around the 24th week of pregnancy (American
Diabetes Association, n.d.). GDM is estimated to occur in about 2% to 10%
of pregnancies in the United States (CDC, 2017b). For the mother with
GDM, there is a higher risk of hypertension, preeclampsia, urinary tract
infections, cesarean section, and future risk of type 2 diabetes. As far as
pathophysiology, GDM is similar to type 2 diabetes, and 50% of women with
GDM eventually develop type 2 diabetes during their lifetimes. Because
growth and maturation of the fetus are closely associated with the delivery of
maternal nutrients, particularly glucose, maintenance of appropriate glucose
levels is essential to the health of the fetus. Daily self-monitoring of blood
glucose levels is recommended. Women should be encouraged to monitor
blood glucose levels regularly 6 weeks postpartum and periodically
throughout their life (CDC, 2017c).
The infant is at increased risk for fetal death because GDM has been
associated with macrosomia, or large-for-gestational-age babies, birth
injuries such as broken shoulders, breathing problems, and abnormally low
blood sugars at birth (CDC, 2017c). The C/PHN can help in the control of
GDM by encouraging early prenatal care, adequate nutrition, rest and
exercise, and adherence to the particular dietary, activity, and blood glucose
monitoring regimen suggested by the woman's health care provider. Those
C/PHNs working with pregnant women should provide education on early
warning signs for GDM and the importance of regular prenatal care,
reminder about getting the glucose tolerance test around the 24th week of
pregnancy, and follow-up.

Postpartum Depression
Although most people recognize the common fleeting mood swings
immediately after childbirth known as “baby blues,” high-profile cases like
Andrea Yates, who suffered from postpartum psychosis and drowned her five
small children, are rare (1 or 2 per 1,000 births) but nonetheless tragic
(Criminal Justice, n.d.). Actresses Chrissy Tiegen and Reese Whitherspoon,
among others, have discussed their postpartum depression and treatment with
antidepressant medications, making this condition more visible and less
stigmatizing (Davis, 2016).
According to need studies, one in seven women will experience
postpartum depression (Lieber, 2018). Also, depression and posttraumatic
stress disorder have been found in both mothers and fathers subsequent to a
healthy birth following a prior perinatal loss (Gundersen Health, n.d.). Risks
for postpartum depression include a family history of psychiatric illness,

1632
poor social support, stressful life events, anxiety during pregnancy, the
personality traits of neuroticism, and more recently perfectionism (National
Institute of Mental Health [NIMH], n.d.). Depression can affect anyone, even
women without a history of prior depression. Perinatal depressive symptoms
may not indicate major clinical depression. Nevertheless, symptoms may
cause considerable psychological distress, such as irritability and
restlessness; feeling hopeless, sad, and overwhelmed; having little energy or
motivation and crying unexpectedly; sleeping and eating too little or too
much; problems with cognition (memory, decision-making, focus); loss of
pleasure or interest in usually pleasant activities; and withdrawal from family
and friends (Fig. 19-5).

FIGURE 19-5 C/PHNs need to watch for signs of postpartum

depression among their clients and offer assistance.

There are several nonpharmacologic interventions the nurse can initiate

in addition to the ones mentioned above. First, caffeine can lead to sleep
disturbance, and alcohol is a depressant that has been implicated in
depression. A simple yet helpful suggestion is the elimination of both.
Getting adequate sleep is important because sleep deprivation exacerbates
psychiatric symptoms. Napping when the baby naps, resting when possible
throughout the day, and going to bed early (albeit with the knowledge that
sleep may be interrupted two or more times to feed the infant) will provide
more hours of rest and sleep. Exercise is helpful and raises levels of
endorphins. Anxiety symptoms often coexist with depression. Relaxation
techniques that reduce anxiety can be helpful, including listening to relaxing
music, doing yoga, or performing a simple exercise routine. Having a daily
routine and setting realistic goals are also helpful (NIMH, n.d.). Participation
in a support group allows women to identify with others who may be

1633
experiencing similar difficulties. Through discussion, women provide each
other with both emotional and practical support.
C/PHNs can intervene by initiating primary preventive mental health and
coping measures that promote mental health throughout pregnancy and the
postpartum period. Helping pregnant women to appreciate themselves and
their strengths, embrace their new body changes, and positively anticipate
their new role is primary preventive intervention for good mental health and
promotion of attachment to their infant. If women are assessed to be at risk,
mental health resources can be identified, and then, positive mental health
outcomes may be fostered by supporting their self-esteem, optimizing the
quality of their primary intimate relationships, anticipatory guidance on
issues that may arise during pregnancy and the postpartum period, and
reducing day-to-day stressors. At times, the nurse's efforts alone are not
sufficient, and a referral to community mental health services for early
detection and treatment is essential for the women and their children.

Fetal or Infant Death

An infrequent role for nurses in maternal–child health is that of grief
counselor, but this may be a role for the advanced practice nurse in certain
settings or communities. A couple may experience a miscarriage or ectopic
pregnancy, stillbirth, or the death of an infant from sudden infant death
syndrome (SIDS). The exact cause of SIDS is not certain, but it may be
associated with brainstem control of heart and lung functions (Illinois
Department of Public Health, n.d.). It is more common in boys and most
often occurs in infants between 1 and 4 months of age (Safe to Sleep, n.d.).
Increased rates of SIDS are associated with side/stomach sleeping position,
exposure to cigarette smoke, premature birth, cosleeping, having a sibling
that died of SIDS, and soft bedding in the crib. SIDS is the leading cause of
death for infants from 1 to 12 months of age; about 2,000 infants die
annually from SIDS. Since 1990, the SIDS rate has dropped, but the rates for
Black and American Indian/Alaska Native infants are disproportionately
higher (Illinois Department of Public Health, n.d.).
In each situation of loss, the C/PHN has an important supportive role.
People respond to grief in a variety of ways: some express deep sadness,
shock, or disbelief; some weep and are unable to talk; and others talk
incessantly about regrets or guilt. Even if a miscarriage occurs early in a
pregnancy, the bonding between the mother and fetus has begun, and
expressions of grief may be as intense as with the loss of an infant or child.
Women often have feelings of abandonment, bereavement, and guilt,
thinking that they did something wrong. When parents are unable to identify
the exact cause of their fetal loss, they have a more difficult time letting go of
grief and anxiety. Increased anxiety levels are also found, sometimes more

1634
frequently than depression. Psychological counseling has been associated
with greater decreases over time in levels of worry, grief, and self-blame
(Gundersen Health, n.d.). For couples that have delivered a stillborn baby,
the shock is compounded by the experience of carrying the pregnancy to full
term, along with the anticipation of an imminent delivery and the expectation
of an addition to the family. This is especially true if all signs before the
birthing event itself were positive.
Mothers who experience stillbirths recognize the need for spiritual and
psychosocial support from professional caregivers. Families must
acknowledge the death of the child and integrate the loss into their family
lives. Home visitation and simply being there for the family and listening
well are invaluable nursing interventions. Referral to mental health
counseling or support groups specific to parents of stillborn children where
they can share their feelings may be very helpful (March of Dimes, 2019).
Providing continuity and support to the family for months after the death of
an infant gives the C/PHN an opportunity to assess the family for signs of
unresolved grief. Grieving families may find comfort, support, and helpful
information from support groups and resources such as Compassionate
Friends or First Candle. When a family experiences loss of an infant after the
baby has been brought home from the hospital, grief and guilt are
compounded by the loss of an anticipated future and the disrupted continuity
in family life. An infant may die of SIDS, a congenital anomaly, an infection,
or an accident. There are constant reminders of the infant's presence in the
home from memories, photos, videos, and accumulated possessions. This
death disrupts family homeostasis and the psychological and physiologic
equilibrium of the family. In many cases, the police are involved, and an
autopsy is required, contributing to the anguish of the grieving family. This
promotes both guilt and loss of self-esteem and can even threaten the
marriage.

1635
INFANTS, TODDLERS, AND
PRESCHOOLERS
Healthy children are a vital resource to ensure the future well-being of
nations. They are the parents, workers, citizens, leaders, and decision makers
of tomorrow, and their health and safety depend on today's decisions and
actions. Their futures lie in the hands of those people responsible for their
well-being, including the C/PHN, whose dominant responsibility is to the
community and populations, such as dependent children.
The well-being of children has been a subject of great public health
concern globally and in the United States. Its importance has been
emphasized through development of numerous laws and services, yet the
needs of many children continue to go unmet. Young children (up to age 4
years) are totally dependent on their caregivers. This contributes to their
vulnerability during these years. Many young children often go to bed
hungry; some infants and toddlers do not receive even the most basic
immunizations before they reach school age. Accidents and injuries are a
leading cause of death; preventable communicable diseases increase
mortality among the very young.
Adverse childhood events (ACE) are potentially traumatic events that
occur in childhood (aged 0 to 17 years) such as experiencing violence or
abuse, witnessing violence in the home or community, and having a family
member attempt or die by suicide (CDC, 2019e). Any aspect of a child's
environment that can undermine their sense of safety, stability, and bonding
are linked to chronic health issues, mental illness, and substance abuse as an
adult. According to the CDC (2019e), 61% of adults surveyed in 25 states
reported experiencing at least one type of ACE; one in six reported
experiencing four or more types of ACEs. Women and minority groups are at
greater risk for experiencing four or more types of ACEs. The CDC-Kaiser
Permanente Adverse Childhood Experiences (ACE) study is the largest
investigation of childhood neglect and abuse showing the effects of violence
exposure and later-life health and well-being (Felitti et al., 1989). This
seminal study identified seven categories of adverse childhood experiences
that were corelated with multiple health risk factors later in life. ACE can
have lasting and negative effects on children, increasing the risk of injury,
maternal and child health problems, teen pregnancy, sex trafficking, STIs,
and a wide range of chronic diseases. It is estimated that the effects of ACEs
can cost families, communities, and society billions of dollars each year
(CDC, 2019e).

1636
 Home environment and safety are current areas of concern for many
children and families. Children in families make up approximately 33% of
the homeless populations (National Alliance to End Homelessness, 2020).
Point in time data show 56,342 family households identified as homeless,
with approximately 16,000 families living on the street, in a car, or in other
places not designated for human habitation. Typically, homeless families are
headed by single women as head of household with limited education
(National Alliance to End Homelessness, 2020). Children who are homeless
have higher levels of emotional and behavioral problems and may have
lower academic performance due to transience. Access to services and
transition into permanent housing provides stability (National Alliance to
End Homelessness, 2020). See Chapter 26 for Working with the homeless.
Whereas the United States provides leadership in many arenas, its failure
to protect and promote the health of its youngest citizens represents a
significant population health breakdown. However, in many other nations—
mostly less-developed countries—child health and well-being are in even
greater jeopardy.

1637
Global History of Children's Health Care
Only recently in the history of the world have children been considered
valuable assets, even in countries where there are now well-developed
programs of infant health promotion and protection, infant and child day care
services, and strict educational expectations for all children. In some
countries today, however, female infants and children or those born with
congenital anomalies are not valued. Countries, such as India and China,
provide inequitable care for male and female children. Gender-selective
abortions or infanticide also occur. Some birth, growth, and developmental
rituals are harsh and would be considered illegal if judged by Western
standards. Cultural practices that are fostered by political forces prevent
many countries from improving the health of infants and young children
(Save the Children, n.d.). For these reasons, there are great differences
globally in child health care systems. The health of children in one country
can affect that of children in other countries, including the United States.
Major natural disasters place whole populations at risk, especially the very
young and the very old.

1638
National Perspective on Infants, Toddlers, and
Preschoolers
The infant (birth to 1 year), toddler (aged 1 to 2 years), and preschooler
populations (aged 3 to 4 years) are generally healthy years. Most U.S.
children have a usual source of health care (96.9%), and their parents report
them to be in excellent or very good health (CDC, 2017b; Larson, Cull,
Racine, & Olson, 2016). Growth and development of infants and young
children should be monitored regularly. Pediatricians and C/PHNs often
provide anticipatory guidance for parents so that they better understand what
to expect as their child grows and can plan for safety issues that may arise.
See for a link to online growth charts.
The mortality rate for children ages 5 to 14 years is 13.0 per 100,000.
Major causes are unintentional injuries (motor vehicle crashes, falls,
drowning, fires, and burns), cancer, and suicide (CDC, 2016c). Some
variation in mortality rates continues among racial/ethnic groups.

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Accidents and Injuries
Toddlers and preschoolers are at risk for many types of accidents and
unintentional injuries, such as those caused by unsafe toys, falls, burns or
scalding, drowning, motor vehicle crashes, and poisonings. These
unintentional injuries are the leading cause of mortality and morbidity for
children from age birth to 19 years (CDC, 2016c). Male children have higher
rates of death from injuries than females; it is almost twice the rate. Causes
of injury deaths vary across age groups. For those children under age one,
about 66% are caused by suffocation. Between ages 1 and 4, drowning is the
leading cause. In 15-to 19-year-olds, being a passenger in a motor vehicle
crash was the most frequent cause of injury death. American Indian/Alaska
Native children had the highest death rates from injury, and Asian/Pacific
Islander children had the lowest. The loss of children's lives resulting from
all injuries combined represents a staggering number of productive life years
lost to society. Childhood unintentional injuries lead to almost 12,175 deaths
annually (CDC, 2017b).
The National Action Plan for Child Injury Prevention addresses child
safety and provides an agenda for injury prevention (CDC, 2012). It brings
together 60 partners in implementing injury prevention activities and
providing a blueprint for collecting/interpreting data and surveillance and
plans to promote research and enhance communication/education/training on
injury prevention. Improving the outcomes of childhood injuries by working
with health care and health systems and supporting strong policies to prevent
injuries are further goals. Risks for childhood injuries that increase child
vulnerability include “poverty, crowding, young maternal age, single parent
households, and low maternal educational status” (CDC, 2012, p. 9). Using a
public health model, the three levels of prevention are utilized to prevent
injuries from occurring (e.g., safety latches on cabinets containing cleaning
supplies or medications), minimize injuries (e.g., child safety seats), and
improve emergency response and care after injury occurs (e.g., paramedic,
trauma care). For instance, to prevent infant suffocation and SIDS, infants
should go to sleep on their backs, in a crib or child-friendly bed without soft
bedding or pillows, and parents should be cautioned about risk factors for
SIDS and the potential dangers of sleeping with their babies. Information
about the SIDS prevention campaign Back to Sleep should be provided to all
parents of infants, and education should begin with hospital nurses and
continue with C/PHNs in the community.
Burn injuries can affect children of all ages. Bath water that is too hot
can also cause serious scalding injuries. Cigarette lighters and matches are
fascinating to young children. Toddlers or preschoolers may be able to start a
flame, injuring or killing themselves or others. The sound of a smoke alarm

1640
may frighten young children, and it is important for C/PHNs to instruct
parents not only to teach their young children about fire prevention but also
to be aware of the sound of the alarm and know what actions to take when
they hear it, such as the Stop Drop and Roll program taught in Head Start and
other preschool programs (National Fire Protection Association, n.d.). The
C/PHN should also take every opportunity on home visits and in other health
education settings to ask or observe if parents have a functional smoke
detector in their home. Most community fire departments will install and test
smoke detectors for free. Preventing the sources of injury or death from
burns may be accomplished by eliminating opportunity and source. Through
child supervision, safe storage of matches and lighters, and keeping children
away from stoves and electrical outlets, burns and fires can be prevented.
Drowning is another category of unintentional injury in children. Brief
lapses in supervision can have disastrous consequences. Young children are
at risk for drowning wherever water occurs in depths exceeding a few inches
—such as in toilet bowls, bathtubs, mop buckets or cans filled with
rainwater, puddles, ponds, spas, and swimming pools. Lakes, rivers, streams,
and irrigation ditches or canals are other water hazards. Infants, toddlers, and
preschool-aged children are especially vulnerable because they are not aware
of water dangers and they explore without fear. Poor children, especially
children of color, are at higher risk for drowning because of lack of access to
swimming lessons. The C/PHN can work with community groups and
recreation centers to promote swimming for children. Parents need to provide
a drown-free environment. Guidelines include the following (American
Academy of Pediatrics, 2016; CDC, 2020a; Government of Alberta, 2018):

Bathe young children in shallow water.

Never leave young children unattended during a bath.
Keep toilet lids down and bathroom doors closed—preferably secured
with childproof safety handles.
Never leave full mop buckets unattended.
Eliminate water collection sites around the home by turning over or
removing empty buckets, containers, flowerpots, and other items that
can collect rainwater.
Fence swimming pool areas and install childproof locks or alarm
devices that sound when the water is disturbed.
Promote water safety measures, including teaching young children to
swim.
Be aware of the dangers of open pool drains and suction outlets that can
lead to drain entrapment and hair entanglement and ensure that drain
covers and safety vacuum-release systems are installed.
Vigilant supervision of young children at play to prevent involvements
with neighborhood water sources

1641
 Supervising children in or around bathtubs, spas, pools, or other water
receptacles is critical and requires close (arm's length) distances. Parents of
young children should be encouraged to get cardiopulmonary resuscitation
training. The real dangers of accidental drowning are related in Box 19-6.

BOX 19-6 STORIES FROM THE

FIELD
Mop Bucket Drowning I am a Head Start
nurse, and one of my assigned centers is located
within a farm-labor camp. There are many
large, hardworking families in the camp. Older
siblings often watch over young children and
help with household chores. Most families keep
their cinder block homes tidy and clean, and
floors are constantly being mopped (no one has
carpeting—it is a bare-minimum type of
accommodation). One day, several children
were absent from school, and when I made
home visits to determine the cause of the
absences, I discovered that one of the Garcia
family's children, a toddler named Miguel, had
unexpectedly died. Because many of the absent
children were cousins, parents had kept them
home while attending to the family. I knew the
Garcia family well, and when I stopped by to
check on them, they told me that Miguel had
fallen into a large mop bucket the older sister
had been using to clean the kitchen floor. She
had gone outside for just a minute to separate
the 5-year-old twins who were fighting, and
when she returned, she found Miguel headfirst

1642
 in the bucket. She tried to revive him but could
not. The parents were working, trying to earn
extra money for an elderly grandmother who
needed surgery, and only learned of the tragedy
when they returned home at the end of a long
day. It was a very sad situation, and it reminded
me of how even an everyday item can become
deadly. Safety and prevention of unintentional
injuries, especially with curious toddlers and
preschoolers, is extremely important to teach all
families.
1. Address levels of prevention as this concept relates to childhood
accidents. What could you do now to assist this family?
2. What strategies can C/PHNs use in their community to prevent
drowning situations like this from happening again?

Myra, Head Start nurse

Injuries and deaths from motor vehicle crashes continue to be a major

safety problem in the United States. Of the 23,714 vehicle fatalities in 2016
only about 53% to 62% of drivers and passengers were wearing safety
restraints (CDC, 2017d). A recent study found that more than 685,000
children ages 0 to 12 were not correctly placed in child safety seats or
boosters as least at some point (CDC, 2017a). Many families have them and
use them regularly but do not install them properly, placing the child at as
much risk as if there were no restraint. The most current recommendations
for safety seat use are categorized by age. For children birth up to age 2
years, a rear-facing seat should be used (placed in car's back seat); the child
should continue in rear-facing seat until reaching the height or weight limit
of the seat placed in the back seat; age 2 to at least 5 years, child should use
forward-facing car seat until reaching upper weight and height limit for the
seat; age 5 years and up, keep child in back seat with a seat belt–buckled
booster seat until they reach height limit of 57 in. and can use a car seat belt
alone; seat belts are considered to be properly fitting when the lap belt
portion lays across the upper thighs (not stomach area) and the seat belt lays
across the chest and not the neck (CDC, 2016a). There is much opportunity
in this area for the C/PHN to educate the public and ensure that parents have
the information and skills to secure their children properly when traveling by

1643
car. Safety seat clinics, where installations are checked and corrected, can
help to promote the proper use of age-appropriate child restraints (Box 19-7).

BOX 19-7 Evidence-Based Practice

Getting Families to Use Child Booster Seats

Many health departments, law enforcement, and social service agencies

educate parents about the laws and benefits related to the use of child safety
seats. Still, not every family consistently uses them. Education and
awareness are essential to increase the use of child safety seats.
The Strike Out Child Passenger Injury (Strike Out) intervention program
provided booster seat education for children ages 4 to 7 years at instructional
baseball programs in four states. Twenty communities participated in the
nonrandomized, controlled trial. The study tested the effectiveness of the
education program before and after baseball season in increasing proper
restraint use among participating children.
Findings revealed that the intervention program did increase the use of
child restraint use in three of the four participating states (Alabama +15.5%,
Arkansas +16.1%, and Illinois +11.0%). The study reinforces the importance
that unique interventions can positively influence child safety use. It is
essential for C/PHNs to use evidence and a variety of approaches to combat
public health problems. For more information on selecting the proper car seat
for children according to age and size, visit:
https://www.cdc.gov/features/passengersafety/index.html.
Source: Aitken et al. (2013).
Poisoning is a constant safety concern for young children, and toddlers
are most often at risk. Sources of poisoning include household plants,
prescription medications, over-the-counter drugs, unintentional medication
overdoses, household cleaning products, other chemicals stored within a
child's reach, and lead. Parents should be provided with the number for the

1644
Poison Help Hotline (1-800-222-1222) and encourage them to post it next to
each telephone and call immediately in the event of a suspected poisoning or
overdose (American Association of Poison Control Centers [AAPCC],
n.d.b). They can also educate and demonstrate for parents how to childproof
the home by eliminating major sources of poisoning. This includes keeping
plants out of a child's reach or eliminating them from the home until the child
is older, locking up household chemicals (e.g., toilet bowl cleaner, bleach,
mouthwash, oven and drain cleaners, pesticides, gasoline, paint thinner, hair
products) and storing them out of a child's sight and reach, using childproof
medication containers, and storing all medicines in a locked box with a key
that is kept out of reach (AAPCC, n.d.a). Alcoholic beverages should also be
kept out of reach, as should tobacco products. Outside hazards, such as wild
mushrooms and poisonous plants, flowers, and berries, must also be
considered (AAPCC, n.d.b). It is also important to eliminate sources of lead
in and around the home.

1645
Lead Poisoning
Lead poisoning historically resulted in encephalopathy and death. Today,
morbidity from lead poisoning is subtle and most often affects the child's
CNS with long-term changes in behavior and IQ. The CDC estimates that
half a million children between the ages of 1 and 5 years have elevated blood
lead levels, or 5 μg of lead per deciliter of blood (CDC, 2018i). Lead in
paint, dust, and soil can be inadvertently consumed, and lead also crosses the
placental barrier. It can be transferred in breast milk and is also found in
some infant formulas (American Academy of Pediatrics, 2018b). Lead is one
cause of childhood poisoning. There is no safe level of lead, and the
elimination of elevated blood lead levels in children is a U.S. Health Goal.
The primary sources of lead exposure in preschool-aged children continue to
be lead-based paint and lead-contaminated soil and house dust. The critical
age of exposure (or peak level) is thought to be between ages 18 and 36
months. Levels generally begin to decline after age 3 years. Children who
live in poverty and play in substandard housing areas remain at risk for direct
exposure to significant sources of lead. Lead safety and housing code
enforcement, along with periodic monitoring to detect new lead hazards, can
help prevent future lead exposures. C/PHNs working together with
environmental health sanitarians, should promote opportunities for blood
lead screening, especially if it is suspected that children in certain homes,
apartments, or neighborhoods are at risk for lead poisoning. Children have
also been exposed to lead in some toys, candies, cosmetics, traditional
medicines, and eating or drinking utensils imported from other countries.
Many of these have been tested and revealed to have high levels of lead.
Education and public awareness campaigns can help prevent this type of lead
poisoning. The C/PHN can alert clients to the dangers of lead and its sources
and work as an advocate for policies to reduce this danger for infants and
children. See Chapter 9 for more on lead poisoning and water contaminated
with lead.

1646
Child Maltreatment
An estimated 678,000 children were victims of child abuse or maltreatment
in 2018 (National Children's Alliance, 2019). Child maltreatment includes
physical, emotional, and sexual abuse and neglect (e.g., withholding feeding
or medical care) that occurs in anyone under 18 years old. Neglect is more an
act or acts of omission in which a child's basic needs are not met. Children
under age 4 years are at the greatest risk for severe abuse and neglect (CDC,
2018k). Shaken baby syndrome is often an overlooked form of abuse.
Abusive head trauma, which includes shaken baby syndrome, is the leading
cause of all child maltreatment deaths (National Center of Shaken Baby
Syndrome, 2020). Shaken baby syndrome can be suspected in infants or
toddlers who exhibit traumatic brain injuries caused by violent shaking or
impact, is characterized by a triad of symptoms: retinal hemorrhage, subdural
hemorrhage, and/or subdural hemorrhage with few signs of external trauma
(American Academy of Pediatrics, 2018a). The soft brain tissues are injured
as they move violently against the rough cranial bones as the infant is shaken
or thrown against a hard object. The C/PHN has an important role in the
prevention of shaken baby syndrome by providing parents with education
regarding the triggers and intervention strategies. Educating parents that baby
crying patterns are more severe in the first few months and progressively
improve along with baby soothing techniques are essential before and after
delivery (CDC, 2018k).
Failure to thrive (FTT) is characterized by slowing growth rate in height
and weight, as well as head circumference among infants and toddlers. If an
infant's growth rate is consistently below 3rd to 5th percentiles, drops more
than two percentiles, or is lower than the 80th percentile of median weight
for height, a diagnosis of FTT may be made. Problems with growth may be
due to food insecurities and many behavioral or physiologic etiologies for
infants but can also be related to child neglect or abnormal maternal–infant
bonding. Child neglect differs from child abuse in that the action of the
parent or guardian is more one of omission with neglect rather than
commission as in the case of an injury related to abuse. Risk factors that
point to child neglect as the basis for FTT include those most often cited for
abuse and neglect, along with specific concerns about parents intentionally
withholding food, being resistant to recommended interventions, and having
rigid beliefs about nutrition and health regimens that may jeopardize the
infant. The exact incidence of FTT is difficult to determine, and no accurate
estimates are available. The C/PHN can take a careful nutritional history and
determine the mother's knowledge of basic infant needs, as well as checking
for developmental milestones. A psychosocial history is also helpful (e.g.,
income/poverty level, cultural beliefs, social support networks, domestic
abuse, substance abuse, mental health disorders), with careful attention to

1647
maternal bonding and feeding practices. Growth problems in the first 2
months of life may result in cognitive, language/speech, and fine motor
deficits in childhood, and early intervention programs that involve home
visitation have been effective in attenuating the long-term effects of FTT
(Homan, 2016).
C/PHNs play a role in the prevention and management of child abuse and
maltreatment. Preventive strategies such as parent education should begin
prenatally and continue throughout the life span. Parent training programs
can help teach parents to cope and child sexual abuse prevention programs
may also be helpful. Home visiting programs that provide anticipatory
guideline education will also help to prevent abuse and neglect. Early
recognition and reporting of suspected abuse or/and neglect is a
responsibility of C/PHNs.
See Box 19-8 and Chapter 18 for more on child abuse and neglect.

BOX 19-8 Reports of an Emergency

Foster Home The following are
examples of the various situations from
which abused and neglected children
come, as reported by a couple who had
an emergency foster home for the
county department of social services.
The examples represent children placed
with them over a 2-year period in which
they cared for 256 children.
2-Week-old Jose was taken to their home because the parents
(under the influence of drugs) were found swinging Jose upside
down in circles in an infant carrier as they walked along a
downtown street at 3 AM. After being returned to his parents, he
returned to foster care 1 month later after being found abandoned
in an infant carrier at the county fair.
Andre, Otis, and Selma, ages 8, 5, and 4, went to the foster home
when the social services agency discovered they had been living
with their father in an abandoned car for 2 years. They stayed for 3

1648
weeks while the social worker found suitable housing for this
family and counseling for the father.
Victoria, 5 years old, a loving and passive child, arrived wearing a
diaper and appeared developmentally delayed. She had a history of
being physically and sexually abused. Her family was very
dysfunctional, and it took the social worker several weeks to sort
out relatives and their intentions before placing Victoria in a long-
term foster home.
Ronald and Randall, 6-year-old twin boys who were forced to
“sexually please their mother” for several years, came to the
emergency foster home before being placed with relatives while
their mother underwent psychiatric treatment. The boys began
counseling during their stay in the emergency foster home.
Antoinette, age 7, had severe asthma and was very withdrawn. She
came to the emergency foster home because her mother (and the
mother's boyfriend) refused to care for her. The child came with
every photograph of herself and personal mementos because the
mother wanted no reminders of the child. The social worker
located a grandmother who would be the child's guardian.
13-Year-old Robert came home from school one day and found his
mother and all their furniture gone. After a few weeks of Robert
living in the basement of the apartment building, someone alerted
the social services agency, and he was placed in the emergency
foster home for 2 months. His mother finally called social services
after 6 weeks, saying Robert was too difficult for her to handle, but
she may want to see him again someday. Robert was eventually
placed in a group home for boys.
Quyn, a 17-year-old Laotian girl, came into foster care after being
referred by the school nurse because of wounds observed on her
wrists and ankles. Quyn reported being strapped to a chair for 12 or
more hours at a time by her father because she was not following
the old ways and was shaming the family by being seen in public
with a boy, and without a chaperone. Several meetings were held
between the parents, a Southeast Asian community leader, and the
social worker to resolve this situation so that Quyn could go home
safely.

1649
Communicable Diseases
Infants, toddlers, and preschool-aged children experience a high frequency of
acute illnesses, more so than any other age group. Acute conditions
commonly seen from birth to age 5 include sore throat, ear pain, urinary tract
infection, skin infection, and respiratory infections (including ear infections,
colds, influenza). Communicable diseases are prevalent in these age groups,
as very young children are building an immune system and are just beginning
to come in contact with a greater number of people outside their families
(Fig. 19-6; American Academy of Pediatrics, 2017).

FIGURE 19-6 Infants, toddlers, and preschoolers are constantly

putting things in their mouths and sharing items with others,
contributing, in part, to the increased incidence of accidents and
infections among them.

Acute respiratory illnesses are common in children under the age of 5

years. C/PHNs need to emphasize that over-the-counter cough and cold
medications should not be used for children under age 2. The U.S. Food and
Drug Administration (FDA) questioned their safety and effectiveness at a
hearing in October 2007, and manufacturers removed medication targeted to
infants and toddlers; they also changed labels all cold and cough medications
to read that they should not be used in children under age 4 (FDA, 2018).
Parents need to be informed of the dangers and suggest safer interventions.
Bronchiolitis is the most common type of lower respiratory infection
among infants and starts with a runny nose, fever, and cough. It is a common
cause of hospitalization in this age group; about 2% of children with
respiratory syncytial virus (RSV), the most common cause of bronchiolitis,
are hospitalized every year. The majority of hospitalizations for bronchiolitis

1650
are for infants 6 months and younger. RSV is the cause in 70% of cases and
can rise to 100% during winter epidemics. Although wheezing, tachypnea,
and chest retractions can be frightening to parents, most healthy infants
survive (95%). However, C/PHNs working with at-risk infants need to work
with parents and pediatricians to ensure that palivizumab (monoclonal
antibody) or RSV immunoglobulin is given to preterm infants or those born
closer to term but exposed to environmental pollution or to other children.
An effective RSV vaccine has not yet been found, but palivizumab (Synagis)
can be used to help prevent the most severe cases of RSV in high-risk infants
(e.g., premature, congenital heart problems) and is given monthly by
injection during RSV season (CDC, 2018l).

Vaccine-Preventable Diseases
Vaccines are one of the greatest achievements of public health. Since 1980,
there has been a 99% or greater decrease in deaths because of the vaccine-
preventable diseases of mumps, pertussis, tetanus, and diphtheria and 80% or
greater decline in deaths associated with vaccines instituted since 1980:
hepatitis A and B, Haemophilus influenzae type B (HiB), and varicella.
Worldwide, vaccine coverage has increased because of effects of
manufacturers and philanthropists (e.g., Bill & Melinda Gates Foundation).
The WHO has specific disease eradication and vaccine promotion programs
around the world (see Chapter 16). Smallpox has been eradicated worldwide,
and the viruses for polio, rubella, and measles are no longer endemic in the
United States. Newborns immature immune systems and lack of exposure to
antigens, along with somewhat porous physical barriers to microbes, put
them at high risk of infection. By the age of 4 to 6 months, however, a
brisker antibody response to vaccines becomes possible. Successful infant
and childhood immunization programs have been responsible for high
vaccine coverage and the subsequent decline in morbidity and mortality from
these preventable diseases.
State-level immunization registries help track vaccine coverage at all age
levels. Because day care centers and schools require proof of immunization,
vaccination rates have improved over the last two decades. The financing of
immunizations for infants and children has significantly improved as a result
of two major initiatives. The Vaccines for Children Program and the Child
Health Insurance Program (CHIP) cover children on Medicaid, uninsured
children, and American Indian/Alaska Native children. In addition,
underinsured children who receive immunizations at federally qualified
health centers and rural health clinics are covered. Additional state programs
and funds help provide free or low-cost vaccines for children who are not
covered by the other programs. There are several ways for C/PHNs to help
all families obtain free or low-cost immunizations and contribute to

1651
maintaining adequate levels of community immunity to communicable
disease (see Chapters 8, 10, and 12).
Even if financial barriers are removed, there are other barriers.
Transportation is a significant problem for some parents, especially in rural
areas and for families in urban areas who have several children and need to
take public transportation. All 50 states provide for medical exceptions to
mandatory vaccination, and 47 allow religious exemptions; 18 permit
philosophical or personal exemptions (National Conference of State
Legislatures, 2017). Despite public health announcements in the media, some
mothers remain unaware of the disabling consequences of diseases such as
polio and do not realize the importance of fully vaccinating their children.
Also, as more vaccines become available and the deadly diseases they
prevent become a distant memory in the public's mind, more concerns about
the safety of vaccines emerge. There has not been any link established
between thimerosal, a vaccine preservative, and autism (CDC, 2018e). The
use of thimerosal has been reduced or completely curtailed; single-dose
packaging does not require the ethyl mercury preservative (CDC, 2018e) (see
Chapter 8 for information about vaccine hesitancy). Numerous Web sites
have emerged that advise against childhood immunization and provide
graphic horror stories about the handful of severe reactions to vaccination.
Media coverage and online Web sites about vaccine adverse events also
contribute to decreased compliance on the part of parents in getting their
children immunized. C/PHNs and other health professionals are encouraged
to provide parents of very young children with meaningful stories of
preventable deaths because of vaccines and to educate parents about
scientifically based Web sites and resources rather than relying solely on
dispassionate facts and figures.

1652
Chronic Diseases
Infants and young children can be afflicted with chronic diseases that affect
their quality of life.
Dental caries is the most common chronic disease among the 6 to 19
year age group (CDC, 2019c). Young children's diets, often unreasonably
high in sugar, increase the incidence of dental caries in this population group.
The practice of allowing infants to feed from the bottle beyond 15 to 16
months, or to fall asleep with a bottle, can lead to baby bottle tooth decay or
nursing caries. Baby bottle tooth decay occurs when others persist in giving
toddlers and preschool-aged children milk, juice, sodas, or sugared drinks
continually throughout the day (American Academy of Pediatrics, 2018d).
Frequent snacking and sippy cups filled with juice or sugary drinks can lead
to cavities. It is recommended that sugary foods be eaten at mealtimes and
not as snacks and that regular snack times be established. Also, between ages
6 and 12 months, sippy cups are often used to wean infants from the breast or
bottle, but between-meal drinks should consist of water or milk. Nighttime
breastfeeding beyond what is needed for nutrition can also lead to increased
risk of dental caries (American Dental Association, 2016). Parents of infants
older than 6 months who have several erupted teeth should be instructed to
rub the infant's gums with a damp, clean cloth and to begin tooth brushing,
using a soft pediatric toothbrush with a very small amount of fluoride
toothpaste—about the size of a grain of rice. The first dental examination
should be made within 6 months of the first tooth eruption. Addressing
parental misconceptions about dental health and understanding cultural
beliefs and practices related to dental health and hygiene are important
(American Academy of Pediatrics, 2018d).
Dental caries is a preventable condition that can be addressed with
proper nutrition and hygiene. The younger the age when dental caries first
appear, the greater the risk for future tooth decay that increases the risks of
chronic health conditions due the inflammatory response. Untreated dental
caries can also lead to serious infections. Pain can interfere with learning at
school. Many health departments are using fluoride varnishes as a means of
preventing dental caries in young children. Dental hygienists and C/PHNs
may be trained to apply the sealants and varnishes while making home visits,
or children and families may visit clinics for treatment (American Academy
of Pediatrics, 2018d).
Asthma symptoms may begin in infants and toddlers. Approximately 6
million children ages 0 to 17 years have asthma (CDC, 2018c). Inner-city,
low-income, and minority children are disproportionately affected, and
asthma hospitalizations are common. C/PHNs can assist families in finding
appropriate health care providers and encourage proper administration of

1653
asthma medications and treatments. They can also teach families to reduce
the presence of asthma triggers in their homes (see Chapters 9 and 20 for
more information on environmental triggers, asthma, and other chronic
diseases of childhood and adolescence).
Autism is a developmental spectrum disorder that is often first noticed in
toddlers. Parents become aware that the child's communication and
interaction with others are different and that the child may also display
obsessive and narrow interests. Autism spectrum disorder (ASD) is a
complex developmental disorder, and spectrum of ASD indicates that
symptoms for each child varies and may range from mild to severe (CDC,
2018b). A child's communication skills and interaction with others are most
often affected, along with obsessive behavior and narrowed interests.
Behaviors associated with autism include:

Language problems (no language, delay in language, repetitive use of

language)
Motor mannerisms (often repetitive rocking, hand flapping, object
twirling)
Fixation on objects (restricted interests)
No spontaneous play or make-believe play (Fig. 19-7); no interest in
peers (problems making friends)
Little or no eye contact (may also resist hugging)

FIGURE 19-7 Dress-up and playtime are important for toddler

and preschooler development.

Boys are four times more likely than girls to develop autism. An
estimated 16.4/1,000 children were identified to have ASD in 2014 (CDC,
2018c). The causes of autism are unclear—some genetic links have been
found, but environment may also be a factor. There is a higher risk of

1654
subsequent children having autism in a family with one autistic child or a
parent with ASD (CDC, 2018b). It is often associated with other disorders
(e.g., congenital rubella syndrome, Down syndrome, fragile X syndrome,
tuberous sclerosis), but the exact causes are not fully understood (CDC,
2018b). Families may need to be referred to early educational intervention
programs and social service agencies for assistance. Parents need to be
vigilant with daycares and preschools about their child's environmental
sensitivities. It is important for C/PHNs to educate parents that parenting
practices are not a cause of autism and that multiple, large-scale research
studies on childhood immunizations have shown that there is no relationship
between immunizations and autism (CDC, 2018d).
Sickle cell disease, an inherited blood disorder, affects thousands of
children in the United States, most often those of African or Hispanic
Caribbean ancestry. The characteristic chronic and severe anemia are
common in young children with this condition, and it can affect memory,
learning, and behavior. Children can also exhibit jaundice, gallstones, and
joint pain. When both parents have the genetic mutation, the newborn will be
afflicted with the disease. Those with the sickle cell trait have no symptoms
of the disease but can pass it on to their offspring. In many states, routine
newborn screening for sickle cell anemia is offered. Because sickle cell
anemia can lead to splenic sequestration (or pooling of blood in the spleen),
many children either have nonfunctioning spleens or have had them
surgically removed. Risk of infection is always a concern when this occurs
before age 5 (CDC, 2019a). C/PHNs working with populations at risk for
this disease can educate and refer families for diagnosis and treatment.
Food allergies is a growing problem in children. Infants with close
family members who have atopic diseases are at risk for development of
allergies. Prolonged breastfeeding for 1 year is recommended for these
infants or the use of hypoallergenic infant formula. The CDC (2018m) does
not recommend a delay in the introduction of the most allergic foods (milk,
eggs, and peanuts) for infants past the usual 4 to 6 month of age as this will
not prevent a child from developing an allergy. Fortunately, once allergies are
diagnosed, they can be managed through dietary changes and by avoidance
of allergy-producing foods. Parents need to be educated, so that they can
consistently read food labels and alert family members to the young child's
allergy so that inappropriate foods are avoided.
Muscular dystrophy (MD) and cystic fibrosis (CF) are two diseases that
not only affect quality of life but also severely shorten the child's life. MD is
a constellation of genetic disorders characterized by progressive atrophy and
weakening of skeletal muscles. The onset of some forms of MD begins in
infancy or early childhood, and MD is more common in boys (1 in than
3,500 male births). Girls are usually carriers, but a few may be “manifesting
carriers” that have milder symptoms of muscle weakness (National

1655
Organization of Rare Disorders, 2016). Duchenne MD usually begins before
age 6 and progresses rapidly until most boys are wheelchair bound and
require a ventilator (NINDS, 2017). Recently in 2016 and 2017, the FDA
released a disease-modifying drug, eteplirsen for DMD followed by
deflazacort for the treatment of DMD (Muscular Dystrophy Association,
2018). Genetic testing can determine who is a carrier of the gene and can aid
in confirming the clinical diagnosis.
CF is a genetic disease that usually begins in infancy—about 1,000 new
CF cases are diagnosed annually and 75% are diagnosed before a child
reaches age two (Cystic Fibrosis News Today, 2018). CF is characterized by
a persistent cough or wheeze, shortness of breath, poor weight gain despite a
good appetite, and a salty taste to the skin. Sticky, thick mucus builds up in
the lungs and digestive tract. Respiratory infections become increasingly
more frequent as the child ages. It is the major cause of severe chronic lung
disease in children. Chest physiotherapy to help mobilize secretions is
performed daily, usually by the parents. Sometimes, a vibrating inflatable
vest is used that loosens mucus. Aerosolized antibiotic treatments and
mucus-thinning medications help to improve lung function and reduce
respiratory infections. Mucus also affects the pancreas and prevents release
of digestive enzymes needed to digest food and absorb nutrients. Pancreatic
enzyme supplements help with nutrient absorption (University of Pittsburgh
Medical Center, 2018). C/PHNs reinforce these techniques and teach the
family to avoid exposure to respiratory infections and to initiate prescribed
antibiotic prophylaxis promptly. As much as feasible, the young child should
be involved in his own care, offered valid choices, and encouraged to
participate in decision-making. The family needs genetic counseling and
emotional support as members work through feelings of anticipatory grief.

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Nutrition
Proper nutrition is foundational to well-being later in life. The American
Association of Pediatrics recommends exclusive breastfeeding for the first 6
months of life then gradually adding solid foods along with breastfeeding
until 1 year of age (2018d). Bonding between mother and infant and overall
maternal health are predictors of infant weight gain. Both nutrition and
bonding can be accomplished by breastfeeding (Fig. 19-8). Along with
convenience and no to low cost, there are other benefits of breastfeeding
which include the following (American Academy of Pediatrics, 2016):

FIGURE 19-8 Breastfeeding has many benefits for both infant and
mother.

Nutrition: Breast milk provides sugar, fat, and protein; the proteins are
easily digested, and fats are well absorbed; it is the most complete form
of nutrition for human infants.
Anti-infective and anti-allergic properties: Breast milk contains
immunoglobulins, enzymes, and leukocytes that protect against
pathogens, and it decreases the incidence of allergy by eliminating
exposure to potential antigens. Babies exclusively breastfed for 6 or
more months have fewer respiratory illnesses, ear infections, and cases
of diarrhea. The chance of hospitalization for infants that are breastfed
for more than 4 months is reduced.
Infant growth: Breastfed babies usually gain weight at a more moderate
rate and are leaner than bottle-fed babies; rapid weight gain in infancy
has been associated with later chronic diseases.
Long-term health effects: Breastfeeding exclusively for at least 6
months is associated with reduced risk of overweight in later life, and
less change of developing atopic dermatitis, asthma, and leukemia and

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 lymphoma. There has also been a 36% reduction in the risk of SIDS
among breastfed babies and a decreased incidence of type 1 diabetes.
Benefits for mothers: Breastfeeding burns extra calories, helps to reduce
postpartum bleeding, and delays ovulation and menstruation; it also
lowers the risk of later ovarian and breast cancers. Studies show that the
longer the period of lactation, the lower chance she has of developing
hyperlipidemia, hypertension, cardiovascular disease, and diabetes.

The C/PHN can encourage pregnant women to consider the benefits of

breastfeeding their infants and provide education and interventions to assist
them with the most common barriers: concern about insufficient supply of
breast milk, problems with the baby latching onto the breast, painful nipples,
and scheduling problems. Women often choose to breastfeed their babies
when they fully understand the health effects for their infants and themselves
and when they receive positive influence from family and friends. The
C/PHN can join with labor and delivery nurses and lactation consultants in
promoting breastfeeding among mothers in the community. Nurses can lobby
local hospitals to educate new mothers about the benefits of breastfeeding
and stop the routine distribution of free samples of infant formula.
Child and adolescent obesity prevalence in 2015 to 2016 was 18.5%
(Hales, Carroll, Fryar, & Ogden, 2017). In 2015 to 2016, there was a higher
prevalence of obesity among Hispanic children and adolescents (25.8%) and
non-Hispanic Blacks (22%) than among non-Hispanic Whites (14.1%) and
non-Hispanic Asians (11%) (Hales et al., 2017). The Orr et al. (2019) study
identified food insecurities associated with childhood obesity as mediated
through feeding practices and beliefs. Families from insecure households
were more likely to provide food to stop a baby from crying or to console a
child. Another study identified that weight compared to length decreased
from 14.5% in 2010 to 12.3% in 2014 among infants aged 3 to 23 months
enrolled in Women, Infants, and Children (WIC) programs (Freedman et al.,
2017).
Overfeeding can lead to nutrition problems and poor infant growth. The
pattern of growth may also be important, such as growth problems in infancy
along with overweight in later childhood. The most common sources of
energy and nutrients for infants and toddlers are breast milk, formula, and
milk. Fortified foods (e.g., grain-based foods with added vitamin A, folate,
and iron) become increasingly more significant in toddler diets. In general,
most nutrition recommendations include providing for a wide variety of
foods for children. C/PHNs can encourage parents to continue to introduce
new healthy foods to their toddlers and not give up or give in too soon.

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HEALTH SERVICES FOR INFANTS,
TODDLERS, AND PRESCHOOLERS
A variety of programs that directly or indirectly serve the health needs of
very young children may be found in most communities. Nurses play a major
and vital role in delivering these services especially for the working poor and
vulnerable populations. In public and community health, programs fall into
three categories, which approximate the three priorities of C/PHN practice:
prevention, protection, and promotion.

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Preventive Health Programs
Neighborhood community centers found in urban and rural settings provide
families with parenting education, health and safety education,
immunizations, various screening programs, and family planning services. In
some areas, nurse-run clinics are established at local schools or community
centers to assist in outreach services to the community. In collaboration with
an interdisciplinary team, C/PHNs are often the primary care providers in
these programs. The major goals are to keep communities healthy by
focusing on primary and secondary prevention services. Three examples of
preventive health programs for infants and young children are immunization
programs, parent training programs, and quality day care health services.

Immunization Programs
Health departments, community clinics, and private health care providers
continue to offer immunizations against the major childhood infectious
diseases—measles, mumps, rubella, varicella, polio, diphtheria, tetanus,
pertussis, hepatitis A and B, and Hib—some of which can cause permanent
disability and even death. Pneumococcal, meningococcal, and influenza
vaccines are also recommended, as is the vaccine for rotavirus (CDC,
2018h). Many of these diseases no longer plague infants and children, and
newer vaccines offer an even greater promise of health. The current
immunization schedule is available at
https://www.cdc.gov/vaccines/schedules/easy-to-read/child-easyread.html
(CDC, 2018k).
Although the threat of these diseases has been substantially reduced,
vigilance is still essential. Low immunization levels in many areas of the
United States, particularly among the poor and medically underserved, and
increased disease rates signal the need for constant surveillance, outreach
programs, and innovative educational efforts. The C/PHN can help young
families find low-cost vaccinations by using the Vaccines.gov Web site
(https://www.vaccines.gov/getting/where). Whenever infants and young
children come in contact with public health and other community clinics, it is
always important to check immunizations and provide the necessary
vaccines. C/PHNs are deeply involved in preventive activities that promote
immunizations. One important intervention is to provide each parent with
immunization record that they can keep so that they have a record of their
children's immunizations. Immunization information systems are in place but
vary from state to state; therefore, it is essential that parents maintain a
record (CDC, 2018g).

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Parent Training Programs
Parent education and training programs have been useful in providing parents
with the tools needed to deal with the stresses and challenges of parenting
effectively. These programs provide education regarding appropriate growth
and developmental milestones, anticipatory guidance, positive discipline
techniques, parenting skills, appropriate play, and parent–child interaction
promotion (Child Welfare Information Gateway, n.d.c). There are a variety of
programs available for parents at local, state, and national levels with
resources available at
https://www.childwelfare.gov/topics/preventing/prevention-
programs/parented/

Quality Day Care and Preschool Programs

It is estimated that 24% of children under the age of 5 spend time in center-
based child care (Center for American Progress, 2018). Quality child care
centers improve school readiness, reduce family stress, and result in overall
improvements in health and well-being for children and their families (The
Children's Cabinet, 2018a).
Although safe, affordable child care is important, the long-term benefits
of early childhood education are numerous. These benefits include higher
rates of high school completion, college attendance, and full-time
employment and lower rates of felony arrests, convictions, and incarcerations
(The Children's Cabinet, 2018b). Head Start, a federally funded program
that offers early childhood education to low-income children between ages 3
and 5, has consistently demonstrated significant improvements in
preschoolers' social, emotional, and cognitive development, and those
attending Head Start do better on several developmental and educational
measures. Head Start children are also more likely to receive dental and
health screenings, to have up-to-date immunization coverage, to have better
school attendance, and to be less likely to be held back in school. The
benefits of Head Start extend to families because more Head Start parents
read more frequently to their children than do parents of children not enrolled
in the program (National Head Start Association, 2018). However, the
quality of day care and preschool programs varies considerably; licensing
laws can regulate only minimum safety and health standards. In addition,
numerous childcare operations are too small to require licensing, leaving
quality and compliance unevaluated. As educators, C/PHNs play a role in
providing education and referrals. Also, nurses can influence and advocate
for quality of day care and preschool programs through active childcare
consultation efforts that focus on health educational efforts for staff,
monitoring of health and safety standards, and working to improve the state's
or community's role in passing stronger licensing laws.

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Health Protection Programs
Health protection programs for infants and young children are designed to
protect them from illness and injury. Ultimately, these programs may even
protect their lives.

Safety and Injury Protection

Accident and injury control programs serve a critical role in protecting the
lives of children. Efforts to prevent motor vehicle crashes, a major cause of
death, may include driver education programs, better highway construction,
improved motor vehicle design and safety features, and continuing research
into the causes of various types of crashes. Injury prevention and reduction
have been addressed through strategies such as state laws requiring the use of
safety restraints (e.g., seat belts, child safety seats), availability of front and
side driver and passenger airbags, substitution of other modes of travel (air,
rail, or bus), lower speed limits, stricter enforcement of drunk-driving laws,
safer automobile design, and helmets for motorcyclists, bicycle riders, and
skaters.
For infants, toddlers, and preschool-aged children to be safe when
traveling in vehicles, they must be restrained in an approved infant carrier,
child restraint seat, or booster seat. General guidelines recommend that all
children under the age of 2 years ride in rear facing car seats. Forward facing
seats with a harness are to be used when children have outgrown the rear-
facing height and weight limit requirements. It is recommended that children
use these as long as possible as allowed by the car safety seat manufacturer.
Car seats must be positioned and secured as described by the manufacturer;
used at all times, even for the shortest distances; and installed in the
appropriate position (facing rear or front) based on the weight or age of the
infant or young child. Belt positioning booster seats are recommended when
weight or height requirements have exceeded forward facing car seat limits.
All children younger than 13 should ride in the back seat (American
Academy of Pediatrics, 2018c). C/PHNs collaborate with other community
agencies, hospitals, law enforcement, and other community agencies to
provide training, education, and child safety seat checks.
Lead poisoning prevention programs can be found in most state and local
health departments. The Lead Contamination Control Act of 1988 provided
for CDC funding and programs to eliminate childhood lead poisoning (CDC,
2018e). The CDC provides technical assistance, training, and surveillance at
a national level. Another role of the C/PHN is to help with targeted screening
and case management and provide education to clients and communities
about lead poisoning at the local level. They also work with environmental

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health personnel and epidemiologists to reach out to neighborhoods and
communities at risk for testing. See more on this in Chapter 9.

Protection From Child Abuse and Neglect

Services to protect children from abuse and neglect begin with a
collaborative approach that includes social services, law enforcement,
education, community health providers, and child advocacy. Protection
begins with prevention efforts. Child abuse and maltreatment can be
prevented by strengthening family economic and social support systems.
Furthermore, C/PHNs must advocate for policies that support improved
family economic and social systems (CDC, 2018g). “Policies that strengthen
household financial security can reduce child abuse and neglect by
improving parents' ability to satisfy children's basic needs (e.g., food, shelter,
medical care), provide developmentally appropriate child care, and improve
parental mental health, support positive parenting, ensure quality education
and healthcare for children” (Fortson, Klevens, Merrick, Gilbert, &
Alexander, 2016, p. 15). Additionally, social support systems and quality
childcare and early education programs for children in communities are
essential for prevention of child abuse and maltreatment. Working alongside
community leaders, C/PHNs strive to ensure that communities have adequate
resources to support healthy development of children (CDC, 2018g).
Protecting children from abuse and maltreatment also includes the
importance of early recognition of the signs of abuse and reporting this to
authorities (see Chapter 18). Nurses along with day care providers, teachers,
social workers, doctors, clergy, coaches, and all others working with children
that suspect child abuse or maltreatment are required by law to report it. In
addition, animal humane workers and commercial photograph developers are
mandated reporters. Child abuse or maltreatment should be reported to local
child protective services or law enforcement agency when it is suspected.
Most states have hotline or toll-free numbers available for reporting (Child
Welfare Information Gateway, n.d.b).
To promote safe and nurturing relationships and environments where
children live and play free from abuse and violence, ACE must be addressed
in our communities. C/PHNs must recognize those at risk for ACE and
history of ACE in adults referring clients and families to resources; ACE is
preventable. To combat ACE in the community, Washington state has
directed efforts to addressing ACE in the community through legislation that
aims to reduce prevalence through primary prevention of child maltreatment
and community engagement to improve the public's health. Secondary
measures include policy enacted through TANF to strengthen ACE families
through Head Start parenting programs. Tertiary efforts include additional
support for juvenile high-ACE offenders through functional family programs
(CDC, 2019b).

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Primary Prevention
Primary prevention measures include the use of social norming that promote
positive parenting, family support groups, and public awareness campaigns
about child maltreatment and how to report it, along with establishing
community education to enhance the general well-being of children and their
families. Educational-type services are designed to enrich the lives of
families, to improve the skills of family functioning, and to prevent the stress
and problems that might lead to dysfunction and abuse or neglect (CDC,
2018g).
Primary prevention also focuses on parent preparation during the
prenatal period; practices that encourage parent–child bonding during labor,
delivery, the postpartum period, and early infancy; and provision of
information regarding support services for families with newborns. This is
often the ultimate outcome sought by home visitation programs carried out or
managed by C/PHNs. It is also helpful to provide parents of children of all
ages with information regarding child-rearing strategies, anticipatory
guidance for developmental milestones and tasks, and community resources.

Secondary Prevention
Services are designed to identify and assist families who may have risk
factors for impaired parenting to prevent abuse or neglect. High-risk
families are those families that exhibit the symptoms (risk factors) of
potentially abusive or neglectful behavior or that are under the types of stress
associated with abuse or neglect. These can include families living in
poverty, substance abuse or mental health problems, parents who were
abused when they were children, and parents or children with developmental
disabilities. Early intervention with high-risk families can improve emotional
and functional coping and help prevent further problems. High school parent
education programs for pregnant adolescents, home visitation programs
targeted to at-risk families, and respite care for families of children with
disabilities are all examples of secondary prevention actions. Family resource
centers in schools or community centers located in low-income
neighborhoods can offer resource and referral services to families who may
be dealing with multiple sources of stress. Evidence-based home visitation
programs, such as the Nurse–Family Partnership, Early Head Start, and
Healthy Families America, provide parental support and education and
promote healthier family functioning and have resulted in decreased rates of
child abuse and neglect (Child Welfare Information Gateway, n.d.a).

Tertiary Prevention
Intervention and treatment services are designed to assist a family in which
abuse or neglect has already occurred, so that further abuse or neglect may be

1664
prevented, and the consequences of abuse or neglect may be minimized.
There are several evidence-based programs that have been found effective in
reducing the reoccurrence of child abuse. Safe Environment for Every Kid
(SEEK) is an example of an enhanced primary care program; Parent–Child
Interaction Therapy, SafeCare, and The Incredible Years are examples of
behavioral training programs; and Trauma-Focused Cognitive Behavioral
Therapy (TF-CBT) helps to reduce the consequences of posttraumatic stress
disorder and depression after abuse has occurred (Fortson et al., 2016).
Often, families are referred to mental health counselors to improve family
communication and functioning. Some families may require crisis respite
when they feel they cannot manage the stresses of child care. Parent
mentoring programs can provide support and coaching to these parents
(Child & Family Services, 2018).
The C/PHN and school nurse have major roles in all levels of prevention
of child maltreatment. In addition, the nurse is in a unique position to detect
early signs of neglect and abuse. The nurse must establish rapport with
families and assist with appropriate interventions and referrals at the
secondary and tertiary levels of prevention. The advanced practice nurse may
also work with families of abused and neglected children as part of an
interdisciplinary approach with teachers, the department of social services,
the judicial system, foster families, and other health care providers if needed.
The effectiveness of local programs depends, in large measure, on the
willingness of health professionals to increase their awareness and work as a
team to detect, report, develop, and evaluate interventions for the
perpetrators and victims of abuse and neglect. Ongoing education of health
care providers is recommended to increase awareness of changing child
abuse patterns, new reporting laws, and resources available to families.

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Health Promotion Programs
Early childhood development and intervention programs are designed to
have positive effects on the outcomes of children's cognitive and social
development. Some health promotion programs have considered children's
physical health, and fewer have focused on parent–child interaction and child
social development. All are considered important health promotion programs
from birth through preschool years.

Infant Brain Development Research and Parent–Child

Interactions
Research into the normal brain development of infants and toddlers has
revealed that brain maturation in the first few years of life is very rapid: the
brain grows to 80% of adult size by age 3, and the myelination pattern of an
18-to 24-month-old child is similar to that of an adult (Gilmore, Santelli, &
Gao, 2018). The prefrontal cortex of 4-year-olds is already functional and
becomes more organized throughout later adolescence. Early environment
exerts a lasting influence on brain development, even in the womb.
Appropriate early nutrition and stimulation promotes healthy development.
Early in life, rapid myelination is taking place, children need higher fat
levels in their diet (50% of total calories should come from fat). Breast milk
or formula will provide this fat during the first year of life, then breast milk
or whole milk can be used after the first birthday. After age 2, children
should reduce fat content to no more than 30% of calories coming from fat
and 1% or 2% milk should be used (Zero to Three, 2018). Meaningful
parent–child interactions should be established early; they include holding,
rocking, comforting, touching, talking, and singing. When parents talk to
infants and read to young children, children later demonstrate more advanced
language and literacy skills. Providing a caring and supportive environment,
with opportunities to learn and explore, is supportive of healthy brain
development and promotes secure infant attachment (CDC, 2018g).
Important parental behaviors that promote social development include gazing
into an infant's eyes, paying attention to and interacting with toddlers, and
listening to and answering preschoolers' questions. Providing infants and
young children with secure, learning-rich environments where they can use
their senses to discover new things helps them to maximize their potential.
Emotional comfort and a secure environment ensure that young children will
better deal with their feelings. It is important for the C/PHN to provide
information to parents on the most current research results about brain
development as well as tangible suggestions such as low-cost brain-
stimulating toys and community resources to encourage quality parent–child

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interactions that promote appropriate physical growth and cognitive and
social development.

Developmental Screening
With the emphasis on infant and early childhood development, C/PHNs often
routinely carry out developmental screenings (Fig. 19-9). The American
Academy of Pediatrics recommends developmental screening surveillance
for children at each health visit along with an evidence-based developmental
screening tool used at 9, 18, and 30 months, or anytime there is a concern.
Autism-specific screenings are recommended at 18 and 24 months and
social-emotional screenings should be conducted at regular intervals (2018e).
There are a variety of screening tools available with resources available at
https://screeningtime.org/star-center/#/screening-tools.

FIGURE 19-9 Allowing children to play with health care

equipment can help alleviate fear and anxiety.

Developmental screening tools are also helpful in educating parents

about normal child development and can provide a means of anticipatory
guidance on developmental milestones and future safety issues. Bright
Futures, an important resource for nurses and parents, provides tools to help
families determine appropriate developmental milestones and expected
behaviors, along with suggestions about when to seek help from
professionals. A variety of screening tools available to nurses and other
health professionals, ranging from parent report instruments to those that
involve direct assessment of behaviors and skills, can examine overall
physical and cognitive development or screen for such things as
temperament, behavior, autism, and speech and language problems. It is
important for the C/PHN to use tools that have reported validity and

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reliability. Early identification of problems can lead to interventions such as
enrollment in early intervention programs and help children with school
readiness. These early intervention programs are available in most
communities or through the public school system (Bright Futures, 2018).

Programs for Children With Disabilities

Many children have special needs. They may have a congenital or acquired
developmental disability, birth defect, or a chronic emotional, mental, or
physical disease. About 1 in every 33 U.S. infants are born with a birth
defect each year (CDC, 2018f). Some children suffer injuries after birth (Box
19-9). Autism and other mental or behavioral disorders develop after infancy
and may require special services. Educational, health, and social or
recreational services should be available for all children.

BOX 19-9 STORIES FROM THE

FIELD
A Case of Kernicterus A young mother was
hospitalized for the birth of her second
daughter, a beautiful little girl born without
incident. The infant had difficulty latching on
for breastfeeding and was not an active feeder.
The mother told her obstetrical nurse that the
infant seemed very different from her first
child. The infant was irritable, but the nurse
reassured the mother that the baby was fine
and “not all babies are alike.” Still, the new
mother was concerned.
By the second day, the mother noticed that the baby was not very
alert and did not want to feed. She also noticed that the baby's color was
“yellowish,” and the mother notified the nurse. Again, the nurse
reassured the mother that this was “normal” for infants of Asian
descent. The baby still was not feeding well, and there was yellowish-
orange color stool in the baby's diaper. The mother notified the nurse
and asked the nurse to call the doctor. The nurse refused and told the
mother that she was “overreacting.” The nurse again reassured the
mother that the baby was “fine” and no action was taken. The young

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mother was not satisfied with the nursing care and requested additional
assistance. A referral was made to the breastfeeding specialist at the
hospital to help the new mother feed her infant. There were no phone
calls documented to the physician nor was there documentation of the
“yellowish-orange” stool. (The young mother kept the diaper for further
proof of her concerns, though.) There was no documentation of
irritability, inability to breastfeed, lethargy, or jaundiced appearance of
the skin. The physician discharging the infant did not receive any
information regarding irritability, yellowish stool, and yellowish tone of
lower extremities and abdomen. No blood work was done. No referrals
were made to home health or public health for follow-up.
Within 48 hours of discharge, the young mother brought her
lethargic baby to the hospital's emergency room. On day 4 of life, the
infant's bilirubin was 46. The infant was severely neurologically
damaged, and the brain damage that resulted was irreversible. She was
diagnosed with severe cerebral palsy, secondary to kernicterus
(excessive bilirubin). The child has normal intelligence but will never
be able to walk or talk. She will be fed through a gastrostomy tube for
the rest of her life. The family was devastated.
The physician and hospital (nurses) were sued. The nurses on duty
could not defend their actions with their charting or lack thereof. The
attorneys for the hospital, representing the physician and nurses, could
not defend the actions of their clients. A multimillion-dollar settlement
was granted, and the nurses were fired. Unfortunately, this is not an
isolated case. The irreversible brain damage that occurs as a result of
untreated hyperbilirubinemia should not occur in the 21st century. This
was a no-win situation that could have been avoided with proper
nursing intervention. Hyperbilirubinemia should always be in the
forefront of newborn assessment during the first few days of life.
The nurses involved in this case were not acting as the patient's
advocate. The physician should have been notified immediately when
signs and symptoms were first noted. Incorrect assumptions were made
because of the nationality of the patient, an indication of lack of cultural
competence. Home health nursing or public and community health
nursing care should have been arranged for infant follow-up after
discharge.
Linda O., certified life care planner, nurse consultant
1. As a new C/PHN, what services do you think this family needs? Do
you believe these services will change over time? If so, what type
of anticipatory guidance should you provide the family and child?
2. This family may not have any trust of health care providers. How
can you earn this family's trust?

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 3. How can you become culturally competent when working with a
culture you are not familiar with?

Federal law mandates early identification and intervention services for

those with a variety of developmental disabilities. Developmental delays are
characterized by slower development in one or more areas. The Individuals
with Disabilities Education Act (IDEA) provides early intervention services,
usually at home, for those from birth to age 2 who have developmental
delays in physical, cognitive, communication, social/emotional, and adaptive
development. Intervention services are also available to children with a
mental or physical problem that is likely to result in a developmental delay.
Newborns can receive infant stimulation services at home or in some schools
specially designed to meet the needs of the very young. These programs are
offered on a part-time basis for 1 to 2 hours, two to three times a week.
Special education preschools are available for young children from ages 3 to
5. By preschool age, children may advance to half-day programs. Additional
services can be provided to assist the families in getting children to the
programs. Door-to-door bus service in specially equipped small buses or
vans safely transports young children who arrive at school in wheelchairs or
with other assistive devices (Parlakian, 2018).
Availability of health services for children with disabilities varies with
the size of the community. In small rural communities, children and their
parents may have to travel long distances to receive specialized services, and
in inner-city neighborhoods, lack of money for transportation can make even
nearby services equally inaccessible. Accessibility is also influenced by lack
of knowledge, attitudes, and prejudices. The nurse must recognize the power
of these immobilizing factors and be able to deal with them effectively to
make positive changes. See Chapter 23 for more on barriers to health care.
Most communities offer additional social and recreational programs for
children that are disabled. For example, American Lung Association affiliate
offices sponsor camping programs for children with asthma or other lung
diseases. Often, these are camps for school-aged children that may last up to
1 week and be located in mountain or beach areas, but they may also be day
camps, with parents in attendance for preschoolers. Many of these camps
have C/PHNs either working or volunteering. Nationwide programs, such as
the Special Olympics, offer recreational competition for the children in a
variety of sports, such as bowling, track and field, skiing, and swimming.
The C/PHN best serves families as a resource for such programs. Some
parents are not aware of the rights or services available for their children
with disabilities. Nurses can advocate for parents and help establish services
in communities where needed services are lacking.

Nutritional Programs

1670
Adequate nutrition must begin before birth. One of the most productive
health promotion programs is the Special Supplemental Food Program for
Women, Infants, and Children (WIC). In addition to supporting women and
young children with nutritious foods and achieving the initial goals of
decreasing the rates of preterm and LBW babies, increasing the length of
pregnancy, and reducing the incidence of infant and child iron deficiency
anemia, WIC also improves pregnant women's nutritional status. WIC is not
an entitlement program, but rather, Congress sets funding and eligibility
requirements yearly (U.S. Department of Agriculture, 2018).
WIC provides information to parents about eating healthfully and
promoting healthy rates of growth. Parents become more aware of the need
to reduce consumption of saturated fat, salt, sugar, and over-processed foods.
The C/PHN, through nutrition education, reinforcement of positive practices,
and referral, plays a significant role in promoting the health of infants and
young children (Box 19-10). For more information about WIC, see Chapter
20.

BOX 19-10 Levels of Prevention Pyramid

Prenatal and Newborn Care SITUATION: Desire
for a healthy, full-term infant GOAL: Using the
three levels of prevention, avoid negative health
conditions, and promptly diagnose, treat, and/or
restore the fullest possible potential.

1671
1672
ROLE OF THE C/PHN
C/PHNs face the challenge of continually assessing each population's current
health problems as well as determining available and needed services.
Interventions are implemented for the maternal, infant, toddler, and
preschool populations that focus on health promotion, health protection, and
early intervention. Interventions may include work in family planning or
high-risk clinics, telephone information services and hotlines, outreach
interventions, child care consultation, or home visitation programs. The nurse
uses educational and health coaching interventions when teaching family
planning, nutrition, safety precautions, and appropriate health seeking or
childcare skills. Such interventions involve providing information and
encouraging client groups (parents and young children) to participate in their
own health care. Other interventions include strategies in which the nurse
uses a greater degree of persuasion or positive manipulation, such as
conducting voluntary immunization programs, working in a lead screening
program, encouraging smoking cessation during pregnancy, preventing
communicable diseases, and encouraging appropriate use of child safety
devices such as car seats. Finally, the nurse may use interventions that
motivate people into adherence with laws that require certain immunizations
or mandate reporting of suspected child abuse and environmental health
standards violations, such as sanitation issues. Home visiting programs are
effective in addressing needs of high-risk and hard to reach families
(USDHHS, 2018). See Chapter 6 for new programs available through health
care reform.
The C/PHN acts as an advocate and a resource for childbearing women
and couples and families of young children. The nurse may be called upon to
provide information to young mothers about infant temperament, sleep
schedules, colic, parenting, discipline, toilet training, television or video
choices, and nutrition and feeding. The nurse should be aware of federal,
state, and local laws that preserve and protect the rights of children and
families. Knowledge about educational, medical, social, and recreational
services needed by young families is helpful. The nurse works to secure
these services in the community. Ensuring that families have the resources to
provide a safe and healthy environment for their children can take many
forms. The nurse may lobby to change existing laws, initiate the effort
needed to establish programs and services in the community, and teach
families about infant safety or the importance of immunizations. The C/PHN
also has skills of community and neighborhood assessment. These skills are
vital to health departments and community-based organizations and primary

1673
care centers for development of programs needed for women and children
(Aston et al., 2016).

1674
SUMMARY
Maternal–child health clients are an important population group to
C/PHNs because their physical and emotional health is vital to the
future of society.
The United States does not fare well in comparison to other developed
nations on maternal–child health indicators.
Problems of substance abuse, STIs, and teen pregnancy can lead to less
than optimal outcomes for newborns.
Complications of pregnancy and childbirth, such as hypertension,
gestational diabetes, postpartum depression, and fetal or infant death,
offer opportunities for C/PHNs to provide education, outreach,
monitoring, and support.
IMRs in the United States are higher than those in many other countries
around the world. Toddler and young child mortality and morbidity are
often related to unintentional injuries
Preventive services include immunization programs, along with quality
day care and preschool.
Health protection services include accident and injury prevention and
control, as well as services to protect children from child abuse.
Health promotion services include infant development through effective
parent–child interaction, developmental screening, and services to
children with special needs.

1675
ACTIVE LEARNING EXERCISES
1. Using “Assess and Monitor Population Health” (1 of the 10 essential
public health services; see Box 2-2 ), how do your county's statistics
compare with those of others in your state on (1) infant mortality
rates (collectively and by specific ethnic groups), (2) incidence of low
birth weight and very low birth weight in infants, and (3) incidence of
birth defects? What is the major cause of death among infants,
toddlers, and preschool-aged children in the United states, in your
state or local area?
2. Locate some national Web sites that give you current information
about progress toward meeting some of the Healthy People 2030
goals with mothers, infants, toddlers, and preschool-aged children.
Are we making progress? What can a C/PHN do locally to promote
meeting these goals? What needs to be done on the regional, state, or
national level?
3. What is the major cause of death among infants, toddlers, and
preschool-aged children in the United states, in your state or local
area? What community-wide interventions could be initiated to
prevent these deaths? Select one intervention for each age group and
describe how you and a group of community health professionals
might develop this preventive measure.
4. Look at the pertussis, maternal mortality rate, and maternal–child
health vital statistics in your county or community. What do these
statistics tell you about your community's health? What other related
statistics are important to gather to determine if your community is a
positive and healthy place for childbearing women and young
children?
5. Go to the Centers for Disease Control and Prevention Web site
(www.cdc.gov) and look up the current childhood immunization
schedule for children ages 0 to 4 years. How would you determine
how to modify the schedule for a 30-month-old who is missing his
last set of immunizations?

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!

1676
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National Head Start Association. (2018). Head Start facts and impacts.
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CHAPTER 20
School-Age Children and Adolescents
“Youth is the spirit of adventure and awakening. It is a time of physical emerging when the body
attains the vigor and good health that may ignore the caution of temperance. Youth is a period of
timelessness when the horizons of age seem too distant to be noticed.”

—Ezra Taft Benson

KEY TERMS
Adverse childhood experiences (ACE) Anorexia nervosa
Asthma action plan
Attention deficit hyperactivity disorder (ADHD) Autism spectrum disorder
(ASD) Binge eating
Bulimia nervosa
Learning disorders
Obese
Overweight
Pediculosis

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Explain how poverty is a significant social determinant of health in
children and adolescents.
2. Identify major health problems and concerns for U.S. school-age
children and adolescents.
3. Discuss the relationship of academic achievement to health status.
4. Describe and analyze mortality and injury trends among school-age
children and adolescents.
5. Evaluate Healthy People 2030 objectives affecting children and
adolescents and the barriers that may be involved in attaining these
objectives.
6. Evaluate health promotion programs and services for school-age
children and adolescent populations at the primary, secondary, and
tertiary levels.

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INTRODUCTION
According to Erick Erickson's developmental framework, the school-age and
adolescent years are a time of task mastery and development of competence
and self-identity. During these years, children grow physically, as well as
emotionally and socially. They move from being under the total control of
parents and families during the infant and toddler years to being more and
more influenced by those outside the home—classmates, teachers, peers, and
other groups (Hockenberry, Wilson, & Rodgers, 2019).
Poverty, a significant social determinant of health, poses a challenge to
the health of many school-age children and adolescents. Other challenges for
this population include chronic diseases, behavioral and learning problems,
emotional and mental health issues, disabilities, injuries, communicable
diseases, developmental issues, school concerns, and the risk behaviors
characteristic of teenage years. This chapter explores the health needs of
school-age children and adolescents and describes various services that
address those needs, along with the community health nurse's role in
assisting families with children.

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SCHOOL: CHILD'S WORK
Children and adolescents spend most of their waking hours in school. The
quality of their educational experiences (e.g., teacher–child interactions) can
influence learning, and their academic success can predict future education,
employment, and income. Therefore, their future success as tomorrow's
parents, workers, leaders, and decision-makers depends in good measure on
the achievement of their educational goals today.
Child health has been linked to school success—healthy children are
found to be more motivated and prepared to learn (Centers for Disease
Control and Prevention [CDC], 2017a)—and coordinated school health
programs are linked to academic achievement (CDC, 2019a). This is well
known to school nurses and community and public health nurses (C/PHNs)
that work in schools.
In 2018, approximately 56.6 million school-age children and adolescents
(5 to 18 years old) attended elementary and secondary schools in the United
States. Of these students, approximately 50.7 million are educated in public
schools and 5.9 million in private schools (National Center for Education
Statistics [NCES], 2018a).
In 2016, the U.S. population aged 0 to 17 years was 51.1% White/non-
Hispanic, 13.8% Black/non-Hispanic, 4.9% Asian/non-Hispanic, 24.7%
Hispanic, and 4.2% all other groups (Federal Interagency Forum on Child
and Family Statistics [FCFS], 2019c).

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POVERTY: A MAJOR SOCIAL
DETERMINANT OF HEALTH IN
SCHOOL-AGE CHILDREN AND
ADOLESCENTS
Although the United States is making strides against poverty, around 21% of
children still live in poverty. In 2016, 44% of children under the age of 3
years lived in low-income families and 21% lived in poor households.
Moreover, this burden of poverty is not equally shared among racial and
ethnic groups. In comparison with White children, children of color are
almost three times as likely to live in a poor household. One of every ten
White children live below the poverty line and approximately one of every
three Black, Hispanic, and Native American children live below the poverty
line (National Center for Children in Poverty [NCCP], 2018).
Poverty has profound and lasting effects on children, as research has
consistently shown over many years. In the most recent NCCP report, Dr.
Heather Koball stated, “We're seeing promising movements in the year-to-
year measurements of child poverty and economic stability….But while the
number of children experiencing poverty is on the decline, the rate of poverty
for kids still remains stubbornly high, compared to the size of the population.
Children are also more likely to suffer the material hardships associated with
living in poverty; the anxiety, depression, and constant stress of being
financially vulnerable leaves a lasting mark on children as they grow to
adulthood, affecting earnings potential and health outcomes as adults”
(NCCP, 2018).
Children living in poverty have poorer health overall and are more likely
to experience:

Chronic health condition (e.g., asthma, anemia)

Injuries and accidents
Behavioral problems, including academic failure, alcoholism, antisocial
behavior, depression, substance abuse, and adolescent pregnancy
Poor brain growth, neurodevelopment, and learning
Developmental delay
Exposure to environmental toxins, parental substance abuse and neglect,
maternal depression, trauma and abuse, divorce, violent crime, low-
quality child care, inadequate nutrition, and decreased cognitive
stimulation and exposure to vocabulary in early childhood and infancy,

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 all of which can contribute to social, emotional, and behavioral
problems (Center for the Study of Social Policy, 2017; Van Ryzin,
Fishbein, & Biglan, 2018)
Lead poisoning
Iron deficiency anemia
Increased susceptibility to illness
Family and community violence, leading to a view of the world as a
hostile and dangerous place and mental health issues (Child Trends
Databank, 2018a, 2018b)

Social determinants of health (SDOH)—which are the social, economic,

and physical conditions in which children live—can affect their health and
wellbeing; “Growing up in poverty is a powerful SDOH because it can affect
children's access to many [of these] health-promoting conditions” (Francis et
al., 2018, para 1). Children growing up in impoverished and unhealthy
conditions can stress a child's response system, increasing the risk for poor
physical, behavioral, social–emotional, and cognitive health (Francis et al.,
2018). The relationship between lower socioeconomic status (SES) and poor
health persists throughout childhood and adolescence into adulthood.
Children who spend half of their life in poverty are 40% more likely to be
living in poverty by the age of 35 years. As adults, these children are less
likely to have completed high school and more likely to have lower
occupational status and lower wages.
A classic longitudinal study, along with a series of preliminary studies,
on the many stresses of childhood poverty (e.g., crowded homes/classrooms,
inadequate child care, low socioeconomic status, family/peer problems)
found that levels of the stress hormone cortisol influenced results on school
readiness testing and affected cognitive functioning (e.g., impulse/emotional
control, planning, attention), which, in turn, affects school success (Blair,
2012). For more affluent children, other stressors (e.g., divorce, learning
disabilities, harsh parenting) can affect stress levels and outcomes.
Continuing periods of high stress can lead to either high levels of cortisol or
levels that are immediately high but then drop very low and that blunt
children's responses to new challenges. Both those with blunted responses
and those with very high cortisol responses were found to have lower
executive function and more problems with writing, math, and reading, as
well as poor self-control in class. The reverse was found for those with more
characteristic patterns of cortisol response (elevated with a stressful event
and then normalized afterward).
The children in this study were tested in Head Start and again in
kindergarten. Parenting style was also examined, and parents of lower
socioeconomic status were more prone to harsher forms of discipline that
demanded obedience. Their children had lower executive functioning and

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either high or blunted cortisol levels. Parents using a more sensitive
approach, who interacted with children during play and allowed more
exploration, had children with better executive function and normal cortisol
response. Researchers saw this as evidence that parenting style was an
important part of child stress response. They noted that psychological stress
in childhood “can substantially shape the course of their cognitive, social,
and emotional development … and impair specific learning abilities in
children, potentially setting them back in many domains of life” (p. 67).
The negative impact of childhood poverty on learning and later income
along with health continues to be well documented. Van Ryzin et al. (2018)
indicate, “Researchers found that attaining economic security later in life did
not completely attenuate this link between early poverty and health
problems, suggesting that poverty and adverse social experiences early in life
made the strongest contribution to negative long-term health effects” (p.
130).
Because the lifelong effects of poverty can be deeply rooted in children
and adolescents, countering its effects requires a multilayered public health
approach. Prevention programs that increase childhood nurturing have been
shown to decrease behavioral, emotional, cognitive, and neurophysiological
problem development and may be either family or school based.
Family-based prevention programs focus on teaching family
management skills and improving family relationships. Change outcomes
associated with these programs involve cultivating skills for monitoring and
managing child behavior, negotiating conflicts, and improving overall family
environment quality. Studies indicate that parenting programs can alter
cortisol rhythms, improve stress regulation, and improve standard of living
over time. One of these programs, the Nurse Family Partnership program has
directly led to decreased use of welfare and other governmental assistance,
improved employment for mothers, and improved birth spacing (see Chapter
4).
School-based programs focus on child development and the need to
remediate the effects of low-income and deficient home environments.
Change outcomes involve social–emotional and character development, such
as improving decision-making skills, improving management of difficult
situations, and establishing positive relationships. An example of a school-
based program is Cooperative Learning, which focuses on instructional
strategies and can be used in elementary, secondary, and postsecondary
education settings. It involves group learning methods such as peer tutoring,
reciprocal teaching, and collaborative reading. Teachers design their own
small-group activities that focus on “positive interdependence.” Members of
the group are each responsible to achieve their goals and the success of the
group. Such activities improve friendships, increase personal acceptance, and
foster academic achievement (Van Ryzin et al., 2018).

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 Reaching families in need and disseminating programs to larger
populations require policy initiatives and funding at the local, state, and
national levels. Prevention programs can be implemented through improved
access to health care systems. Using new technology strategies such as
telehealth enables health service access and reduces provider-level barriers to
health care. All of the strategies and programs discussed require ongoing
evidence-based practice and community partnerships to educate public and
policy makers, with the goal of disrupting the intergenerational effect of
poverty (Van Ryzin et al., 2018). For more on poverty, see Chapter 23.
Several government programs and legislative reforms have provided
assistance to the poor and attempted to help them move out of poverty.
Welfare reforms enacted in 1996 (i.e., the Personal Responsibility and Work
Opportunity Reconciliation Act) have been successful in moving many
families from welfare to work. With a combination of welfare time limits,
increasing work requirements/sanctions, and reducing financial disincentives
for work, welfare reform and work success programs were projected to lead
to greater employment. After 22 years, however, many are questioning
whether the resulting safety net of Temporary Assistance for Needy Families
(TANF) is adequate. The number of families receiving cash assistance
through TANF decreased since its implementation from 68 of every 100
families in poverty receiving cash assistance in 1996 to 23 of every 100
families in poverty receiving cash assistance in 2016 (Center on Budget and
Policy Priorities [CBPP], 2018). The majority of TANF adult recipients are
single mothers with young children, and Hispanic children represented the
greatest number of recipient children in 2015 (CBPP, 2018; Child Trends
Databank, 2018a).
The Supplemental Nutrition Assistance Program (SNAP), formerly the
Food Stamp Program, is one of the largest programs offered by federal Food
and Nutrition Services. In 2016, the number of children receiving SNAP
benefits was approximately 19 million. Positive health benefits for children
are linked with SNAP. These positive outcomes include improved birth
outcomes and improved adult health and self-sufficiency. However, the
effectiveness of this program is also being questioned, as many families
exhaust the resource by the end of the month and fall short of groceries
(Child Trends Databank, 2018b).
Safety-net programs such as TANF and SNAP have demonstrated a
reduced risk of nutrition-related problems (e.g., anemia, nutritional
deficiency, failure to thrive), improved overall health, and decreased health
care costs. They have also been associated with a reduction in the risk of
child abuse and neglect. Research regarding SNAP and TANF programs
suggests that increased evaluation is needed regarding the effectiveness at
reducing poverty, the overall effect for children's health, and the use of health
care services (Carlson & Keith-Jennings, 2018). Public insurance now covers

1696
the majority of poor and low-income children. In 2016, the rates of uninsured
children reached an historic low, with only 5.3% of U.S. children lacking
health insurance. Although Medicaid and Children's Health Insurance
Program offer insurance coverage for low-income children, insurance
premiums are associated with increased numbers of uninsured children
(Dubay & Kenney, 2018; Kaiser Family Foundation, 2019). See Chapters 6
and 23 for more on insurance and vulnerable populations.

1697
HEALTH PROBLEMS OF SCHOOL-
AGE CHILDREN
The wellbeing of children is a concern both nationally and internationally.
Many organizations have focused their resources on improving the health
and wellbeing of children, including the World Health Organization (WHO),
United Nations International Children's Education Fund, and U.S.
governmental agencies, nonprofit groups, and charitable foundations.
Unfortunately, the needs of millions of children in the United States and
worldwide remain unmet.
The Healthy People 2030 framework for children is shown in Box 20-1.

BOX 20-1 HEALTHY PEOPLE 2030

Objectives to Improve the Health and WellBeing
of Children

1698
Reprinted from U.S. Department of Health & Human Services (USDHHS). (2020). Healthy People
2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

Even in the wealthiest nations, many children face complex and often
chronic health problems that cause them to miss school days or marginally
participate in the classroom. Childhood is a critical period during which
certain health behaviors or conditions can develop that can lead to more
serious adult illnesses. The chronic health problems of children younger than
age 18 years are characterized by the duration and persistence of symptoms
and their impact on social functioning. Examples of chronic conditions in
school-age children include:

1699
Asthma
Autism spectrum disorder (ASD)
Diabetes
Neuromuscular disorders
Poor oral health
Seizure disorders
ADHD
Nutritional problems—anemia or obesity/overweight
Food allergies
Mental illness (CDC, 2017b)

1700
Chronic Diseases
Stomachaches, headaches, colds, and flu are frequent complaints of school-
age children. Common problems such as hay fever, sinusitis, dermatitis,
tonsillitis, and hearing difficulties are also seen. Chronic health problems can
affect a child's ability to learn and/or his or her physical and social
development. Other more serious conditions, such as asthma, diabetes,
hypertension, seizure disorders, food allergies, and poor oral health, have
effects on academic achievement and educational attainment, affect the entire
family, and can lead to developmental and social issues for children, as well
as missed school days and eventual school failure. Understanding the
influence of chronic diseases in children and families is key for public health
and school nurses as they assist children and families in managing health
(CDC, 2019a; Leroy, Wallin, & Lee, 2017; Miller, Coffield, Leroy, & Wallin,
2016).
With the prevalence of childhood chronic conditions increasing over the
past two decades, approximately 25% of school-age children in the United
States now have chronic health conditions and 5% have multiple chronic
conditions. An increasing prevalence of asthma, food allergies, epilepsy,
diabetes, and hypertension are common in the school setting (Table 20-1;
Miller et al., 2016). Three common chronic disorders in children directly
influenced by socioeconomic status and environment are (Food, Allergy,
Research, and Education, n.d.):
TABLE 20-1 Prevalence of Common Chronic Conditions in
School-Age Children

Source: Miller et al. (2016).

Asthma
ADHD
ASD

These chronic disorders have been evaluated according to social

determinant influences such as poverty. Recent studies indicate that
impoverished children have higher-than-average reported prevalence of
asthma, ADHD, and comorbid health conditions. Prevalence of and
comorbidities associated with ASD were comparable across income levels
(Pulcini, Zima, Kelleher, & Houtrow, 2017).
In a study examining the prevalence and health care–related costs for
children ages birth to 18 years with asthma, epilepsy, hypertension, food
allergies, and diabetes; gender and ethnic variances were noted.

1701
 Females had a higher prevalence of all chronic conditions except
diabetes.
African American children had nearly 50% higher rates of asthma than
did White children, and the odds of having diabetes were 85% higher
for White children than for Asian children and 60% lower for Hispanic
children than for non-Hispanic children.
Prevalence of epilepsy was higher in Hispanic children than in non-
Hispanic children, and adolescents and children ages birth to 5 years
had 29% greater odds of having epilepsy than adolescents aged 12 to 18
years.
Food allergy prevalence was comparable across races, with American
Indian children and adolescents having the greatest percentage at 0.50%
(Miller et al., 2016).

With the numbers of children with chronic conditions increasing, more

children with significant health problems are present in schools (Leroy et al.,
2017). Some children require specialized physical health care procedures,
such as catheterization, suctioning, or ventilator care while in the school
setting, even though school nurses are not always present in each school
building every day (Toothaker & Cook, 2018).
The Individuals with Disabilities Education Act (IDEA) and Section 504
of the Rehabilitation Act of 1973 mandate that services must be provided for
children identified as disabled. Many conditions may be characterized as
disabling under these two laws, including autism, deafness or hearing
impairment, blindness or vision impairment, emotional disturbances, mental
retardation, specific learning disabilities, speech or language impairments, or
other health impairments (e.g., ADHD, asthma). Once identified as disabled,
children may qualify for special educational services. Children with chronic
health conditions that can affect learning (e.g., diabetes, seizure disorders)
may receive medications or other related services while in school to maintain
health and promote ability to learn (U.S. Department of Education, 2018).
Many children with chronic health conditions take multiple medications
at home and at school. This is a critical time for teens to develop schedules
and optimal health behaviors. Medication adherence challenges can be
particularly daunting for adolescents as they prepare to manage health as an
adult. Common medication adherence barriers may include medication
adverse effects, scheduling challenges, desire to appear “normal,” and lack of
family, social, or medical support. One recommendation to engage
adolescents and improve medication adherence is the use of mobile
technology-based interventions (Badawy, Thompson, & Kuhns, 2017). Home
visits and consultations by C/PHNs and school nurses could also be helpful
to parents and children or youth with chronic health conditions. See Chapter
28 for more on school nursing.

1702
Asthma
Asthma is one of the most common chronic diseases of childhood. It is
estimated that 8.4% of children younger than age 18 have been diagnosed
with asthma. Childhood asthma rates steadily increased over the past two
decades. Although reasons for increased asthma rates are somewhat unclear,
experts speculate that better recognition and diagnosis of the disease,
overcrowded conditions, and exposure to air pollution (indoor or outdoor),
allergens, and irritants in the environment are probable culprits and may
trigger asthma attacks.
Recent research indicates that prenatal and early postnatal exposure to
environmental triggers and even prenatal stress and gender may increase
asthma susceptibility. Children and adolescents with asthma may have
attacks triggered by infections, exposure to cigarette smoke, stress, strenuous
exercise, or weather changes (e.g., cold, wind, rain). Asthma
disproportionately affects minority groups and families living below the
poverty level (Bose et al., 2017; Miller & Lawrence, 2018; National Heart,
Lung, and Blood Institute, 2018).
Children with asthma incur greater health care costs associated with
increased emergency department visits and hospitalizations. Treatment for
chronic asthma usually includes cromolyn sodium, leukotriene modifiers,
inhaled and oral corticosteroids or long-acting beta agonists, and anti-
immunoglobulin E therapy, but acute symptoms may involve inhaled beta2
agonists and sometimes anticholinergics (National Heart, Lung, and Blood
Institute, 2018). Asthma education programs are central to effective disease
control and management. In 2018, the National Center for Environmental
Health of the CDC published “EXHALE: A Technical Package to Control
Asthma.” The EXHALE program focuses on the following evidence-based
strategies:

E—Education on asthma self-management (AS-ME)

X—X-tinguish smoking and secondhand smoke
H—Home visits for trigger reduction and asthma self-management
education
A—Achievement of guidelines-based medical management
L—Linkages and coordination of care across settings
E—Environmental policies or best practices to reduce asthma triggers
from indoor, outdoor, and occupational sources

School nurses and C/PHNs often work with students, families, and
physicians to develop an asthma action plan to control, prevent, or
minimize the untoward effects of acute asthma episodes. It is hoped that
professionals in public health, health care, education, social services, and
nongovernmental organizations will use the EXHALE program tools to

1703
improve asthma control/management and monitor and evaluate program
success (Hsu, Sircar, Herman, & Garbe, 2018).
C/PHNs are in a unique position to implement many of the EXHALE
strategies, especially education for children and their families. Education
should include foundational asthma self-management (AS-ME) concepts
including medication use, asthma self-management techniques, symptom
recognition and appropriate treatment, and asthma trigger reduction.
Monitoring asthma medications and teaching proper methods of inhaler
use are vital school nursing or C/PHN functions. Evidence indicates that AS-
ME results in better asthma control, improved medication adherence,
decreased health care costs, and fewer missed school days (Healthy Schools
Campaign, 2018; Hsu et al., 2018).

Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a complex developmental disorder
frequently noticed within the first few years of life and typically lasts
throughout a person's lifetime. The spectrum of ASD indicates that
symptoms for each child varies and may range from mild to severe and from
gifted to severely challenged (CDC, 2020a). A child's communication skills
and interaction with others are most frequently affected, along with obsessive
behavior and narrowed interests. Behaviors associated with autism include
the following:

Social issues such as

Does not respond to name by 12 months of age
Avoids eye contact
Prefers to play alone
Has flat or inappropriate facial expressions
Does not understand personal space boundaries
Communication issues such as
Language problems—delay in language, repetitive use of words
Talks in flat, robot-like or sing-song voice
Does not pretend in play
Unusual interests and behaviors
Is very organized
Has to follow certain routines
Fixation on objects and/or interests
Repetitive motions such as rocking or spinning (CDC, 2020a)

Autism has become an urgent public health concern with prevalence

estimated at 1 of every 59 children by the age of 8 years. The disorder varies
among racial/ethnic groups and communities with greater prevalence among

1704
males than females, and whites than minority group, although gender and
ethnic prevalence differences are decreasing (Baio et al., 2018).
The yearly expense for autistic children is approximately $11.5 billion to
$60.9 billion (2011 US dollars). This estimate includes a variety of costs
including health care, special education, and lost parental productivity.
Health care costs for children and adolescents with ASD are 4.1 to 6.2 times
greater than for those without ASD, and when intensive behavioral therapy is
required, the cost differential is even greater (CDC, 2020b).
The cause of autism is not clear—some genetic links have been found,
but environment may also be a factor. There is a higher risk of subsequent
children having autism in a family with one autistic child or a parent with
ASD and for children born to older parents (CDC, 2020b).
ASD is frequently associated with genetic and chromosomal disorders,
but the exact causes are not fully understood (CDC, 2020b). Through the
CDC sponsored multi-year Study to Explore Early Development (SEED),
additional autism risk factors are being identified. These include a family
history of immune conditions and birth spacing (Croen et al., 2019; Schieve
et al., 2018).
C/PHNs may come in contact with families dealing with autism through
work in well-child or immunization clinics. It is important to assist families
in accessing services for their children (early intervention is advantageous).
It is also important to educate that parenting practices are not a cause of
autism and that multiple, large-scale research studies on childhood
immunizations do not indicate a relationship between immunization and
autism (CDC, 2019b).

Diabetes
Although diabetes ranks lower as a prevalent childhood chronic illness, it is
associated with significant complications and self-management challenges.

Type 1 diabetes mellitus (T1DM) is usually diagnosed in early

childhood and is the leading cause of diabetes in children and
adolescents with non-Hispanic Whites having the greatest number of
new cases.
Type 2 diabetes mellitus (T2DM) is generally diagnosed later in life and
associated with metabolic syndrome and being overweight. It is more
prevalent in U.S. minority groups than non-Hispanic Whites (CDC,
2018a; Miller et al., 2016).
Both type 1 (T1DM) and type 2 diabetes (T2DM) are found in school-
age children, with T2DM rising almost exponentially in this age group,
leading some scientists to call this a major public health crisis. This
epidemic is thought to stem from increasing rates of childhood obesity,

1705
 sedentary lifestyle, and the predisposition of certain ethnic groups (e.g.,
African American, Native American/Alaska Native, Hispanic/Latino,
Pacific Islander) to the disease. A family history of T2DM and having
one or more conditions related to insulin resistance also plays a role
(CDC, 2017d).

A recent review by Mayer-Davis et al. indicates that the health burden of

T1DM and T2DM among children and adolescents has increased
substantially, especially among minority racial and ethnic groups. These
findings are parallel to an increased prevalence of obesity and reflect an
increased need for public health interventions to reduce the disease burden
disparity. It is possible that variations in the prevalence of obesity will
contribute to variations in insulin resistance and an increasing incidence of
T2DM. Over time, there will be a substantial increase in U.S. youth with
diabetes, especially in minority groups (Mayer-Davis et al., 2017).
Yoshida and Simoes (2018) discuss the increasing evidence about the
relationship between sugar-sweetened beverages (SSB), obesity, and T2DM
in children and adolescents. Their report indicates that the intake of SSB by
children and adolescents corresponds with the rising obesity prevalence.
Public health solutions that are all-inclusive and wide-ranging are needed to
combat the obesity and T2DM epidemic. Programs that limit the availability
and access to SSBs, improve the quality of all foods available in schools, and
increase physical activity are being evaluated. Initiatives involving SSB
taxation and healthy beverages subsidization are being considered. It is
hoped that such a program will increase revenue available for health
promotion and develop awareness of SSB consumption health risks. Multiple
challenges for these programs exist, including inconsistency among school
wellness and nutrition policies, SSB substitution by other high-calorie drinks,
increased student calorie intake at home, and opposition from the beverage
industry (Yoshida & Simoes, 2018).
Research continues on the pathophysiology of diabetes and prevention
strategies (e.g., lifestyle changes, causes of autoimmunity), as well as
refining methods of diagnosis and treatment (e.g., insulin pumps, continuous
glucose monitoring, closed loop systems).

School-based interventions focusing on lifestyle modifications, weight

loss, healthy eating, and exercise have effectively decreased T2DM risk
factors short term. Additional research to determine long-term effects is
recommended (Geria & Beitz, 2018).
Studies regarding oral medication adherence in children and adolescents
with T2DM demonstrate that self-management and medication
adherence is similar to youth with other chronic diseases. Social and
family support, pairing medication dosing with daily routines, and

1706
 developing personal problem-solving skills improved self-management
(Venditti et al., 2018).

Younger children with T1DM, especially those who use insulin pumps,
may need careful monitoring, something that is not always possible for the
school nurse assigned to several school sites. It is important for C/PHNs and
others working with children and youth who have diabetes to consider their
psychosocial needs, as well as their physical needs (Box 20-2). A
multidisciplinary team approach coordinating family, school staff, and
physician collaboration is optimal. See Chapter 28 for more on the school
nurse's role with school-age children with diabetes.

BOX 20-2 Evidence-Based Practice

Emotional Impact on Children and Youth of
Having Diabetes Children and adolescents with
diabetes (both T1DM and T2DM) cope with
unique disease self-management and health
challenges. They are required to pay stricter
attention to their health and management of
their chronic condition. In addition, there are
emotional challenges such as anxiety.
In a descriptive pilot study, nurses Elertson, Liesch, and Babler
(2016) explored expressing emotion through drawings by youth with
T1DM. Participating youth were given a blank piece of white paper and
asked, “If diabetes had a face, what would it look like?” A variety of
emotions and self-expression were portrayed through pictures depicting
sadness, tears, helplessness, frustration, and even monster-like images.
Some of the drawings portrayed happiness, guilt, anger, judgment, and
resentment. Some included written messages describing their experience
with diabetes, for example, “Diabetes is my blood sucking monster”;
“mad, angry, scared, it hurts”; and “diabetes has an effect on everyone,
even people you don't think about” (Elertson et al., 2016, p. 36).
In another study, youth with T1DM are at increased risk of mental
health symptoms. Nurses Rechenberg, Whittemore, and Grey (2017)
wanted to better understand the emotional impact of children with
diabetes. They conducted an integrative review of the literature about
anxiety in youth with T1DM. Their research indicates that
approximately 20% of youth with T1DM are positive for significant
anxiety and depressive symptoms. The review evaluated health

1707
 outcomes and anxiety-related symptoms including hypoglycemia fears,
family conflict, glycemic control, depressive symptoms, blood glucose
monitoring, general anxiety, quality of life, and interventions.
Rechenberg et al. (2017) found that it is important to distinguish the
anxiety type when designing interventions. For example, state anxiety
(“transient experience of the physiological arousal associated with
feelings of dread and tension”) has been more highly associated with
depressive symptoms, and trait anxiety (“likelihood to respond
anxiously to a stimulus”) is associated with fear of hypoglycemia
(Rechenberg et al., 2017, pp. 66, 69). Hypoglycemia fears are more
prominent in girls and linked to poorer HbA1c levels and worse self-
management. Social anxiety was associated with a poorer quality of life
and decreased adherence. Promising interventions included behavioral–
cognitive therapy and feasible implementations that strengthen
connectedness among youth with T1DM. Adults (e.g., parents,
caretakers, nurses) need to be aware of children's physical needs and
offer assistance. They also must consider their emotional and
psychosocial needs.
Source: Elertson et al. (2016); Rechenberg et al. (2017).

Children and adolescents with diabetes may be reluctant to comply with

their medical regimen, but strict adherence has proved to reduce later
microvascular complications. Intensive insulin regimens are recommended
for T1DM and for some cases of T2DM. Automated insulin delivery systems
should be considered and glucose levels monitored multiple times each day.
Research is ongoing regarding the long-term effects of diabetes and best
management strategies. It is important for school nurses and C/PHNs to
understand each child's unique needs and circumstances and keep in mind a
child's developmental stages. In addition to meeting the obvious emergency
health–related concerns for diabetic children, it is imperative to teach
children and families that proper diet, oral antidiabetic medications or insulin
administration, physical activity, and blood glucose testing are vital strategies
to keep blood glucose levels as close to normal as possible. This includes
alerting teachers and school personnel to the signs and symptoms (as well as
treatment) of hypoglycemia. Alerting teachers to these concerns may help
them better understand the academic complications of this disease and ensure
their support (Chiang et al., 2018).
The prevention of T2DM through education and improvement in
exercise, nutrition, and lifestyle can be one of the most important areas of
focus for health professionals who work with the school-age population—
including C/PHNs who may come into contact with them during
immunization or child health clinics (Box 20-3). Health education and health

1708
promotion to decrease childhood obesity and sedentary lifestyles may help
stem the tide of T2DM in children and adolescents (Geria & Beitz, 2018).

BOX 20-3 Levels Of Prevention Pyramid

Prevention of Type 2 Diabetes Mellitus in School-
Age Children SITUATION: The public health
nurse and children with type 2 diabetes (T2DM)
GOAL: By using the three levels of prevention,
avoid or promptly diagnose and treat negative
health conditions and/or restore the fullest
possible potential.

Seizure Disorders

1709
Seizure disorders are fairly common in the school-age population. Epilepsy
is a disorder of the brain in which neurons sometimes transmit abnormal
signals. Epilepsy is considered to be one of the most common disabling
neurologic conditions, and it is most common in the very young and in
elderly populations.
Approximately 3.4 million people in the United States live with seizures,
and of those, 470,000 are children (Epilepsy Foundation, n.d.). Lifetime
prevalence of seizure disorders/epilepsy is estimated at 48 per 100,000, and
new cases are most common in younger children and families of low-
socioeconomic status.
Those with seizure disorders have an increased risk for developmental
(ASD, delays), mental health (e.g., anxiety, depression, ADHD, conduct
disorders), and physical comorbidities (e.g., headaches) (Epilepsy
Foundation, n.d.).
Although there are some instances of intractable or drug-resistant
epilepsy, many children diagnosed with seizure disorders/epilepsy can have
their seizures controlled with antiepileptic medications. Treatment is based
upon many factors including the type of seizures, history, and physical status.
Vagus nerve stimulators, deep brain stimulation, and ketogenic diets are used
in some cases after other treatments have failed (Mayo Clinic, 2018b).
Rectal diazepam is commonly prescribed for younger children and those
with developmental disabilities, yet nurses are not always available to make
an appropriate nursing assessment of the child before the drug is given to
stop a seizure. Often, school staff is trained to give the emergency
medication—highlighting the conflict between education laws and nurse
practice acts (CDC, 2017b; see more on this in Chapter 28).
Parents may be reluctant to disclose a seizure diagnosis due to associated
stigma. Children and adolescents with seizure disorders may feel
embarrassed or be the victims of teasing or bullying. They may exhibit signs
of school avoidance, or they may have problems learning. Seizure activity,
along with the side effects of antiepileptic medications, may lead to problems
with memory and learning, as well as changes in behavior. Moreover,
seizures can affect short-term memory or language functions. Health care
providers are in a position to educate and support families as they cope with
the unique challenges of epilepsy (Benson, Lambert, Gallagher, Shahwan, &
Austin, 2017; Kerr & Fayed, 2017). It is important to monitor medication
adherence and teach school staff about first-aid measures for seizure victims.
When teachers are anxious about having a child with epilepsy in the
classroom, educational programs for them and other school staff members
can be provided. Community health nurses or school nurses can help allay
fears and promote appropriate and timely care.

1710
Childhood Cancers
In 2017, cancer was the second leading cause of death from disease among
U.S. children between infancy and age 14 years. Leukemias and brain,
central nervous system, and neuroblastoma cancers are the most common
types of childhood cancers. Childhood cancers, especially leukemias, now
have better outcomes than ever before. Five-year survival rates for childhood
cancers have increased by 0.6% each year since 1975 (Simon, 2018).
More children are surviving childhood cancers, and concern has shifted
to later complications of treatment rather than about cancer recurrence.
Survivors are at greater risk of cognitive and vision impairments, pituitary
problems, delayed growth, and heart disease. Also, children who have been
treated with chemotherapy and/or radiation may develop a second primary
cancer, and the risk of leukemia may be increased (American Cancer Society,
2017a).
The cause of most childhood cancers remains unknown; however, high
levels of ionizing radiation, Down syndrome, and other genetic syndromes
(e.g., Beckwith-Wiedemann syndrome) have been linked to a higher risk for
some childhood cancers. Pesticide exposure may be a factor, but research
findings have not been decisive. Parental smoking may be linked to an
increased cancer risk, but evidence for this is also inconclusive (National
Cancer Institute [NCI], 2017).
Because many children return to school after initial hospitalization and
treatment for cancer, school nurses or C/PHNs can help make this transition
easier by educating classmates about cancer (e.g., it is not contagious),
helping the children make necessary adjustments, and vigilantly protecting
any immunocompromised students from communicable diseases (American
Cancer Society, 2017b).

1711
Behavioral and Learning Problems
Other childhood health problems, less easy to detect and measure but often
just as debilitating, are those of emotional, behavioral, and intellectual
development. Although these problems are not new, awareness and concern
have increased as the rates of occurrence for other life-threatening childhood
diseases have diminished. Emotional or behavior problems and learning
disabilities are prevalent in childhood. It is estimated that one of every five
children in the United States has learning and attention issues and yet only a
few are actually identified (National Center for Learning Disabilities
[NCLD], 2017).

Learning Disorders
Children with attention and learning issues come from all income levels and
all nationalities (NCLD, 2017). Learning disorders (LDs), also known as
learning disabilities, are often recognized as the child progresses in school,
and special education services may be needed. The cause of LDs is not
known; however, differences in brain structure have been noted. Maternal
alcohol or substance abuse during pregnancy, poor nutrition, childhood
exposure to toxins, and traumatic brain injury may also contribute to LDs
(Eunice Kennedy Shriver National Institute of Child Health and Human
Development, 2018a).
Some LDs are apparent in early school years, whereas others do not
present problems until early adolescence. Battles over homework, poor
grades, acting out in school, or frequent child complaints about school,
teachers, or schoolwork are often harbingers of LDs. Children with LDs are
more likely to repeat a school grade, miss multiple school days, be suspended
from school, and drop out (NCLD, 2017). Early identification and
intervention are key to the success of a child with LDs. Students must first be
carefully identified through specialized testing; then, special education or
resource teachers can build on the child or adolescent's strengths while
working to compensate for weaknesses.
The recently legislated Research Excellence and Advancements for
Dyslexia Act and the Every Student Succeeds Act provide initiatives and
strategies for early identification and response for struggling students
(NCLD, 2017).
Common signs of LDs are (Eunice Kennedy Shriver National Institute of
Child Health and Human Development, 2018b; NCLD, 2017):

Reading problems (Fig. 20-1)

1712
 Writing problems (fine motor control and handwriting; problems with
spelling, grammar, punctuation, capitalization; difficulty controlling
flow of thoughts)
Math problems (problems learning and understanding concepts, missing
steps or sequencing of problems, and placement of numbers in columns)
Language problems (cannot quickly process what is heard, problems
with multiple instructions, difficulty organizing thoughts and speaking
in classroom situations)
Motor problems (problems with fine motor planning activities, such as
tying, cutting, coloring; gross motor planning, such as jumping and
running; trouble with visual–motor activities, such as hitting or catching
a ball)
Sequencing (getting letters or numbers out of order); organization
(messy binders)
Memory (difficulty retaining what was learned); abstraction (confused
or not understanding what was said)

FIGURE 20-1 Reading is important to education and may be

problematic for children with learning disabilities.

If LDs are not dealt with in childhood and adolescence, they can lead to
later, more serious, problems related to employment, relationships, and
quality of life in adulthood (NCLD, 2017). The C/PHN and school nurse can
assist individuals and families in recognizing LDs and locating necessary
resources. Some students with significant LDs may qualify for special
education services, and school nurses can be helpful in facilitating this
process along with teachers and learning specialists.

Attention Deficit Hyperactivity Disorder

1713
Attention deficit hyperactivity disorder (ADHD), a common childhood
disorder, is a cluster of problems related to hyperactivity, impulsivity, and
inattention (National Institute of Mental Health [NIMH], n.d.a). The number
of children with ADHD has increased over time; however, due to variations
in testing and survey criteria, it is difficult to ascertain if percentages reflect
the numbers of children with ADHD or the numbers of children diagnosed.
It is estimated that in 2016, 9.4% children ages 2 to 17 years had ever
been diagnosed with ADHD, representing 1.6 million U.S. children. Of
children with ADHD, approximately 62% were taking medications, 60%
were being treated with behavioral therapy, and nearly 64% had a co-
occurring condition such as anxiety, autism, depression, or behavioral issues
(CDC, 2018b).
Diagnosis of ADHD involves a several-step process and should include
reports from parents/guardians, teachers, and mental health providers if
applicable. The primary care clinician generally makes the final diagnosis
after considering all symptoms and reports, and ruling out other possible
symptom causes. Boys are often recognized as having ADHD in early
elementary grades, because they most often exhibit hyperactivity symptoms.
Girls, on the other hand, are at increased risk for not receiving appropriate
services because they exhibit lack of attention more frequently than
hyperactivity (CDC, 2019c).
The exact cause of ADHD remains unknown. Research indicates,
however, that a number of factors may be linked, including:

Genetics and heredity

Fetal exposure to cigarette smoking, alcohol use, drug use, or
environmental toxins during pregnancy
Childhood exposure to environmental toxins, such as high levels of lead
Premature birth and/or low birth weight
Brain injuries and/or central nervous system development problems
(Mayo Clinic, 2018a; NIMH, 2018)

At each stage of development, those with ADHD are presented with

distinct challenges. For example, children in elementary school may be
involved in conflicts with peers and have problems organizing tasks. They
may be more prone to accidents and may have more school-related problems,
such as grade retention and suspension or expulsion. As adolescents, they
may show less hyperactivity but continue to have restlessness, difficulty
focusing, and impulsivity. These symptoms often continue into adulthood.
Compared with non-ADHD teens, they may have more conflict with their
parents, poorer social skills, and ongoing problems at school. They are also
more likely to use tobacco and alcohol and have delinquent behaviors. As
young adults, they are less likely to be enrolled in college and more likely to

1714
experience lower job performance ratings than their peers. In adulthood, they
tend to have more marital and occupational problems (Mayo Clinic, 2018a;
NIMH, 2018).
In a recent longitudinal cohort study, the frequency of digital media-use
among adolescents was associated with subsequent ADHD symptoms.
Researchers recommend that this area of research be expanded for further
insights to ADHD causes (Ra et al., 2018).
Collaboration among the child's family, school, and physician is needed
to diagnose ADHD and to plan appropriate interventions and educational
accommodations. Although parents have a wealth of knowledge about the
child, teacher confirmation of ADHD-related behaviors is very important.
School nurses and C/PHNs can assist parents in recognizing the symptoms of
ADHD and in obtaining appropriate treatment and follow-up.
A multimodal treatment approach is recognized as most effective. The
main goals of medical treatment are to strengthen positive behaviors and
decrease unwanted behaviors. Treatment strategies include medication,
usually methylphenidate (Ritalin, Metadate, or Concerta),
dextroamphetamine (Dexedrine), or combined dextroamphetamine and
amphetamine (Adderall); school accommodations for learning problems; and
social skills training for the child with ADHD.
Nonstimulant medications, such as clonidine, atomoxetine (Strattera),
and guanfacine hydrochloride (Intuniv), are also used in children and
adolescents (Mayo Clinic, 2018a; NIMH, 2018).
Family and individual counseling, parent support groups, and training in
behavior management techniques, as well as family education about the
condition, are also essential features of this treatment method. Recent
research indicates that highly effective treatment includes group parent
behavior therapy and/or individual parent behavior therapy with child
participation (CDC, 2019c).
Parental resistance to treatment may result from side effects (e.g.,
problems with sleep, appetite, greater anxiety) or stem from fears about later
abuse of substances. Alternative treatments that have been tried but not
proven effective through research include yoga or meditation; special diets
with decreased sugar and allergens such as wheat or milk, vitamin or herbal
supplements, or increased omega-3 oils; and increased exercise (Mayo
Clinic, 2018a). School nurses and C/PHNs can work closely with school
staff, parents, and physicians in determining the efficacy of treatment
regimens.

Behavioral and Emotional Problems

1715
Good mental health is important to our overall health and wellbeing.
Monitoring and understanding children's mental health is an important public
health issue. Approximately 13% to 20% of U.S. children experience a
mental health disorder each year. The lifetime prevalence of any mental
disorder among 13-to 18-year-olds is 49.5%, and of those diagnosed, 22.2%
have severe impairment. It is estimated that one out of every seven U.S.
children between the ages of 2 and 8 years has had a diagnosed mental,
behavioral, or developmental disorder (CDC, 2019d; NIMH, 2017).
Living in an environment where children are not safe or that undermines
their stability or ability to bond—such as households with mental health
issues, substance misuse, or separation due to prisons—can have lasting and
negative effects on their health and wellbeing (CDC, 2020c). Adverse
childhood experiences (ACE) are traumatic events that occur in childhood
(ages 0 to 17), such as violence, abuse, or having a family member attempt or
die by suicide. ACE is linked to mental illness, substance misuse, and
chronic health problems; it can also negatively impact employment
opportunities and education (CDC, 2020c). Associated conditions related to
ACE (such as food insecurities or living in under-resourced or racially
segregated neighborhoods) compound an already stressful environment,
leading to toxic stress. As children grow up, they may have difficulty
forming healthy or stable relationships, with these effects being passed on to
their children; this chain reaction can result in such individuals or their
children being more likely to perpetrate or be the victims of acts of violence
(CDC, 2020c). ACE is preventable through education, strong economic
support for families, legislation that protects against violence, and
community support for safe and nurturing environments for children.
Of the millions of children living with mental health issues, ADHD (see
previous section) is the most prevalent among children and youth ages 3 to
17 years. Children between the ages of 3 and 17 years of age experience
additional types of mental health disorders including behavioral or conduct
disorders (3.5%), anxiety (3.0%), depression (2.1%), ASD (1.1%), Tourette's
syndrome (0.2% ages 6 to 17 years), and posttraumatic stress disorder
(PTSD). Disruptive behavior disorders include oppositional defiant disorder
(ODD) and conduct disorder (CD). Coexistence of ODD or CD with ADHD
occurs in 1/3 to ½ of all children with ADHD. Males are more frequently
diagnosed with both disorders as well as children of divorced parents and
lower socioeconomic status. These children are more likely to be aggressive
and hostile and have an increased risk of serious school or social
delinquency. Early recognition, treatment, family support, school
management, and child and family therapy increase the child's success
(National Resource Center on ADHD, 2018). It is important to find referral
sources for these children and their families, and this may be difficult in
more rural or outlying areas.

1716
 Children are barometers of their environment. About 40% to 50% of
couples in the United States divorce, and the second marriage rate of divorce
are even higher. In 2016, 65% of children age 0 to 17 years lived with two
married parents, 23% of children lived only with their mothers, 4% lived
only with their fathers, 4% lived with unmarried parents, and 4% did not live
with either parent. Children of divorce are more likely to exhibit behavior
problems, with children who are products of highly contentious divorces
most at risk (FCFS, 2019b).
Being aware of a child's family situation and living arrangements is
helpful for understanding social, economic, and developmental wellbeing.
C/PHNs can be alert to early symptoms and refer parents to marital
counseling or suggest family therapists. Some schools also offer support
groups for children of divorce.
School refusal, where a child develops a pattern of refusing to go to
school or remain in school for the entire school day, is common in school-age
children and differs from truancy. Unlike truancy, school refusal is
commonly associated with symptoms of emotional distress—usually anxiety
or depression—but may also be associated with oppositional defiant disorder,
ADHD, or other disruptive behavior disorders. Often, the children complain
of headaches, stomachaches, or other physical ailments, but some are
motivated to miss school to gain parental attention. School refusal is most
commonly found in children between ages 5 and 7 or ages 11 and 14.
Transitional periods, such as school entry or moving to middle school or high
school, are often the most difficult.
Children usually present to the school nurse or C/PHN with headaches
and/or abdominal pains. They may throw tantrums, cry, or exhibit panic and
fear to their parents in an attempt to stay home from school. Sometimes,
children are afraid of something in the school environment (e.g., bullies,
teachers, test taking), or they may have separation anxiety (American
Academy of Child & Adolescent Psychiatry [AACAP], 2018). Family
enmeshment or detachment, or high levels of family conflict, may contribute
to school refusal problems, as well as parental anxiety disorders like
agoraphobia and panic disorder (Maynard et al., 2015).
The best interventions include early return to school, with parental
involvement in school, systematic desensitization (graded exposure to the
classroom), relaxation training, emphasize positive aspects of going to
school, and counseling being the most effective (ADAA, n.d.). If symptoms
persist, evaluation by a mental health provider is recommended. C/PHNs and
school nurses can serve as a liaison with the child, family, school, and health
care/mental health care providers to promote a positive outcome.

1717
Disabilities
In 2014 to 2015, the number of children ages 3 to 21 years served under
IDEA was approximately 6.7 million—accounting for 13% of the total
school-age population. Specific learning disabilities and speech or language
difficulties were the two most common disabilities reported, followed by
other health impairments (asthma, chronic illnesses), autism, intellectual
disability, developmental delay, and emotional disorders. American
Indian/Alaska Native children (17%) had the highest prevalence, followed by
Black (16%), White (14%), Hispanic and Pacific Islander (both at 12%), and
Asian (7%) (NCES, 2018b).
Many children with perceived disabilities or problems are referred for
assessment and considered for placement in special education programs each
year. School nurses often serve as a liaison between parents, physicians, and
educators and are part of the team developing an individualized education
plan (IEP) for children who qualify for special education services. Most
children receive special services in a regular classroom because full inclusion
or mainstreaming legislation mandates that fewer children be segregated into
special classes or separate schools.
See Chapter 24 for more on clients with disabilities and Chapter 28 for
more on school nursing.

1718
Injuries
The loss of children's lives that results from all injuries combined suggests a
staggering loss to society in the number of years of productive life lost. An
injury is damage to the body, either unintentional or intentional, but use of
the word accident is considered incorrect, as injuries may be prevented
through environmental, individual behavioral, legislative, and institutional
policy changes.
In the United States, unintentional injuries are the leading cause of death
and disability for children between the ages of 1 and 19 years.
Approximately 31.3% of deaths between age 1 and 9 years and 39.6% of
deaths between age 10 and 24 years result from unintended injuries (Heron,
2017). Falls are the leading cause of injury between the ages of 1 and 14
years, followed by being struck by or against an object or person (FCFS,
2019c). Injuries not resulting in death often cause permanent disabilities or
emotional and physical consequences for children and their families. (See
for an infographic and a link to more information on falls in
children and youth.) Although injury death rates have dropped over the past
two decades, injuries are responsible for approximately 75% of deaths during
adolescence.

Being struck by or against an object is the leading cause of injury

between the ages of 15 and 19 years, followed by falls, motor vehicle
crashes (MVC), overexertion, and being cut or pierced (FCFS, 2019d).
During 2015, the leading causes of adolescent deaths were motor
vehicle accident or firearms related (FCFS, 2019a).
Suicide was the second leading cause of death of 15-to 19-year-olds
during 2016 and homicide ranked third. Firearms were involved in
44.5% of teen suicides and 88.7% of teen homicides (CDC, 2020d).

Disparities exist among racial and ethnic groups. In 2014, homicide was the
second leading cause of death among ages 1 to 24 years. In 2014, it was the
leading cause of early death for non-Hispanic Black males, the second
leading cause of Hispanic male death, and the third leading cause of death
among non-Hispanic White males (CDC, 2017c). (See for an
infographic and a link to more information on the homicide rate in this age
group.) Two public health concerns contributing to child and adolescent
MVC are alcohol use and cell phone use while driving. A large-scale study
examining the relationship between alcohol policies and fatal motor vehicle
crashes (MVCs) found that alcohol was a factor in more than 25% of cases of
motor vehicle fatalities involving children, adolescents, and young adults
<21 years of age. Research indicated that restrictive alcohol policies are

1719
associated with reduced alcohol-related MVC among youth (Hadland et al.,
2017).
Another concern for adolescents (and the general population) is use of
cell phones while driving (Fig. 20-2). Adolescent cell phone use while
driving has been legislatively banned in several states and yet reports
indicate continued cell phone use while driving. Research investigating self-
reported cell phone use indicates decreased handheld cell phone use but
continued adolescent texting while driving—perhaps because of decreased
visibility to officers and difficulty in enforcing bans. Increased education and
intervention are recommended public health interventions for the adolescent
population (Rudisill, Smith, Chu, & Zhu, 2018).

FIGURE 20-2 Cell phone use while driving—whether talking,

texting, or using an app—is dangerous.

Cell phone use while driving is dangerous, especially for inexperienced

adolescent drivers (Fig. 20-2).
In 2015 to 2016, approximately 69% of public schools reported one or
more violent incidences. Fifty-seven percent of primary schools, 88% of

1720
secondary schools, and 90% of high schools reported violent incidents as
defined by criminal incidents, violent victimization, and physical violence
(NCES, 2017).
C/PHNs can promote injury prevention and control through education,
promotion of safety engineering and environmental protection strategies, and
legislative advocacy.

C/PHNs can advance the prevention of unintentional injuries and deaths

by working with families to initiate consistent use of seat belts and child
safety seats in vehicles and the use of helmets and other protective gear
for children riding bikes and skateboarding (Box 20-4).
Where water is a natural hazard, wearing life jackets while boating and
swimming can help decrease accidental drowning.
Promotion of smoke and carbon monoxide detectors, poison prevention,
and sudden infant death syndrome (SIDS) education can help to further
decrease injury death rates.
Teaching parents about presetting hot water heaters to lower than 130°F,
recognizing the hazards of infant walkers, storing matches and lighters
safely, and using pool fencing can help to prevent common
unintentional injuries (Safe Kids Worldwide, 2018).
Advocacy for stricter seat belt and child safety seat enforcement, as well
as programs to provide child safety seats and bicycle helmets, has been
shown to positively affect mortality and injury rates. Enforcement of
seatbelt laws, graduated driver licensing programs, and adolescent
education about MVC causes are also effective (CDC, 2020e).

BOX 20-4 STORIES FROM THE

FIELD WHY PARENTS AND
CAREGIVERS ARE INCONSISTENT
IN THEIR USE OF CAR
RESTRAINTS FOR CHILDREN A
LEADING CAUSE OF CHILDHOOD
INJURY AND DEATH CONTINUES
TO BE MOTOR VEHICLE CRASHES
(MVC). THE USE OF RESTRAINTS
(SEATBELTS, INFANT CAR SEATS,

1721
CHILD BOOSTER SEATS) HAS BEEN
SHOWN TO BE AN EFFECTIVE
POPULATION-LEVEL
INTERVENTION THAT REDUCES
FATALITIES AND SERIOUS
INJURIES (CDC, 2019K). I WAS PART
OF A TEAM OF NURSES,
EPIDEMIOLOGISTS, AND
PHYSICIANS FROM AN EASTERN
CENTER FOR INJURY RESEARCH
AND PREVENTION WHO STUDIED
FACTORS ABOUT PARENT AND
CAREGIVER USE OF BOOSTER
SEATS. OUR GOAL WAS TO
UNDERSTAND WHY PARENTS AND
CAREGIVERS INCONSISTENTLY
USE CAR RESTRAINT SYSTEMS.
OUR GROUP DESIGNED A CROSS-
SECTIONAL ONLINE SURVEY
WITH A CONVENIENCE SAMPLE
OF PARENTS IN THE UNITED
STATES. SURVEY PARTICIPANTS
WERE >18 YEARS OF AGE, SPOKE
AND READ ENGLISH, WERE THE
PARENT OR CAREGIVER OF A
CHILD BETWEEN 4 AND 10 YEARS

1722
OF AGE, AND HAD DRIVEN THEIR
CHILD AT LEAST SIX TIMES IN
THE PAST 3 MONTHS.
PARTICIPANTS ANSWERED
QUESTIONS ABOUT THE
SITUATIONAL USE OF CAR SEATS
AND BOOSTER SEATS WITH THEIR
CHILD AGE 4 TO 10 YEARS AND
CARPOOLING CHILDREN. OUR
RESEARCH FOUND THAT PARENTS
AND CAREGIVERS USING
BOOSTER SEATS DID NOT FULLY
RESTRAIN A CHILD DUE TO
PRACTICAL REASONS MORE
OFTEN THAN
PARENTS/CAREGIVERS USING CAR
SEATS DID. PRACTICAL
SITUATIONS FOR NOT USING A
CRS INCLUDED DRIVING SHORT
DISTANCES, TOO MANY PEOPLE IN
THE CAR, AND NOT HAVING A CRS
IN THE CAR. DECREASED USE OF
CRS PUTS CHILDREN AT A HIGH
RISK OF INJURY. IT IS IMPERATIVE
THAT HEALTH CARE PROVIDERS
CONTINUE TO EDUCATE

1723
 PARENTS/CAREGIVERS AND
IMPLEMENT PROGRAMS TO
PROMOTE CRS USE.
—Catherine, RN
1. As a C/PHN, what resources would you provide to a family with
young children using a car seat?
2. What does the data in your community indicate regarding
childhood morbidity and mortality for MVA? What strategies
would work best for prevention in your community?
Source: CDC (2019k); McDonald et al. (2018).

Community health nurses can work with their local health departments and
community action groups to provide seats and helmets to families who
cannot afford them, organize clinics to educate about proper installation and
use, and encourage local law enforcement to enforce seat belt and safety seat
laws.

1724
Communicable Diseases
The mortality rates of school-age children 5 to 14 years old are
comparatively low and have decreased substantially over the last century, a
reduction that can be attributed to the effective prevention and control of the
acute infectious diseases of childhood, a significant achievement in the last
century. Although mortality rates are low in this country, worldwide
mortality because of communicable diseases continues with lower respiratory
infections the most deadly. Globally, among children ages 5 to 14 years, the
risk of dying from communicable disease has significantly decreased,
whereas the prevalence of mortality related to injuries has increased to 25%
(WHO, 2018b).
It is estimated that immunizations save 33,000 lives, prevent 14 million
causes of disease, and save approximately $40 billion. The U.S. public health
efforts (Healthy People 2030) focus on reducing vaccine-related illnesses and
disease. School-age children must show proof of required vaccinations
before they are allowed to enroll in school, although most states still allow
exemptions for personal or religious beliefs (for information on which states
allow religious and philosophical exemptions, visit:
http://www.ncsl.org/research/health/school-immunization-exemption-state-
laws.aspx). Vaccine hesitancy by parents has been linked to outbreaks such
as measles; however, individual cases in 2017 to 2018 were similar to recent
years (CDC, 2019e, 2020f).

Results from a 2016 national immunization survey revealed that around

90% of children between ages 19 and 35 months received vaccinations
for polio, MMR, varicella, and hepatitis B.
Non-Hispanic Black children were less likely to receive the full
immunization series than non-Hispanic White children. Children in
poverty, those covered by Medicaid, and children without insurance
were also less likely to receive the full immunization series (see CDC
for childhood immunization schedule, available at
https://www.cdc.gov/vaccines/schedules/easy-to-read/child.html).

The National Immunization Survey–Teen (NIS-Teen) indicates that

adolescent vaccination coverage in the United States has gradually increased.
However, disparities continue with teens living in nonmetropolitan statistical
areas undervaccinated (see CDC adolescent immunization schedule available
at https://www.cdc.gov/vaccines/schedules/easy-to-read/preteen-teen.html).
Over the past several decades, the incidence of vaccine-preventable
deaths has decreased; however, infectious diseases continue as a major cause
of childhood illnesses, disability, and death. Vaccines are one of the most

1725
cost-effective health promotion services (ODPHP, 2018). Strong campaigns
have been taken by health departments to get children immunized.

Strategies shown to improve vaccination rates include the Vaccine for

Children (VFC) Program, cost reduction, home visits, and linking
vaccination opportunities with WIC visits.
Public health professionals should continue to focus on eliminating
socioeconomic barriers, strengthening school-entry requirements, and
addressing vaccine misinformation.
A Cochrane review by Jacobson Vann, Jacobson, Coyne-Beasley,
Asafu-Adjei, and Szilagyi (2018) indicates that vaccination increases
are seen in all age groups when reminders by telephone or text message,
letter, or postcard are used. Combinations of reminders were also
effective; however, reminding people over the phone are the most
effective.
Cancer prevention for preteens and adolescents through HPV
vaccinations is effective. While HPV immunization rates have increased
5% from 2016 to 2017 with 66% of adolescents receiving the first dose
to start the vaccine series, and 49% of adolescents completing all
vaccinations in the series, there is still room for improvement. Parental
resistance and a focus on vaccinating only girls can inhibit successful
immunizations efforts in communities (CDC, 2018c).

Community-acquired methicillin-resistant Staphylococcus aureus (CA-

MRSA) is another communicable illness seen in the school-age children
population. C/PHNs and school nurses must be alert when skin infections or
other conditions do not resolve quickly in children and adolescents. Sports
teams, for instance, may spread this infection as team members come into
close contact or use common-use facilities such as swimming pools. Referral
to an infectious disease specialist may need to be considered (CDC, 2019f).
Pediculosis (head lice), another highly communicable disease, is a
frustrating and common problem for many preschool and school-age
children, and the incidence has been increasing with approximately 6 to 12
million 3-to 11-year-olds infected annually.

Preschoolers and elementary-age children and their caretakers and

family members are at highest risk for head lice.
Close crowded conditions can also be a risk factor. Although lice are
wingless, because children frequently play close to each other, they
easily move from child to child.

Head lice may be white, gray, or brown in color—about the size of a sesame
seed. They attach to the scalp and lay eggs (nits) in the hair. Nits typically
hatch within 8 to 9 days. They reach adulthood during the next 9 to 12 days

1726
and live about 30 days. Without treatment, the cycle repeats every 3 weeks.
Complete eradication generally requires that all viable nits be removed along
with lice; family and close contacts should be checked for head lice and, if
found, treated at the same time. Treatment typically involves over-the-
counter insecticide shampoos (or pediculicides), such as pyrethrin-based RID
and Nix or prescribed medications such as Ulesfia, Natroba, or Sklice (U.S.
Food & Drug Administration [FDA], 2017).
School nurses and C/PHNs also need to educate families about reducing
re-infestations by careful application of pediculicides, retreating in 2 weeks if
necessary, and cleaning of any fomites (e.g., combs, hats, towels, sheets,
clothing, and upholstered furniture) and removal of any viable nits. Drying
sheets, blankets, and towels on high heat and washing all hats and clothing
are effective measures. It is not necessary to use fumigant sprays, as they can
be toxic (U.S. Food & Drug Administration [FDA], 2017).

1727
Other Health Problems
Other health problems found in this age group include nutritional problems
(primarily overeating and inappropriate food choices) and poor dental health.
Obesity often begins in childhood and is a risk factor for CVD, diabetes,
cancer, stroke, and osteoarthritis later in life. The percentage of children and
adolescents has more than tripled in the last 40 years. Risk factors
contributing to childhood obesity include genetics, metabolism, short sleep
duration, eating and physical activity behaviors, and community environment
(CDC, 2018d).
Food allergies can also play a role in poor nutritional status, especially
with school-age children and adolescents. Researchers estimate that about 6
million children have food allergies, with teens and young adults being at
greatest risk of anaphylactic reactions (Food, Allergy, Research, and
Education [FARE], n.d.). Food allergies can be especially problematic in the
school setting as strict avoidance of the food is the only way to prevent a
reaction (see Chapter 28). It is recommended that parents and adolescents
carefully read labels at the time of each use and that education systems have
a plan to prevent allergic reactions and an response plan if an emergency
should arise (CDC, 2018d; FARE, n.d.).
Dental caries is another common problem among school-age children.
Approximately 18.6% of U.S. schoolchildren (5 to 19 years) have untreated
cavities. In 2015, 84.7% of children age 2 to 17 visited a dentist during the
year (CDC, 2017e).

Childhood Obesity
About one in five U.S. children are obese, making childhood obesity a
national concern. The CDC uses the term overweight for children and
youth at or above the 85th percentile and less than the 95th percentile
for youth the same age and gender. Children with a BMI greater than the
95th percentile are defined as obese (see Box 20-5 for an explanation
and examples).
Obese children are more likely to become obese adults and are at
increased risk of chronic health diseases such as asthma, sleep apnea,
bone and joint problems, metabolic syndrome, type 2 diabetes, cancer,
and heart disease. They are also more likely to be teased, bullied, and
suffer from social isolation, depression, and poor self-esteem (CDC,
2018d).

1728
BOX 20-5 EXPLANATION AND
EXAMPLES OF OVERWEIGHT
CLASSIFICATION FOR CHILDREN AND
TEENS BMI IS USED AS A SCREENING
TOOL TO IDENTIFY WEIGHT
PROBLEMS IN CHILDREN AND TEENS.
THE CRITERIA ARE DIFFERENT FROM
THOSE USED FOR ADULTS, AS BODY
FAT DIFFERS BETWEEN BOYS AND
GIRLS AND THE AMOUNT OF BODY
FAT CHANGES WITH AGE. BMI-FOR-
AGE GROWTH CHARTS FOR BOYS
AND GIRLS ARE AVAILABLE AT
HTTPS://WWW.CDC.GOV/GROWTHCH
ARTS/CLINICAL_CHARTS.HTM.

Source: Centers for Disease Control and Prevention (2018m).

1729
Preventive measures and early management of cardiovascular risk factors are
now considered more effective forms of treatment than just clinical treatment
of the disease complications after the fact.

Multiple factors influence childhood obesity including genetics,

decreased physical activity, increased television time, familial weight,
poor nutrition knowledge, food insecurity, parental smoking, not having
family mealtime, perceived neighborhood safety, and low economic
status.
Early childhood may be the best time to modify preventable factors
influencing obesity. Studies recommend that health care providers begin
discussing behaviors such as family mealtime and parental smoking
with families of young children to reduce the risk of childhood obesity
(Williams et al., 2018, p. 515).

Schools have been identified as a setting to promote healthy behaviors and

provide nutrition for children. The Healthy, Hunger-Free Kids Act of 2010,
authorized funding for foundational child nutrition programs at schools. A
legislative goal was to provide balanced nutrition for children and reduce
childhood obesity. Ninety percent of schools now report that they meet
updated national meal provision standards, school lunch revenues have
increased, and children are being educated to choose healthier food options
(USDA Food & Nutrition Service, 2017). Centeio et al. (2018) examined the
influence of the “Building Healthy Communities: Elementary School
Program” on 5th grade children. This comprehensive program focused on
physical activity, health education, and creating a healthy school culture.
Study outcomes demonstrated decreased body mass index (BMI) and waist-
to-height ratio (WHtR). School culture change and sustainability are
predicted as school personnel were mentored to maintain the program
(Centeio et al., 2018). Practice applying the nursing process to the problem
of childhood obesity is shown in Box 20-6.

BOX 20-6 C/PHN Use Of The Nursing

Process
Addressing Childhood Obesity James Lopez is
entering 3rd grade. His teacher comes to you,
the school nurse, because she is concerned
about his poor performance in school. He
frequently comes to school late and often puts
his head on his desk and appears to be falling

1730
asleep. You notice that James has gained a
significant amount of weight over the summer.
His face is much fuller now than in his 2nd
grade picture.
Assessment (Initial Visits) You do the following:
Call James' mother and make an appointment for a home visit.
Complete a health history, noting family history of diabetes,
current eating, activity, and sleeping patterns for James and the
family, and determine whether he has a regular physician and
insurance or Medicaid.
Assess his vital signs, height and weight, hearing, and vision.
Talk with James' teacher about his playground activity level and
any signs of excessive thirst, hunger, or general fatigue.

Nursing Diagnoses After a home visit, a meeting

with James' teacher, and two observations and
interviews with James, you decide a nursing
diagnosis would look at:
James' body requirements are more than what is required. James
has a sedentary lifestyle, and he may be eating as a way to cope.
Changes in the family's home life. Mother is single and attending
truck-driving school necessitating several days' absence at a time.
James cared for by a married teenage sister and her husband.

Findings, Plan, and Implementation For the

past 3 months, since his mother started her
training, James has been eating large quantities
of snack food and fast-food meals. He stopped
participating in soccer and baseball because of
lack of transportation. James' bicycle was
recently stolen, and he now spends a lot of time
playing video and computer games. James says
that he misses his mother when she is away and
that he “stays up late watching television” and

1731
has “trouble getting up for school” when he is
at his sister's house.
You plan to work with the family to refer James to his physician to
rule out diabetes. A family meeting is scheduled to provide health
education on childhood obesity and inactivity. You discuss some
possible interventions that the family can put into place:

Decrease reliance on fast-food meals.

Have a regular evening mealtime and encourage less snacking.
Provide fresh fruit and vegetable snacks and decrease purchases of
high-calorie, high-fat snack foods.
Decrease sedentary activity (e.g., video and computer games,
television viewing) and increase physical activity (e.g., team
sports, walking, bicycling, active outdoor games).
Establish a reasonable bedtime and consistently enforce it.
Offer referral for family counseling so James can discuss his
feelings in a safe environment.
With the family's input, seek ways to improve contact between
James and his mother and opportunities for his sister to improve
understanding of good parenting practices.
Meet with the teacher, family, and James to discuss ways to help
with school performance.
Continue to monitor James' progress with monthly height and
weight checks, personal interviews, home visits, and teacher
conferences.

Evaluation
The physician reported that James does not have diabetes; however,
if he continues to gain weight and remains inactive, he is at a higher risk
for type 2 diabetes. Evaluation of nursing diagnoses 1 and 2 includes the
following goals:

The family will report less reliance on fast-food and more meals
cooked at home.
The family will report more purchases of fresh fruits and
vegetables and fewer purchases of high-calorie, high-fat snacks.
James will report more physical exercise (by the use of a calendar)
and fewer hours spent in sedentary activity (corroborated by
family).
James will exhibit less tardiness and fewer signs of sleep
deprivation at school, and his school performance will improve.

1732
 James and his family will complete sessions with a family
counselor.
James' weight will remain stable or will decrease as his height
increases over time.

The causes of childhood obesity are multifactorial, and as a result, health

care providers should take a multiple health behavior approach. Parental
support and influence are key. Parents can help their younger children
develop healthy eating habits by following recommendations of the
American Heart Association (2018) and the CDC (2020g), for example:

“Eat the Rainbow.” Provide a variety of fruits and vegetables. Let

children pick fruits/vegetables and have them help cook or prepare it.
Choose lean meats, poultry, beans for protein.
Watch out for added sugars. Avoid/limit sugar-sweetened drinks.
Help kids be physically active at least 60 minutes each day (Fig. 20-3).
Serve whole-grain/high-fiber cereals and breads.
Serve low-fat and fat-free dairy products (two to three cups of milk
daily).
Read food nutrition labels—pick healthy nutritional foods.
Be a role model—help your child develop healthy habits early
(American Heart Association, 2018; CDC, 2020g).

FIGURE 20-3 Physical activity is important for health and in

childhood obesity prevention.

The benefits of following a healthy diet, increasing physical activity, and

maintaining a healthy diet are well-documented. Research has also shown
that there is a link between obesity, cognition, and school achievement
among children. A recent systematic review by Martin et al., (2018) explored

1733
the connection between cognition, school achievement, and school-based
interventions to reduce weight and improve nutrition with child and
adolescent obesity/weight. Their research indicated the following:

School and community-based physical activity benefited cognitive

function of obese or overweight children.
School-based dietary interventions may benefit general school
achievement.
Nutritional diets at school can lead to improved general school
achievement.
Future studies should assess academic and cognitive outcomes along
with physical outcomes.

Inadequate Nutrition
Poor nutritional status of schoolchildren is a global issue but also a problem
in this country. Undernutrition can also have serious consequences, including
effects on the cognitive development and academic performance of children
and chronic health. Irritability, lack of energy, and difficulty concentrating
are only some of the problems that arise from skipped meals or consistently
inadequate nutrition. Infection and illness that lead to loss of school days can
affect academic progress and interfere with the acquisition of basic skills,
such as reading and mathematics. Food insecurity has been associated with
child development problems, psychological and social issues, and poor
general health (Shankar, Chung, & Frank, 2017).

About 21.0% of U.S. households reported some degree of food

insecurity in 2017, representing approximately 40 million people.
Approximately 15.7% of households with children were food insecure,
and of those headed by single women with children, 30.3% reported
food insecurity (USDA, 2018).

A national study by Lee, Scharf, and DeBoer (2018) suggests that there is an
association between food insecurity and obesity in school-age children
(kindergarten through 3rd grade). A study by Rongstad, Neuman, Pillai,
Birstler, and Hanrahan (2018) provide additional validation that there is a
significant relationship between food insecurity and chronic diseases such as
obesity and metabolic syndrome, ADHD, and anemia.
Undernutrition is frequently associated with poverty and hunger, but
social pressure to be thin can also spark purposeful undernutrition. Because
prepubertal children often exhibit a period of adiposity before a growth spurt,
they are at risk for developing eating disorders. Along with childhood
obesity, prevention of eating disorders is also a high priority in this age
group.

1734
 Some sources find pediatric eating disorders to be more prevalent than
T2DM, and minority groups, boys, and younger children have higher
rates. An estimated 5.4% of children between 13 and 18 years will
suffer from an eating disorder. Of children with a lifetime prevalence of
an eating disorder, 3.8% will be female and 1.5% will be male (James,
2017).
The 2017 Youth Risk Behavior Survey indicates that 47.1% of students
are trying to lose weight. The prevalence of trying to lose weight was
higher in females than males, and higher among Hispanic students than
White or Black students (CDC, 2017d).
Yilmaz et al. (2017) indicated that there is increased prevalence of
disordered among adolescents with ADHD. Authors recommend health
care providers monitor youth with ADHD for disordered eating
symptoms and early identification of eating disorders.

Research also indicates that youth with a history of obesity are at a higher
risk of disordered eating. Signs of disordered eating include food rituals,
refusal to eat foods once enjoyed, avoiding meals, overexercising, secret
eating, preoccupation with food, calorie counting, fear of becoming fat, binge
eating, and food phobias. Other concerning behaviors include depression,
irritability, sudden mood changes, and anxiety around food and eating.
Parents and health care providers alike should be aware of symptoms and
seek evaluation of the child or adolescent (Dawson, 2017).

School nurses and C/PHNs should be aware of signs and symptoms of

this disorder, noting that T1DM children may be at higher risk, and
watch for unexplained weight loss, stunting of normal growth patterns,
concerns about body image, delayed puberty, and abnormal or
restrictive eating.
They can provide families with necessary information to promote
healthful eating and exercise, as well as provide guidance for parental
and child support (Dawson, 2017). Some school districts include BMI
screening programs as part of healthy lifestyle promotion.
The CDC recommends that schools have a series of safeguards in place
before launching a BMI measurement program. This includes fostering
a safe and supportive environment for all students and a comprehensive
program to prevent and reduce obesity (CDC, 2017f).

Inactivity
An association between poor eating habits and physical inactivity has been
found in numerous research studies. More television watching, fewer family
meals eaten together at home, and living in an unsafe neighborhood were
shown to be associated with overweight (Williams et al., 2018).

1735
 The YRBS revealed that approximately 70% of children surveyed who
were enrolled in physical education classes did not attend class on a
daily basis.
In addition, fewer than 15.4% of respondents stated that they were
physically active for 60 minutes daily.
About 22% watched 3 or more hours of television daily and 43% used a
computer (other than for schoolwork) or played a video game on a daily
basis (CDC, 2017d).

School nurses and C/PHNs can work with families to increase their levels of
physical activity and to encourage limited television viewing for school-age
children. They can also advocate for increased physical education in the
school setting and for increased safe recreational opportunities in all
neighborhoods.

Dental Caries
Dental caries is thought to be the most prevalent chronic childhood infectious
disease.

Caries affect 45.8% of children between the ages of 2 and 19 years with
84.7% of children age 2 to 17 years with a dental visit in the past year.
Hispanic children have the highest rates of decay and non-Hispanic
Black youth have the highest prevalence of untreated caries (Fleming &
Afful, 2018).

The prevalence of dental caries in school-age children has decreased

significantly since the early 1970s because of community fluoridation
projects and the use of fluoride toothpaste. Fluoridated drinking water, the
availability of school-provided fluoride rinse or gel, and dental sealant
programs are cost-effective, proven methods of reducing dental caries in
school-age children (National Institute of Dental & Craniofacial Research,
2018).
The peak incidence of dental caries is found among school-age children
and adolescents, although the effects of decay are observed in adulthood as
caries activity recurs or various restorations fracture or wear out and must be
replaced.

In 2016, 84.7% of children aged 2 to 17 years visited a dentist in the

past year; but for children living in poverty, the percentage remains
lower (FCFS, 2019e).
Over time, these rates have improved with coverage through the State
Children's Health Insurance Program and preventive programs such as
community water fluoridation and the expansion of sealant programs.

1736
 In a nationally, representative study of children and adolescents, Slade,
Grider, Maas, and Sanders (2018) reaffirm the importance of fluoridated
drinking water. Their study results support the continuation of
community water fluoridation (CWF) policies and provide evidence for
CWF as a key public health intervention.

Yet, access to dental care is still problematic. Barriers to dental care are more
prevalent among the poor. Financial barriers, lack of education, and limited
numbers of dentists accepting Medicaid lead to poor dental health values and
adversely affect the appropriate use of early dental services and
conscientious personal oral health care (Simmer-Beck, Wellever, & Kelly,
2017).

A recent strategy for improving oral health of low-income children

provided preventive services by registered dental hygienists in school-
based clinics. Both adults and children are seen at the clinic; however,
during school hours, at least 80% of the appointments were for children.
Success of the program suggests that changes in licensing policies
provide increased RDH autonomy in the public health setting (Simmer-
Beck et al., 2017).

C/PHNs and other community health nurses working with school-age

children and families can promote good dental health through education and
advocacy, as well as through collaboration to provide adequate dental
services to uninsured children and promotion of fluoridation and sealant
programs.

1737
ADOLESCENT HEALTH
Adolescence is a time of self-discovery, movement toward self-reliance,
increasing opportunities, and pivotal choices that can affect the remainder of
an individual's life.

Adolescence generally begins with puberty and encompasses the ages

between 10 and 24; it consists of early adolescence (aged 10 to 14),
middle adolescence (15 to 17), and late adolescence (18 to mid-20s).
Adult society largely segregates adolescents and often has ambiguous
expectations for them. Adolescents are part of a subculture, one with its
own language, dress, social mores, and values.
The tasks of adolescence remain fairly constant: adolescents must
become autonomous, come to grips with their emerging sexuality and
the skills necessary to attract a mate, and acquire skills and education
that can prepare them for adult roles, all while resolving identity issues
and developing values and beliefs (ODPHP, 2018; Office of Adolescent
Health, 2017a).
The search for and expression of developing identity, along with the
strong drive for social acceptance, are evident in the personal home
pages and blogs of adolescents on social networking Internet sites such
as Twitter and Facebook (Nesi, Choukas-Bradley, & Prinstein, 2018).

Adolescents and young adults make up 22% of the nation's population.

Adolescents are generally healthy, but multiple health-related behaviors and
social problems begin during this stage of development. Examples include
mental health disorders, substance abuse, tobacco use, nutrition-related
disorders, sexually transmitted diseases, unintended pregnancy,
homelessness, homicide, suicide, and motor vehicle crashes (ODPHP, 2018).

The leading causes of morbidity and mortality for U.S. youth are related
to health risk-taking behaviors. Six health-related adolescent and young
adult behaviors are monitored by the Youth Risk Behavior Surveillance
System (YRBSS). These include behaviors contributing to unintentional
injuries and violence; tobacco use, alcohol use, and substance abuse;
sexual behaviors including unintended pregnancy and sexually
transmitted diseases; dietary behaviors; and physical activity.

During the period that generally encompasses the teen years, adolescents
encounter many complex changes physically, emotionally, cognitively, and
socially. Rapid and major developmental adjustments create a variety of

1738
stresses with concomitant problems that have an impact on health and risk-
taking.

Because the amygdala influences adolescent brains more than the

frontal cortex, teens base their decisions more on emotion—solving
problems differently than adults. As a result, it is important to guide
adolescents through the decision-making process before they engage in
risky behaviors.
The U.S. Office of Adolescent Health (2018a) explains that in stressful
situations, adolescents are more likely to:
Think one way but act or feel differently
Misinterpret social cues
Participate in risky behaviors

Unintentional injuries were the leading cause of death in the 10-to 24-year
age group. Most deaths in this adolescent/young adult age group are due to
preventable causes.

In 2016, 74% of adolescent deaths related to injury, with motor vehicle

collision (MCV) accounting for approximately 22% of deaths,
unintentional injuries (20%), suicide (17%), and homicide (15%).
Although MVC deaths have decreased, they remain a significant cause
of injury with adolescents and young adult drivers disproportionately
represented in the data (Figs. 20-4 and 20-5). Teen males are two times
more likely to be involved in an MVC than female adolescents are.
In 2017, 5.5% of U.S. students reported using alcohol while driving,
13% of students reported using marijuana while driving, and 39.2% of
students reported texting or e-mailing while driving a car (Kann et al.,
2018).

1739
 FIGURE 20-4 Total injury and noninjury death rates for children
and adolescents aged 10 to 19 years: United States, 1999 to 2016.
(Reprinted from CDC. [2018]. Recent increases in injury mortality
among children and adolescents aged 10 to 19 years in the United
States, 1999–2016. Retrieved from
https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_04.pdf)

FIGURE 20-5 Emergency department visit rates for adolescents

ages 15 to 19 by leading cause of injury, 2014 to 2015. (Reprinted
from
https://www.childstats.gov/americaschildren/phys_fig.asp#phy8b)

Public health interventions are key to reducing teen injuries. A recent study
investigated the effectiveness of the Save A Life Tour (SALT) program
implemented in high schools. SALT is a safe-driving awareness program
designed to educate about the harmful effects of distracted driving and drunk
driving. Researchers concluded that that annual education regarding teen
driving while intoxicated or distracted might reduce the morbidity and
mortality associated with MVC. Key components of the program were to
deliver a clear message of dangers and provide ongoing education (Layba,
Griffin, Jupiter, Mathers, & Mileski, 2017).
Unintentional injuries also cause the greatest level of adolescent
morbidity; the largest cause being transportation (drivers and passengers,
bicyclists, pedestrians). Other causes include being struck by/against
something, falling, poisoning, overexertion, and cutting/piercing.

Emergency rooms treat approximately 22,000 children daily for

nonfatal injuries. These injuries are highest among adolescents aged 15
to 19 years and can have a lasting effect for the children, their families,
and society.

1740
 The most common cause of unintentional injury for 10-to 19-year-olds
(250,000 youth) is assault—being struck by/against, sexual assault,
cut/pierce, and firearms. It is important to note that disparities exist
between race/ethnicity.
Black youth are significantly more at risk of homicide. This may be
related to social determinants of health such as poverty, neighborhood
crime, limited educational and occupational opportunities, and racism
(Ballesteros, Williams, Mack, Simon, & Sleet, 2018).

Social stressors and strained relations with peers and parents are also linked
to adolescent health complaints.

Common complaints of adolescents include sleep deprivation, fatigue,

chronic insomnia, acne, and concerns about weight and body image
(Hockenberry et al., 2019). As children become adolescents, their sleep
patterns change—they move from early risers/sleepers to staying up
later and sleeping in later or catching up on sleep over weekends. This
transition becomes more apparent through high school.
Scientists believe that these changes in circadian and homeostatic sleep
regulation support this delayed sleep phase, and there are concerns
about consistent lack of sleep (Hale & Troxel, 2018).
Recent studies confirm the support for delaying adolescent school start
times and indicate several health risks associated with sleep deprivation
including being overweight, drinking alcohol, using drugs and tobacco,
and poor academic performance (CDC, 2018e).
A review of literature showed support for delayed start time for
adolescents with improvement seen in attendance and tardiness, less
falling asleep in class, improvement in grades, and reduction in MVA
(Wheaton, Chapman, & Croft, 2016). Even modest delay times can be
beneficial for student outcomes and supports development of evidenced-
based policies for school districts and communities. Hale and Troxel
(2018) suggested that, based on confirming research, later school times
are also a social justice issue.

In the past, routine health care visits by adolescents were not commonplace.
Newer recommended vaccines and better awareness of the health needs of
adolescents have led to improvement, but concerns remain.

In 2016, only 19.4% of 12-to 17-year-olds had a health care provider

visit within the past year (CDC, 2017g). Reasons for underutilization of
health care services may be related to lack of transportation, lack of
parental support, past experience with health care system, lack of health
care insurance, and cost.
Research has also identified trust of health care providers as a possible
reason for low or inconsistent use of health care services. In a cross-

1741
 sectional, descriptive study regarding reasons for low use of health care
systems by rural adolescents, Hardin, McCarthy, Speck, and Crawford
(2018) founded that many of the barriers regarding adolescent access to
care were resolved by a school-based health clinic.

Health literacy during adolescence is another important consideration. Teens

are frequent users of mass media (Internet, television, radio, text messaging),
and specific health-related educational interventions can be targeted to them
by using these media. Although social media offers benefits such as health
education, it can also put youth at risk for exposure to violence and risky
behavior examples, opportunistic bullying, sexually explicit material, sexual
solicitation, and Internet addiction.

Research estimates that 92% of teens are online daily, with 88%
belonging to at least one social networking site, and 88% having access
to a cell phone.
Increased use of social media designates it as a unique context that
shapes an adolescent's behavior and life experience (Nesi et al., 2018).
C/PHNs can help young people find reliable sources of information, as
well as work with families to ensure proper monitoring of social media
use.

1742
Health Objectives for Adolescents
Healthy People 2030 objectives are focused on improving the health of all
Americans. Goals and objectives for adolescent health have been developed
(Box 20-7). Because much of the mortality and morbidity in this age group
stems from risk-taking behaviors, many objectives addressing alcohol-related
unintentional injuries, violent behaviors, and suicide and mental health
issues, as well as more responsible reproductive health behaviors, are
included throughout the document under Substance Abuse, Mental Health,
etc. As of 2017, eight of the Healthy People 2020 objectives had been met
with the objective to reduce the proportion of adolescents who have been
offered, sold, or given an illegal drug on school property being met for the
first time (Kann et al., 2018).

BOX 20-7 HEALTHY PEOPLE 2030

Objectives to Improve the Health and WellBeing
of Adolescents

1743
Reprinted from U.S. Department of Health & Human Services (USDHHS). (2020). Healthy People
2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

1744
Emotional Problems and Suicide
The adolescent years are a time of rapid growth and change. Complex
developmental changes physically, emotionally, cognitively, and socially
may cause a teen to be emotional and unpredictable at times (Office of
Adolescent Health, 2018a). The influence of peers increases, and peer
pressure may influence behavior. Teens test family rules and generally search
for their own identity and individuality apart from the family. Most parents
and teens ride out this period with love and understanding and no long-term
negative effects. For some children, however, a real or perceived lack of
emotional support can lead to temporary or permanent emotional problems.
Additionally, increased risk behaviors such as suicide, risky sexual behavior,
and mental health disorders are associated with child and adolescent
maltreatment. Because adolescents have less contact with the health care
system than children, many conditions may go undetected. The transition
from high school into early adulthood is often difficult and individuals with
mental health issues often have worse outcomes than those with physical
conditions (Jordan et al., 2018; Office of Adolescent Health, 2018a).

Depression, anxiety disorders, and eating disorders may first appear

during adolescence. It is estimated that one in five adolescents have
mental health disorders with depression being the most commonly
reported diagnosis.
Prevalence rates of depression vary (Fig. 20-6). About 35% of high
school students report feelings of sadness or hopelessness every day for
longer than 2 weeks. Of those reporting symptoms, 41.1% are female
and 21.4% are male.
Anxiety disorders such as OCD, posttraumatic stress disorder, social
anxiety disorders, and phobias are reported by approximately 32% of
students between ages 13 and 18 years. Of concern is research
indicating that the percentage of youth using alcohol after a major
depressive episode is double that of youth not experiencing a major
depressive episode (Office of Adolescent Health, 2018a).

1745
 FIGURE 20-6 Percentage of youth ages 12 to 17 who had at least
one major depressive episode in the past year by age and gender,
2004 to 2017. (Reprinted from
https://www.childstats.gov/americaschildren/health_fig.asp#health
4a)

Many adolescents are reluctant to seek help for emotional problems, or help
may not be readily available to them. Most mental health disorders are
treatable; however, in 2016, only 41% of adolescents experiencing
depression received treatment. Barriers to treatment may include social
stigma, cultural norms, and lack of qualified providers.

Survey results indicate that 12.7% of youth aged 12 to 17 have been

given some type of mental health services, but the usual disparities
apply (e.g., ethnicity, income level, rural vs. urban locale).
Treatment for serious mental health problems may include
hospitalization or placement in a group home. Use of a team-based
Collaborative Care program has improved mental and physical health
outcomes.
Mental health disorders experienced during adolescence may persist
into adulthood, becoming more difficult to treat. It is critical to identify
negative adolescent mental health behaviors, provide access to services,
and educate teens about healthy physical and mental health skills
(Office of Adolescent Health, 2018a).

The presence of major depressive disorder (MDD) is common in children

and teens; it is associated with suicide and self-injury. It is more common in
adolescents with chronic disease and can result in obesity, suicidal thoughts
and attempts, and academic performance.

Major depressive disorder is most commonly associated with lifetime

prevalence of adolescent suicidal ideation, plans, and attempts. Health

1746
 care providers can play an integral part in identifying adolescent
depression and those at risk for suicide.
Recent stressful events and preoccupation with suicide, as well as
substance use, are also important to note. Being bullied, a history of
sexual or physical abuse, aggressive conduct disorders, and personality
disorders are risk factors for adolescent suicide attempts. When
evaluating adolescent mental health, the broader context of school,
social, and family influences needs to be considered (Diamond et al.,
2017).

Suicide is the second leading cause of death in 10-to 19-year-olds.

Between 2007 and 2015, suicide deaths increased by 130% in the 10-to
14-year-old group and 46% in the 15-to 19-year-old age group.
Overall, male suicide rates are higher than female rates, and American
Indian and Alaskan Native adolescent suicide rates are the highest.
Ethnic disparity may result from social and environmental factors such
as discrimination, exposure to others' suicides, and inadequate health
care system access (Ballesteros et al., 2018).
In 2017, 17.2% of high school students reported that they seriously
considered suicide in the previous 12 months, and 7.4% made at least
one suicide attempt. Approximately 2.4% made an attempt that required
medical attention. Suicide attempt rates for adolescent female versus
male students were higher (9.3% vs. 5.1%) (CDC, 2018f).

School-based programs to educate adolescents about depression and suicide

prevention have been useful. C/PHNs and school nurses often participate in
the development or administration of these types of programs.

Suicide prevention programs and direct intervention by counselors or

school nurses to determine an adolescent's suicide intentions may be
effective school-based interventions. It is important for counselors to
identify markers for attempted suicide, such as a precipitating event,
intense affective state, suicide ideation or actions, deterioration in social
or academic functioning, or increased substance abuse.

C/PHNs and community mental health counselors may serve as consultants

to schools in the development of sound prevention programs.

Hallmarks of good prevention programs include student education on

suicide awareness and intervention; coping and problem-solving skills
training; skill building by reinforcement of strengths and protective
factors while dealing with risk-taking behaviors; and teaching about the
association between suicide and mental health (especially depression).

1747
 Suicide screening is often thought to be effective in reducing suicidal
ideation (Bhatta, Champion, Young, & Loika, 2018).

Youth suicide has been of great concern over the past several decades.
Communities across the nation have been urged to implement effective
school-based suicide prevention programs. There is some evidence that
universal school-based programs decrease the number of adolescent suicide
attempts.

The SOS Signs of Suicide program is an evidence-based school-based

intervention that educates adolescents about poor mental health, suicide,
and coping mechanisms. It has been shown to decrease self-reported
suicide attempts.
Skills training programs that target a broader range of problems (e.g.,
depression, anxiety, negative self-perceptions) have been effective in
teaching adolescents how to monitor feelings, identify triggers, and
avoid and reframe negative thoughts. Relaxation skills training, learning
how to seek out help from others, and promoting healthier responses to
stress have also been successful in impacting internalizing behaviors.
The Substance Abuse and Mental Health Services Administration
(SAMHSA) awards grants in support of youth suicide prevention
programs. SAMHSA has also developed a suicide prevention toolkit to
help school around the nation implement programs (available online at
https://store.samhsa.gov/product/Preventing-Suicide-A-Toolkit-for-
High-Schools/SMA12-4669) (County Health Rankings & Roadmaps,
2018).

A behavior that can sometimes accidentally result in suicide is self-injury or

cutting (Fig. 20-7). Adolescents with this abnormal behavior who overdose,
head bang, cut, burn, brand, mark, or otherwise dangerously harm
themselves are attempting to find relief from profound psychological pain.
The physical injury distracts them from these painful emotions, often giving
them a feeling of control or providing a means of feeling emotions when they
are cut off from them.

1748
 FIGURE 20-7 An adolescent girl with evidence of “cutting” self-
injury.

Emergency room visits for adolescents with nonfatal injuries have

significantly increased in the United States since 2009. CDC research
indicates that self-inflicted injuries among male adolescents remained
stable, while female adolescents have increased about 8.4% each year
between 2009 and 2015.
For female youth aged 10 to 14, the percentage increased by 18.8% each
year. This behavior most often begins in early adolescence or late
childhood and can continue into adulthood.
It is more common in those with a family history of suicide, self-injury,
or maternal depression. Isolation, neglect, or abuse may predispose an
adolescent to this behavior. Depression, poor quality of relationships,
excessive seeking of reassurance, and eating disorders are often
associated with self-injury (Stockwell, 2018).

C/PHNs and school nurses can provide education to adolescents and families
about this condition and can work with schools to promote prevention
strategies, such as early detection and referral to mental health providers.

1749
Violence
Youth violence is defined as “the intentional use of physical force or power
to threaten or harm others by young people ages 10–24” (CDC, 2020h). The
physical, emotional, and social effects of youth violence can be severe and
long lasting. Youth violence affects entire communities and has become a
leading cause of death for U.S. youth. The Youth Risk Behavior Surveillance
Survey—United States, 2017, indicated that:

15.7% of high school students carried a weapon at least 1 day within 30

days of the survey.
Male students (24.2%) carried a weapon more than female students
(7.4%), with prevalence higher among White male students (29.0%),
followed by Hispanic male students (18.4%), and Black male students
(15.3%).
In 2017, 3.8% of students did not go to school on at least 1 day prior to
the survey because of safety concerns (Kann et al., 2018).
It is not uncommon for children (0 to 17 years) to be exposed to more
than one type of violence. Within the past year, approximately 37% of
children were physically assaulted and 5% were sexually victimized
(FCFS, 2019a).
Homicide is a leading cause of death for adolescents and youth (aged 15
to 24). It is the leading cause of death for African American youth, the
second leading cause of death for Hispanic youth, and the third leading
cause of death for American Indian/Alaska Native (CDC, 2020h).
Unfortunately, in the United States, more than 33% of homicide victims
are young adults, meaning that approximately 13 adolescents are
murdered each day.

Gangs are often associated with teen violence. In the United States, with a
rise in gang membership to approximately 750,000 members, gangs are
found in all 50 states.

Gang participants are often young, male, and Black or Hispanic.

Authorities believe that gangs are responsible for up to 13% of
homicides, in addition to other crimes and drug sales. A survey of some
of the largest city police departments in the United States indicated
“significant criminal activity by youth gangs or gang-like groups of
young people” (United States Department of Justice, 2018).

Multiple successful antigang programs have been implemented in

communities including Gang Resistance Education and Training
(G.R.E.A.T.). The G.R.E.A.T. program is taught by local law officials to
students in middle and high schools. The goal of the program is to teach

1750
students how to avoid violence, resist gang pressure, and improve positive
attitudes about law enforcement. This promising program has shown
promising results as it successfully meets its goals (Bureau of Alcohol,
Tobacco, Firearms, and Explosives [ATF], 2018).
Although gang members may engage in violence and intimidation, other
instances of school violence have captured greater media attention. Incidents
of high school shootings are of great concern to parents, teachers,
communities, and the nation. These high-profile events are becoming more
common and bring attention to the need for change (University of Virginia,
2018).
School violence has been linked to bullying and the overall school
environment and should be addressed quickly.

Bullying can result in depression, social anxiety, internalizing and

psychosomatic symptoms, loneliness, and poor school performance
(Jordan et al., 2018).
In 2017, bullying incidents were reported by 19% of students in public
schools, cyberbullying was reported by 14.9% of students, and 6.7% of
students did not feel safe going to school.
In 2017, 6.0% of adolescents reported being threatened or injured with a
weapon; this statistic has decreased significantly since 2007.
Males were more likely to be involved in carrying weapons and
fighting. Another form of violence found among adolescents and young
adults is dating violence.
In 2017, 8.0% of high school students reported physical violence while
dating. This is significantly higher than the percentage reported in 2013
(CDC, 2018f).

Of recent concern is the growing prevalence of school shootings and the

effects this can have on students' wellbeing. Many students and their parents
fear a shooting could occur in their school; nonwhite teens expressed a
higher level of concern than white counterparts, and girls a greater concern
than boys (Pew Research Center, 2018). School-aged children have become
involved in the debate surrounding gun violence, where proposals focus on
addressing mental illness, assault-style weapon ban, and the use of metal
detectors in schools. To address this issue, researchers examined the
relationship between 36 high schools' shootings and student achievement in
14 states and found that academic achievement was associated with
standardized test scores in math and English, which were lower in affected
schools 3 years following a deadly shooting (Beland & Kim, 2016). In
addition, students' parents were likely to change their school selection due to
a shooting; enrollment dropped for 9th grade students following a deadly
shooting. Graduation and suspension rates showed no significant impact,
despite a reduction in students' standardized test scores.

1751
 Cultural and environmental influences on youth include the violence to
which children and adolescents are exposed. Increased aggressive behavior
among children and teens has been attributed to violence in the environment,
the home (spousal and child abuse), and the community, as well as to what
children see on television and in movies. The effects of family violence
(domestic violence, child maltreatment) can lead to internalizing and
externalizing behaviors among youth.

Personally experiencing or witnessing violence as a child is a risk factor

for adolescent behaviors such as school dropout, running away from
home, attempting suicide, and delinquency (Fix, Alexander, & Burkhart,
2018).
School climate is important in reducing the levels of violence in this age
group, as is adequate parental support. Family cohesion can also be a
mediating factor for delinquency as a consequence of childhood effects
of violence.
The Functional Family Therapy (FTT) 3-month program used with
adolescents with behavioral issues such as delinquency, and drug and
alcohol abuse, has been adapted for adolescents with gang involvement
and those at risk for gang involvement. A study found that prevention of
gang involvement, subsequent delinquency, and decreased substance
abuse were all positive outcomes of the program (Gottfredson,
Thornberry, Slothower, & Devlin, 2018).

1752
Substance Abuse
Why do adolescents turn to alcohol or illicit drugs? Substance abuse is one of
the greatest threats to adolescent health (Fig. 20-8).

FIGURE 20-8 2019 Monitoring the Future Survey key findings:

percent reporting use of selected substances. (Reprinted from
https://www.drugabuse.gov/publications/drugfacts/monitoring-
future-survey-high-school-youth-trends)

In 2017, 14.0% of high school students reported using illicit drugs

including cocaine, inhalants, heroin, methamphetamines, hallucinogens,
or ecstasy. This is a significant decrease over the past 10 years in the
United States (CDC, 2018f).
There are many influences associated with adolescent substance use
including influence and monitoring by parents and guardians, family
structure, history of physical abuse and maltreatment, adult example and
parental substance use, and teen peer influence.
Some research indicates that friend and peer influences become an even
stronger predictor of substance abuse as teens age (Henry, Fulco,
Agbeke, & Ratcliff, 2018).
Depression has also been linked to alcohol and substance use. Increased
emphasis on family values was noted to be a protective factor for
alcohol use. This includes not only the parenting style of the

1753
 adolescent's parents but also the parenting influences of the teen's
friend's parents (Office of Adolescent Health, 2018b).

Alcohol is the most frequently used substance for U.S. adolescents—it is

often their first drug of choice. As adolescents get older, they are more likely
to drink. Although rates of adolescent drinking have decreased since 2002, in
2017, 33% of 12th grade students report drinking, as compared to 20% of
10th grade students, and 7% of 8th grade students (Office of Adolescent
Health, 2018b).

The teen brain is very susceptible to the damaging effects of alcohol and
a number of social, physical, and academic are associated with its use.
Early drinkers more often report damaged family relationships,
academic problems, problems with concentration and memory, use of
other substances, and delinquent behavior in middle and high school.
Early use of alcohol, even sipping/tasting with parental permission, was
found to be a marker for increased alcohol use later in and the
associated alcohol-related behaviors/problems (Colder, Shyhalla, &
Frndak, 2018). It is important to stress education and prevention in late
childhood to delay the initiation of alcohol use (Box 20-8).
Family drinking, perceived family norms, and neighborhood societal
contexts related to drinking have been found to affect adolescents'
perceptions of the benefits of drinking. This perception, in turn, predicts
their drinking behavior. Parenting practices (e.g., monitoring, discipline,
enforcing rules related to alcohol use) have also been found to have an
influence on adolescent drinking behavior (Cambron, Kosterman,
Catalano, Guttmannova, & Hawkins, 2018; Colder et al., 2018).

BOX 20-8 Population Focus Using

Evidence-Based Practice to Design
Substance Abuse Prevention Strategies
for Adolescents School nursing runs in
my family. In the 1980s, when my
mother was a school nurse in a small,
rural school district located in an
agriculturally dependent county, there
was only one high school in the small

1754
town of about 10,000 people. School
personnel were aware of some “keg
parties” after football games and the
occasional alcohol-related fight on
school property between some of the
rougher students, but they were not fully
aware of the substance abuse problems.
The school psychologist conducted an
anonymous survey and found, much to
the surprise of teachers and
administrators, that most of the teens
involved in alcohol and drug abuse were
the athletes and cheerleaders. They had
assumed that the lower-income, trouble-
making kids were much more involved,
but this was not necessarily the case. My
mother worked with the psychologist to
implement health education classes in
the high school and eventually the
middle school and elementary schools to
address this issue and health promotion
in general.
I am a school nurse at a suburban, larger school district serving over
30,000 students with four high schools, a charter high school and a
continuation high school. Each high school has a full-time school nurse,
and the middle schools have one most of the week. We utilize evidence-
based practice as school nurses, and there are many resources available
to us. We are aware of national surveys on substance use among

1755
 adolescents (e.g., YRBSS) and have conducted some ourselves to better
understand our students' needs. Although alcohol is still a concern, drug
use has increased since my mom's school nursing experience. A national
survey found that 14.0% of high school students use some type of illicit
drugs (CDC, 2018f).
The district school nurses met with our advisory board, parent
groups, school administration, and eventually the school board to
discuss the problem and address potential interventions. We discussed
our population demographics, our various cultural and ethnic influences,
and our community statistics. After examining the best research-based
methods, we found screening, brief interventions (SBI), and referral to
treatment is key to delaying and decreasing substance abuse in teens.
Additionally, family-focused prevention programs often provide skills
to parents (e.g., parenting, helping children develop social resistance
skills, monitoring/rule setting). Parental education and family-centered
interventions have been found to be most effective in preventing risk
behaviors and promoting self-regulation among teens and early adults
(Stormshak, DeGarmo, Chronister, & Caruthers, 2018).
Based on the evidence, our school district decided to implement
SBIRT and a family-based prevention program for upper elementary
students and their parents. I hope we can eventually encourage a more
community-based approach to population health for our children and
adolescents. I feel that with the resources we have today, we can really
make a difference in the lives of our students and their families. I know
my mother is proud of the work I am doing, and I hope my daughter
considers carrying on the family tradition!
Holly, age 30, school nurse
Source: Centers for Disease Control and Prevention (CDC) (2020l);
Lunstead et al. (2017); Stormshak et al. (2018).

Adolescents who are engaged emotionally and connected to school usually

have better outcomes. Positive parenting practices such as open
communication, monitoring adolescent activities, and teaching methods of
self-control have also been associated with a reduction in adolescent alcohol
use.

Family mealtimes have been shown to promote family cohesion and

problem-and emotion-focused coping by encouraging parents to help
their children feel part of the family and allowing them valuable time to
coach them in effective methods for dealing with daily stresses and
problems. The benefits of family mealtime include improved self-
esteem, improved mental health, decreased alcohol and substance abuse,
and decreased depression (Youth.Gov, n.d.). To promote the health and

1756
 welfare of adolescent children, it is vital to stress to families with young
children the continued importance of family meals throughout
adolescence.

Marijuana is the most commonly used illicit drug among 14-to 17-year-olds
—35.6% of high school students reported ever using marijuana (Fig. 20-9).

FIGURE 20-9 Marijuana use is common among adolescents.

Marijuana use during adolescence has been associated with a much

greater likelihood of drug abuse and dependency, poorer mental health,
poorer academic performance, increased delinquency, and
neurocognitive deficits (D'Amica, Rodriquez, Tucker, Pedersen, & Shih,
2018).
Marijuana use has negative health effects, including anxiety, panic
attacks, increased heart rate, frequent respiratory infections, impaired
memory and learning, and tolerance. Regular marijuana smokers often
have respiratory complications similar to those of tobacco smokers—
cough, phlegm, respiratory infections, and airway obstruction (National
Institute of Drug Abuse for Teens, 2017a).

Inhalant abuse is very common and frequently used by young teens. Inhalant
use begins in early adolescence—more 12-and 13-year-olds reported using
inhalants than any other illicit drug.

The most commonly reported inhalants used were shoe polish, glue or
toluene, spray paints, and lighter fluid or gasoline.
Other inhalants commonly used include amyl nitrite “poppers”; locker
room deodorizers or “rush”; cleaning fluid, degreasers, or correction
fluid; halothane, ether, or other anesthetics; lacquer thinner or other

1757
 paint solvents; butane or propane gases; nitrous oxide or “whippets”;
and other aerosol sprays.
Inhalant abuse can result in severe nervous system damage or death.
Control of legal products, such as spray paint, lighter fluid, household
solvents, gasoline, and glue, is difficult, making this problem almost
impossible to monitor adequately (National Institute of Drug Abuse for
Teens, 2017b).

Other drugs that are used by adolescents and young adults include “club
drugs” such as MDMA (Ecstasy), a synthetic drug with amphetamine and
hallucinogenic properties, and its purer form “Molly” often glamorized by
singers and musicians. Visits to the ED and deaths have occurred from the
use of many of these drugs. Cocaine and heroin use has significantly
decreased since 1999 with 1.2% of teens using cocaine and <0.03% of teens
using heroin in the last month. Methamphetamine use is also down with
<0.03% of teens using in the last month and 0.06% use in a year (National
Institute of Health, 2017). Methamphetamine labs are a public health hazard.
Prolonged exposure to methamphetamine can result in cognitive deficits and
psychosis (National Institute of Drug Abuse for Teens, 2017c, 2017d).
C/PHNs should be aware of this when making home visits.
Another drug used by adolescents is anabolic steroids. The illicit use of
anabolic steroids is difficult to monitor; however, 0.6% of 8th graders, 0.7%
of 10th graders, and l.1% of 12th graders reported using steroids in a national
survey (National Institute of Drug Abuse for Teens, 2017e). The Youth Risk
Behavior Surveillance—United States, 2017 noted that use was higher in
males, and more prevalent among Hispanic (3.5%) than White (2.2%)
students.

The prevalence of nonprescription steroid use increased between 1991

and 2001 and then decreased during 2001 to 2017 (Kann et al., 2018).
Adverse effects of illicit steroid use include irritability, increased risk-
taking behavior, extreme mood swings, paranoia, jealousy, and
euphoria, as well as psychiatric conditions that may be intensified or
induced (National Institute of Drug Abuse for Teens, 2017e).
Because steroids are often readily available through Internet
pharmacies, policymakers, health educators, and parents must make
adolescents aware of the dangers, such as altered serotonin levels and
increased aggression.

Adolescents are becoming more involved with prescription drugs, often

found in their parents' medicine cabinets, purchased on the Internet or bought
from friends at school. Secondary too marijuana and alcohol, they are the
most commonly abused substances by teens. Medications are often mixed
with alcohol, and adolescents often mistakenly believe prescription

1758
medications are safer than street drugs when used to produce a high. The
Youth Risk Behavior Surveillance—United States, 2017 indicated that
adolescent misuse of prescription drugs ranges from 7.8% to 19.3% across
36 states (Kann et al., 2018). Prevalence of prescription drug misuse by 12th
grade students decreased significantly between 2014 and 2017; however, this
remains one of the most commonly abused substances by all Americans aged
14 years and older (National Institute of Drug Abuse for Teens, 2017f).
Tobacco products are also easily acquired, often from parents.
Approximately 28.9% high school seniors report ever trying a cigarette.

Between 1991 and 2017, the overall rates of adolescents currently using
cigarettes significantly decreased from 27.5% to 8.8%.
In 2017, 1.6% of teens reported using smokeless tobacco such as
chewing tobacco, snuff, dip, snus, or dissolvable products, and 8% of
students reported smoking cigars.
Electronic cigarettes (e-cigarettes) are becoming increasingly used in
the adolescent population. In 2017, 42.2% of adolescents reporting that
they had ever used an electronic vapor product, and 13.2% reported
using e-cigarettes in the past 30 days (Kann et al., 2018).
Research regarding adolescent e-cigarette use indicates an association
between e-cigarette use and the subsequent use of tobacco (Soneji et al.,
2017; Wills et al., 2017).

Social disapproval and heightened perception of health risks are thought to

help contribute to the downward trend of smoking and smokeless tobacco
use, along with price increases and advertising bans. But tobacco marketing
continues to be problematic, as the tobacco industry has joined with
convenience stores to more prominently display tobacco products, and even
though state and federal taxes comprise about half the cost of a pack of
cigarettes, states have not always sufficiently invested these funds in
adolescent tobacco prevention (Cruz et al., 2018). Flavored nicotine products
are marketed to youth luring children with such flavors as bubble gum and
cotton candy (Tobacco Free Kids, 2017).

Risk factors associated with cigarette smoking include being an older

adolescent, male, and white. Also, having parents without college
education and adolescent lack of college education plans (Office of
Adolescent Health, 2017b).

Primary health care providers do not always question adolescents about

smoking, drinking, and use of other substances. Some evidence highlights
the effectiveness of brief interventions by health care providers in
encouraging smoking cessation and improvement in other risk behaviors.

1759
Research recommends that health care professional counseling be provided
as a preventive measure to adolescent tobacco users.

Important to note is research indicating that education regarding the

harmful effects of tobacco use are more effective than messages about
the benefits of not smoking. This research may prove influential
regarding the risk warning on tobacco products and in social media
(Mays, Hawkins, Bredfeldt, Wolf, & Tercyak, 2017).
C/PHNs and community health nurses can provide information to teens
about smoking cessation programs and promote primary prevention by
educating children and adolescents to choose not to smoke or engage in
other health risk behaviors. They can also encourage physicians and
parents to question and monitor adolescents about smoking and the use
of tobacco products.

1760
Teen Sexuality and Pregnancy
Teenage pregnancies, sexually transmitted diseases (STDs), and HIV/AIDS
are public health concerns associated with the sexual activity of adolescents.

In the 2017 YRBSS, 39.5% of high school students reported ever

having sexual intercourse, and 53.8% used a condom during their last
sexual intercourse.
About 10% reported having had sexual intercourse with four or more
persons, and 20.7% used birth control pills to prevent pregnancy (Kann
et al., 2018).

Adolescent birth rates differ by age, racial and ethnic group, and country
region. The downward trend in teen birth rates has continued over the past 25
years; however, the rate in the United States remains higher than many other
developed countries.

In 2016, teens (aged 15 to 19) experienced 209,809 pregnancies, with

74% of all teen births occurring to 18-to 19-year-olds.
Teen births are more prevalent among Hispanic and Black females,
although this rate has decreased in recent years.
Preventive teenage pregnancy factors include being engaged in learning
and after school activities, having a positive attitude toward learning
and school, academic excellence, and living in a wealthier neighbor
with higher income levels (Office of Adolescent Health, 2017c).

Teenage pregnancy is associated with increased health risks to both the

mother and the child. These risks include increased risk of illness and death,
increased risk of mother's death from violence, and increased developmental
concerns of the child. In addition, young mothers are more likely to live in
poverty and to be delayed in their own education. The children of teen
mothers are at risk of several social and health challenges, including lower
academic achievement, health problems, incarcerations during adolescence,
teenage pregnancy, and young adult unemployment (CDC, 2019g).

By 19 years of age, 39.5% of males and females have had sexual

intercourse. Approximately 3.4% of teens have had sex by age 13.

As such, it would be appropriate for U.S. society to provide effective

sexuality education. There is often debate about the virtues of comprehensive
versus abstinence-only educational programs. Despite the controversy about
the subject, in 2014, 72% of private and public schools in the United States
taught pregnancy prevention as part of required health education. Most
adolescents (aged 15 to 19) received education about STDs and abstinence

1761
(76%), 61% were taught about contraceptives, and 35% were taught how to
use a condom. Many sexually active teens have no instruction on
contraception before their first sexual experience (40% girls, 45% boys)
(Guttmacher Institute, 2017). Teaching about contraception has not been
shown to increase the risk of adolescent sexual activity or STIs, but it may
decrease the risk of pregnancy. A systematic review and meta-analysis
assessing the effectiveness of school-based programs found that sex
education, of any type, when compared to no education was associated with
delayed adolescent sexual intercourse. Research, however, was divided
regarding effectiveness in preventing teen pregnancy (Marseille et al., 2018).
Besides formal education through schools, adolescents note that peers, the
media, and parents are also sources of information on sexual health. Between
70% and 78% of teens report talking with a parent about sex, although girls
more often talk with parents about how to say no to sex or use birth control
(Guttmacher Institute, 2017).
Pregnancy prevention programs can be effective in reducing teen
pregnancy and birth rates (Fig. 20-10), as well as in reducing the number of
second births to teenage mothers. Research regarding the effectiveness of a
multicomponent, community-wide teen pregnancy prevention (TPP) program
focusing on 15-to 19-year African American and Latino/Hispanic youth
found that key elements influenced the success of a community mobilization
program. Learnings included:

FIGURE 20-10 Pregnancy prevention programs can be helpful in

decreasing rates of adolescent pregnancy.

1762
 1. Communities are generally willing to “‘face’ the issue of teen
pregnancy.”
2. Support of the program by key stakeholders was critical to success.
3. Collaboration of health and human service agencies strengthened the
program.
4. Education of and establishing trust within the community was
essential.
5. Engagement of youth teams and extensive training for youth leaders
was imperative.

Review of the TPP intervention research by project coordinators was

positive, “The model was important in creating a network of community
partners and concerned citizens—including the youth of the community—
who would contribute to normalizing TPP within their communities”
(Saunders, 2018). Health promotion professionals were important allies
throughout the TPP community mobilization program through direct service,
community advocacy and networking, and being actively involved in health
promotion (Saunders, 2018).
Primary care providers often miss opportunities to provide counseling on
prevention of pregnancy, HIV, and STDs, as well as other risk factors for
unintentional injury. Nurses can provide information and counseling on birth
control and emergency contraception to adolescent clients and collaborate
with schools to promote effective pregnancy prevention programs. It is
important for C/PHNs to provide education and health counseling on these
subjects. A recent study by Rabbitte & Enriquez (2018) demonstrated the
importance of nursing collaboration in high school sexual education and
counseling, stating “If implemented correctly, sex education teaches students
about anatomy and physiology, healthy relationships, hygiene, positive self-
image, how to handle uncomfortable situations, and about health resources
available to them. School nurses are in a unique position to play a critical
role in policy change with regard to sex education” (p. 10).

1763
Sexually Transmitted Infections
STI and HIV infections are epidemic among adolescents worldwide (WHO,
2018a). More than 20 diseases can be transmitted sexually; only the most
common are reportable.

Each year, about half of the STD cases occur among the 15-to 24-year-
old age group, even though they represent only 27% of the population
of sexually active individuals. These diseases include syphilis,
gonorrhea, Chlamydia, HPV, and herpes simplex virus.
Almost all sexually active people will get an HPV infection in their
lifetime. HPV infections can lead to several types of cancer in both men
and women and other health-related problems (CDC, 2018g).

Chlamydia, gonorrhea, and syphilis are other STDs/STIs found in the

adolescent population.

Of the 19 million new cases of STDs annually, about half are among
adolescents (15 to 24 years old), and 21% of 13-to 24-year-olds in
reporting states had a new HIV infection in 2016.
In the adolescent population, STIs are more common among those
engaging in sexual risk behaviors. In 2017, 40% of high school students
reported ever having sexual intercourse and 30% were active within the
previous 3 months.
About 10% had sex with four or more partners, and 54% used a condom
with their last sexual contact (CDC, 2020i).
Gonorrhea is the most commonly reported STD (70%), followed by
Chlamydia (63%), HPV (49%), genital herpes (45%), HIV (26%), and
syphilis (20%) (CDC, 2018g).

About one in four sexually active adolescent females have an STD.

Compared with adults, adolescents (10 to 19 years) and young adults (20 to
24 years) are at increased risk for acquiring STDs. Reasons for this may
include a greater likelihood of multiple sex partners, unprotected intercourse,
and selection of higher-risk partners. Immature biology makes adolescents
more vulnerable to infection and earlier sexual initiation.

Barriers to prevention and care include social and cultural conditions

such as lack of health insurance and transportation, concerns about
confidentiality, and lack of quality STD prevention services.
Adolescent girls also have a physiologically amplified susceptibility to
Chlamydia infection because of increased cervical ectopy.
Serious complications from STDs include pelvic inflammatory disease
(PID), sterility, increased risk of cancers of the reproductive system,

1764
 and, with syphilis, blindness, mental illness, and death. There are also
complications for the unborn children of those infected with STDs
(CDC, 2018g).

Even though death rates from HIV/AIDS have dramatically fallen, new HIV
infections reported annually do not reflect the same steep decline.

It is estimated that as many as 51% of youth with HIV are not aware of
their infection. Adolescents and young adults (aged 13 to 24) comprised
21% of all new cases of HIV infection in 2016 and young gay and
bisexual men accounted for 81% of the new cases.
As a result, in 2017, the CDC granted approximately $11 million per
year/5-year community-based organizations for HIV testing of young
gay and bisexual men. The goal of these grants is to identify
undiagnosed HIV infections and connect those diagnosed with HIV to
appropriate health care resources (CDC, 2020j).

As noted earlier, sex education is effective at both delaying the onset of

sexual activity and possibly increasing the use of contraception in
adolescents who are already sexually active. It is also effective in increasing
safer sex practices, knowledge of birth control method efficacy, and overall
sexual knowledge when that content is taught (Rabbitte & Enriquez, 2018;
Saunders, 2018). Prevention strategies identified by the CDC to reduce
sexual risk behaviors included:

Targeting behaviors that are most easily amenable to change (e.g.,

condom use, decreased number of sexual partners, abstinence)
Tailoring programs to the target population, using theory as a guide in
development of programs (e.g., modeling discussions with partners
about condom use, skill building by role-playing situations, increasing
self-efficacy)
Addressing a broader content than just STI/HIV prevention education
(e.g., problem-solving, social skills, gender pride, capacity building)

Evidence-based prevention interventions are the most effective (CDC,

2018h). See Chapter 28 for the school nurse's role with STD/HIV.

1765
Acne
Acne is a skin disease that primarily affects adolescents going through
puberty.

The prevalence of acne in the adolescent population is nearly 95%. The

precise cause of acne is not fully understood. It is often related to
several factors. Genetics play a part (there is often a family history of
acne), hormonal influences are also a factor (especially an increase in
male hormones), and greasy cosmetics may plug cells of follicles,
producing a plug.
Acne usually begins during puberty (10 to 12 years of age) with the
increase in circulating male hormones that stimulate sebaceous glands
in the skin. It often affects adolescent men more than females (Skroza et
al., 2018).

Common acne treatment includes skin cleansers, peelers, and medications to

decrease sebaceous gland activity. Topical retinoids are the first-line drugs of
choice because of their anti-inflammatory properties. Benzoyl peroxide is
used to kill bacteria on the skin and in the pores. It may be sold over the
counter (OTC) or by prescription. Other OTC medications include salicylic
acid and resorcinol. Retin-A (a topical vitamin A ointment), glycolic acid,
and alpha-hydroxy acids help to peel the impacted cells from the pores.
Antibiotics (oral or topical), such as tetracycline or doxycycline, may be
prescribed to help control bacteria on the skin. Isotretinoin reduces the size
and activity of sebaceous glands but can cause liver or kidney dysfunction.
Because of an extremely high risk of birth defects, female adolescents taking
Isotretinoin are prescribed oral contraceptives and must participate in a Food
and Drug Administration–approved risk management program.
Corticosteroids may be injected directly into the comedones. Some
adolescents choose to try complementary therapies such as tea tree oil, fish
oil, or brewer's yeast, as well as biofeedback and traditional Chinese
medicine (Cao et al., 2017).
The best preventive measures are keeping the skin clean, eating a
balanced diet that includes fresh fruits and vegetables, drinking lots of water,
and getting adequate sleep. It is important for male adolescents to shave
carefully and for all teens with acne to avoid touching their faces or picking
at their blemishes. They may want to use skin and hair products that are
noncomedogenic. Adolescents with severe acne may need to be referred to
dermatologists who specialize in this skin disorder (Mayo Clinic, 2017).

1766
Poor Nutrition and Eating Disorders
Poor nutrition and obesity are common among adolescents, whose diets often
consist of snacks with limited nutritional value interspersed among
unhealthful meals. The nutritional needs of adolescents increase as their
growth rate and body composition changes with puberty. Many things, from
psychosocial factors, family and peers, availability of fast-food, and mass
media marketing, influence the eating behaviors of adolescents. Research
indicates that two thirds of adolescents are not aware of dietary needs,
sources of nutrients, and diet–disease relationship (Demory-Luce & Motil,
2018).

Girls are more at risk for problems with nutrition for several reasons:
they tend to diet inappropriately, to have more finicky eating habits, and
to be less physically active than teenage boys.
Approximately 5.4% of adolescents (13 to 18 years) suffer from an
eating disorder, with the majority being female. Issues with body image
and control are at the heart of anorexia nervosa and bulimia nervosa,
common problems for adolescent girls.
Anorexia nervosa is an eating disorder with an emotional etiology that
is characterized by body image disturbance (i.e., girls see themselves as
fat, although they may be extremely thin), an intense fear of becoming
fat or gaining weight, and refusal to maintain adequate body weight.
Bulimia nervosa is an eating disorder characterized by recurrent
episodes of binge eating with repeated compensatory mechanisms to
prevent weight gain, such as vomiting (purging type) and fasting or
exercise (nonpurging type) (National Institute of Mental Health, n.d.b).
Binge eating, also a recognized eating disorder, involves recurrent
episodes of binge eating without fasting, self-induced vomiting, or other
compensatory measures. Self-esteem, depressive symptoms, and
emotional eating are very sensitive predictors of binge eating. Low
levels of support from peers can also be linked to binge eating, and
binge eating is associated with an increased risk of becoming
overweight or obese (National Institute of Mental Health, n.d.b).

These diseases affect both male and female adolescents. Research indicates
that they are caused by multiple factors including genetics, biological,
behavioral, psychological, and social elements. Nutrition education,
psychological counseling, and cognitive–behavioral techniques that teach
clients how to control stimuli, substitute alternative behaviors, and use
positive visualization are all part of treatment; development of a support
network is also important. Family and individually based treatments are most
often used for severe cases of adolescent eating disorders and have been

1767
studied most often. Medications (e.g., antidepressants) have been used to
treat some adolescents with eating disorders, when co-occurring illnesses
exist (National Institute of Mental Health, n.d.b).

1768
HEALTH SERVICES FOR SCHOOL-
AGE CHILDREN AND
ADOLESCENTS
A number of programs serve the health needs of school-age children and
adolescents. Community health nurses play a major and vital role in
delivering these services. Such programs fall into three categories that
approximate the three practice priorities of community health nursing
practice: illness prevention, health protection, and health promotion.

1769
Preventive Health Programs
Among programs to prevent physical illness and other health problems
among adolescents are immunizations and TB testing, as well as school-and
community-based education, and support programs. Private and public
counseling programs and other social services are also geared to promote
health and prevent illness.

Immunizations and Tuberculosis Testing

C/PHNs are deeply involved in each of the preventive activities of
immunizations and tuberculosis testing. Health departments and schools
often work collaboratively to provide immunization services. Compulsory
immunization laws are helpful in carrying out these preventive services, but
recent survey results reveal that not all adolescents are fully covered.

A national immunization survey revealed mixed results for adolescent

vaccination. There were significant increases in vaccination rates for
varicella, tetanus/diphtheria/acellular pertussis (Tdap), and
meningococcal conjugate vaccine. HPV coverage also increased with
65.1% of females and 56% of males being vaccinated (Walker et al.,
2017).

It is important for adolescents, as well as adults, to get a single dose of Tdap

to protect themselves and infants who may be around them from whooping
cough. Although pertussis in adolescents or adults often manifests as an
upper respiratory infection with a chronic cough, for infants who have not
yet been fully immunized, it can lead to serious complications.
In the recent past, adolescents were only given “catch-up” vaccinations
(those missed in childhood), except for a tetanus/diphtheria booster.
Recommended immunizations now include Tdap, meningococcal vaccine,
pneumococcal polysaccharide vaccine, both hepatitis A and B, influenza
vaccine, and HPV vaccine for both boys and girls. Additionally, any missed
vaccines such as polio and varicella are recommended (for immunization
tables, see ).
Often, school nurses and community health nurses work with nurse
volunteers to provide immunization clinics at elementary and middle
schools; these are convenient for adolescents and their parents. School-based
clinics are also great places to catch adolescents who need updated
immunizations. There is some evidence that adolescent vaccinations are
becoming more available at retail pharmacies. Researchers note, however,
that higher levels of medical and health needs are met when children and
adolescents have an annual visit with a health care provider (Office of

1770
Adolescent Health, 2018c). Routine visits give the health care provider an
opportunity to discuss risk behaviors and health concerns with adolescents
and to intervene early as problems arise. Annual tuberculosis (TB) testing is
often recommended for children and adolescents from high-risk populations.
Targeted TB skin testing identifies adolescents and children at risk for latent
TB who could benefit from treatment to prevent progression of the disease
(CDC, 2018h). See Chapter 8 for more on TB skin testing.

Education and Social Services

The health education of school-age children and adolescents includes a wide
variety of approaches and can range from the basics of handwashing for
elementary school students to health risk behavior for adolescents. Parental
support services are commonly available through many public and private
agencies, including churches. These services can have long-range effects on
the health of school-age children, because emotionally healthy parents and
stable families offer a healthful environment and support system for children
and can facilitate their progress in school. In most states, community health
nurses provide teaching and counseling services to parents in their homes
and in groups. School nurses, school mental health counselors, and school
psychologists also organize parent support groups in local schools. This is
particularly important during periods of transition (e.g., from elementary to
middle school, from middle to high school). Discussing parenting concerns
and increasing parents' understanding of normal child growth and
development help to allay fears and prevent problems. Through such efforts,
family violence and abuse can be averted. Reduction in rates of divorce and
the attendant consequences may also be a benefit of strengthening family
resilience.
Family planning programs, often stationed strategically in inner cities,
near schools, or in school-based clinics, provide birth control information
and counseling to young people.

In some communities, the school-based clinic dispenses condoms. In

many states, adolescents have the right to consent for sexual and
reproductive health care without parental permission. It is important that
health care providers be aware of local and regional options for
counseling.
C/PHNs, in collaboration with an interdisciplinary team, are usually the
primary care providers in these programs. Their major goals are to
prevent teenage pregnancy, educate teens about reproduction and
contraception, and encourage responsible sexual behavior.
Schools can foster evidence-based health education and create healthy,
safe, and nurturing school environments, especially when implementing

1771
 policies and programs regarding reproductive health and health risk
behaviors.
Collaborative efforts by the student, family, school, community, and
society are essential to promoting adolescent health. Developing healthy
and safe health education environments will influence adolescent health
and academic achievement (CDC, 2019h).

Children and adolescents can be influenced by adults' smoking in the home.

C/PHNs should educate parents about the effects of smoking in the home
and its relationship to adolescent smoking. Youth tobacco use is also
associated with peer approval, mental health (strongly associated with
depression, anxiety, and stress), lower socioeconomic status, lower academic
achievement, accessibility, and tobacco advertising.

Multiple programs to reduce and prevent teen smoking have been

implemented in recent years. Successful activities include higher
tobacco costs, indoor smoking prohibition, raising minimum age of
tobacco sales, social media, and community antitobacco programs
(CDC, 2019i).

It is essential that C/PHNs work with law enforcement officials, school

district administrators, and other community agencies to ensure compliance
with local regulations and prevent or delay the use of tobacco products.
Information on smoking cessation and resources to help prevent tobacco use
by children and adolescents is available through the CDC and the Foundation
for a Smokefree America.

1772
Health Protection Programs

Safety and Injury Prevention

Accident and injury control programs serve a critical role in protecting the
lives of school-age children and adolescents. They are cost-effective: seat
belt laws, child safety seats, and helmet laws have saved millions of dollars
in medical care. Efforts to prevent motor vehicle accidents, a major cause of
adolescent death, include driver education programs, better highway
construction, improved motor vehicle design and safety features, and
continuing research into what causes various types of crashes.

Injury prevention and reduction have been addressed through multiple

strategies. These include state laws requiring the use of safety restraints;
installation of driver and front passenger airbags; substitution of other
modes of travel (air, rail, or bus); lower speed limits; stricter
enforcement of drunk driving laws; graduated drivers licenses (GDLs)
for teenagers; safer automobile design; and helmets for motorcyclists,
bicycle riders, and skaters (Ballesteros et al., 2018).
In developing interventions, community health nurses need to recognize
that adolescents are prone to risk-taking/novelty-seeking behaviors as a
result of their cognitive, physical, and psychosocial developmental stage
(Nesi et al., 2018).
A campaign from the CDC, “Parents are the Key,” focuses on the
influence of parents, pediatricians, and communities as safety features
for teens (CDC, 2017h). Communities can also work with law
enforcement officials to ensure compliance with mandatory seat belt
laws and to promote safe speeds and appropriate driving behaviors near
schools.

Safety programs also seek to protect school-age children and adolescents

from the hazards of poisonings, ingestion of prescription or OTC drugs,
product-related accidents (unsafe toys, bicycles, skateboards, skates,
playground equipment, and furniture), and recreational accidents, including
drowning and sports-related injuries. Safety services assume various forms.
Poison control centers in many localities offer information and emergency
assistance. Whereas the federal Consumer Product Safety Commission
monitors the safety of products, education programs in schools or through
local fire or police departments teach school-age children about bicycle and
water safety, fire dangers, and hazards related to poisoning. Generally, the
community health nurse can educate families to recognize potentially
hazardous situations and encourage efforts to eliminate them. Working with

1773
school nurses and school district officials to reduce playground hazards can
contribute to the reduction of school-related injuries.
Environmental hazards and other dangers await school-age children and
adolescents in the workforce.

There were approximately 19.3 million workers under age 24 in 2016,

and 403 workers under age 24 died from a work-related injury in 2015.
Hospitals treated nearly double the number of workers aged 15 to 19
years, as compared to workers over age 25; it is necessary to reduce the
number of occupational-related injuries among 15-to 19-year-olds (The
National Institute for Occupational Safety and Health (NIOSH), 2018).
C/PHNs can join with occupational health nurses and school nurses to
teach parents and children about the dangers and risks inherent in the
workplace, and they can work with local employers to ensure safe
working conditions and reasonable hours of employment that do not
interfere with school.

Infectious Disease Prevention

Programs that protect school-age children and adolescents against infectious
diseases encompass such efforts as closing swimming pools that have unsafe
bacteria counts, conducting immunization campaigns in conjunction with
influenza or measles outbreaks, and working with hospital pediatric units to
reduce the incidence and threat of iatrogenic disease. Prevention of
community-acquired MRSA is a new challenge for public schools, and
C/PHNs may work with school nurses or others to provide educational
programs covering a variety of infectious diseases. Epidemiologic
investigations, especially with school sports teams, may be necessary to
determine the cause of outbreaks (CDC, 2019f).

Child Protective Services

The Children's Bureau collects and analyzes information on child abuse and
neglect, serves as an information clearinghouse, publishes educational
materials on the subject, offers technical assistance, and conducts research
into the problem (Administration on Children and Families [ACF], 2018a).

In 2016, an estimated 4.1 million referrals were made alleging child

abuse and/or neglect of approximately 7.4 million children.
Approximately 58% of these referrals were screened, and almost 3.5
million cases had an investigation or alternative response. This reflects a
Child Protective Services (CPS) response increase of 9.5% since 2012.
Most victims suffered from neglect (74.6%), approximately 18.2% were
physically abused, and 8.5% were sexually abused.

1774
 There were 2.36 deaths per 100,000 children, and 70% of children were
under age 3. More than 70% of deaths were attributed to neglect or a
combination of neglect and another form of maltreatment.
Nearly 45% of deaths were attributed to physical abuse or a
combination of physical abuse and another form of maltreatment. Most
perpetrators of child abuse and maltreatment (78%) were biological
parents (ACF, 2018b).

Consequences for affected children include lower self-esteem, depression,

suicide, self-abuse, substance abuse, eating disorders, less empathy for
others, antisocial behavior, delinquency, aggression, violence, low academic
achievement, and sexual maladjustment. Long-term emotional, social,
cognitive, and physical consequences are well documented, and often follow
abused children into adolescence and adulthood. Posttraumatic stress
disorder, poor attachment and problems with trust, difficulties with language
development and abstract reasoning, high-risk health behaviors, and abusive
or violent behavior may be seen later in life (CDC, 2020k). These findings
were first noted in a large-scale, landmark research study, the Adverse
Childhood Experiences study (Felitti et al., 1998).
In some areas, C/PHNs are working together with social workers, mental
health workers, and substance abuse counselors as part of a team that
provides services to families. Improved training of mandated reporters, such
as teachers and physicians, has led to better reporting of abuse; as
professionals and the public become more aware of the problem, an increase
in reporting has occurred. Child abuse prevention programs can be found in
many public health departments and through some school districts as a
primary preventive intervention. Primary prevention of child maltreatment
can also occur through home visiting programs utilizing C/PHNs. These
visits can also help to connect high-risk families to the community and
promote better child outcomes when an appropriate curriculum is followed
(Matone et al., 2018). Programs that target at-risk families, especially
adolescent mothers and young couples prone to partner violence or harsh
parenting practices, may help to prevent later child abuse. C/PHNs and
school nurses must be vigilent for signs of family stress, harsh parenting
practices, family violence, and other risk factors for child abuse and neglect,
and must provide resources and respite as needed (for additional information,
see Chapters 18 and 19).

Oral Hygiene and Dental Care

Fluoridation of drinking water, school-provided fluoride rinse or gel, and
dental sealant programs are cost-effective and can reduce dental caries.

1775
Fluoride makes teeth less susceptible to decay by increasing the
resistance of tooth enamel to the bacterially produced acid in the mouth.
School-based programs that provide fluoride rinses and dental sealants
and promote tooth brushing and nutrition education for dental health can
be found in most areas of the country.
Fluoridation of community water supplies is considered the most
effective, safe, and low-cost means of protecting the dental health of
children and adolescents.
Although most dental care is focused on children, adolescents remain in
need of dental health services. In addition to regular dental care, good
nutrition, and proper oral hygiene, C/PHNs can promote public water
fluoridation as an important program for protecting children's dental
health. Nurses can also recommend that parents talk with their primary
health care provider and dentist about fluoride varnish or supplements
(CDC, 2019j).

1776
Health Promotion Programs: Nutrition and
Exercise
Nutrition and weight control programs form another important set of health
promotion services. Children need to learn sound dietary habits early in life
to establish healthy lifelong patterns. Being overweight during childhood or
adolescence may persist into adulthood and may increase the risk for some
chronic diseases later in life.

A number of weight control programs for overweight children and

adolescents are available through schools, health departments,
community health centers, health maintenance organizations, and
private groups (Geria & Beitz, 2018; Williams et al., 2018).
Children and adolescents are particularly vulnerable to media and peer
pressures with regard to their food choices. Because of increased rates
of childhood obesity and a greater awareness of the need for better
nutrition in adolescence, district-level policies to increase the
availability of healthy foods at public schools is growing (Micha et al.,
2018).

The C/PHN, through nutrition education and reinforcement of positive

practices and policy advocacy, plays a significant role in promoting the
health of children.

1777
SUMMARY
The physical and emotional health of children and adolescents can
affect not only their academic achievement but also the future of
society. Children and adolescents need the guidance and direction
provided by community health nurses.
Poverty is a significant social determinant of health that has been shown
to contribute to many physical, psychological, and behavioral problems
in children and adolescents. There is concern that government assistance
programs are not sufficiently meeting the needs of poor children and
adolescents.
Health problems that affect learning and achievement in school-age
children include chronic diseases, behavioral and learning problems,
disabilities, injuries, communicable diseases, dietary and physical
activity concerns, and poor dental health.
The federally and state-mandated immunization program for school-age
children and adolescents is one measure to prevent communicable
diseases. Among vaccines given on schedule throughout childhood are
those that prevent polio, smallpox, diphtheria, tetanus, typhoid, and
many other diseases.
Mortality rates for children and adolescents have decreased dramatically
since the early 1900s, but morbidity rates remain high. Children and
adolescents are vulnerable to many illnesses, injuries, and emotional
problems, often as a result of a complex and stressful environment.
Violence against children and deaths because of homicide occur in the
United States at alarming rates. Unintentional injuries, suicide, and
homicide are the leading threats to life and health for adolescents.
Other health problems include alcohol and drug abuse, unplanned
pregnancies, STIs and HIV/AIDS, and poor nutrition. All of these
problems create major challenges for the community health nurse who
seeks to prevent illness and injury among children and adolescents and
to promote their health.
Healthy People objectives for children and adolescents provide key
goals for reduction of alcohol-related unintentional injuries; declines in
violent behaviors, suicide, mental health issues; and more responsible
reproductive health behaviors. Barriers to achieving these goals vary
and include economic inequities; lack of sufficient immunization,
educational, and community-supported health programs; and the
presence of risk behaviors typical among developing youth.
Community health nurses play a large role in promoting the health of
adolescents, their families, and communities, through education

1778
programs and by developing strategies to support healthy growth and
development and prevent risky behaviors that lead to injury, teen
pregnancy, and sometimes death.
Health services for children and adolescents span three categories:
prevention, health protection, and health promotion. The community
health nurse plays a vital role in each.
Preventive services may include immunization programs, parental
support services, family planning programs, services for those with
STIs, and alcohol and drug abuse prevention programs.
Health protection services often include accident and injury
control, programs to reduce environmental hazards and control
infectious diseases, and services to protect children and adolescents
from child abuse and neglect.
Health promotion services may include programs in nutrition and
weight control, along with HIV/AIDS prevention and smoking,
alcohol, and drug abuse education.
C/PHNs are integral to the health and wellbeing of children and
adolescents, through their work with families, schools, and other
community agencies.

1779
ACTIVE LEARNING EXERCISES
1. You are a community health nurse assigned to work at a school. You
learn that more than 20% of the students in this school district are
receiving medications for treating attention deficit hyperactivity
disorder (ADHD). Why is this significant? Explain your reasoning.
What evidence-based information will you use to prepare an
individualized health care plan for each child?
2. You are working in a rural health department and are researching the
leading causes of death among children and adolescents. Where can
you find national and state data for your search? What evidence-
based public health interventions have been successful in preventing
childhood deaths? Select one intervention for children or adolescents
and describe how you and a group of community health professionals
might develop effective preventive measures.
3. A 14-year-old girl from a middle-class family and a 14-year-old girl
from a poor family both come to the health department clinic where
you work. The girls have similar symptoms that suggest gonorrhea.
Would your assessment and intervention be the same for the two
girls? What personal assumptions or biases might influence your plan
of care? Compose a sexually transmitted infections prevention
instruction document for this population group.
4. Your school district is searching for ways to improve adolescent
nutrition and diet. What influencing factors should you consider (e.g.,
student behaviors, environment/cultural influences, school policies)?
What key stakeholders should you include as you research and
develop a health improvement plan? Describe an evidence-based
program that you could implement to increase physical activity and
improve nutrition for school-age children and adolescents.
5. You are assigned to work with a rural elementary school with repeated
outbreaks of head lice and limited access to health care. Search
credible online resources for causes of recurrent head lice infestations
and effective over-the-counter treatment products. Describe two head
lice treatments and the supporting evidence. What are the advantages
and disadvantages of each treatment?
6. Apply “Utilize Legal and Regulatory Actions” (1 of the 10 essential
public health services; see Box 2-2 ), to the following: Your school
district allows personal exemptions for vaccination (i.e., parents can
refuse to get mandatory vaccinations for their children based on
personal, not solely religious, beliefs). The public health department
has informed you that there is a measles epidemic in your county.

1780
 What information do you need to promote a safe and healthy school
environment? Outline your concerns and formulate a health
intervention for your school.

thePoint: Everything You Need to Make the

Grade!
Visit http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, study aids for
all learning styles, and more!

1781
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1799
CHAPTER 21
Adult Health
“Male and female represent the two sides of the great radical dualism. But in fact, they are
perpetually passing into one another. Fluid hardens to solid, and solid rushes to fluid. There is no
wholly masculine man, no purely feminine woman.”

—Margaret Fuller (1810–1850), Woman in the Nineteenth Century, 1845

KEY TERMS
Adult
Anorexia nervosa Binge eating Bisexual
Bulimia nervosa Cancer
Cardiovascular disease (CVD) Chronic lower respiratory disease (CLRD)
Diabetes mellitus Erectile dysfunction (ED) Life expectancy Menopausal
hormone therapy (MHT) Menopause Myalgic encephalomyelitis/chronic
fatigue syndrome (ME/CFS) Osteoporosis Perimenopause Prostate
Substance use disorder (SUD) Transgender Unintentional injuries

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Identify key demographic characteristics of women and men throughout
the adult life span.
2. Discuss the concepts of life expectancy, health disparities, and health
literacy and how they apply to adult women and men living in the
United States.
3. Discuss the major chronic illnesses found in adult women and men in
the United States.
4. Compare and contrast the manifestations of chronic illnesses in adult
women and men.
5. Discuss factors affecting the health of adult women and men in the
United States.
6. Identify primary, secondary, and tertiary health promotion activities
designed to improve the health of women and men across the life span.
7. Identify the Healthy People 2030 objectives for adult women and men.
8. Describe the role of the community health nurse in promoting the health
of adult women and men across the life span.

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INTRODUCTION
Mrs. Anderson is a relatively healthy middle-aged woman, with no chronic
health conditions. Her family history is positive for type 2 diabetes mellitus,
cardiovascular disease, and colon cancer. She tries to eat healthy, but her
moderately stressful career and busy family make it difficult to find time to
cook and exercise. Over the past few years, she has noticed weight gain and
is concerned that this, along with her family history, may lead to the
development of chronic disease. What are considerations for Mrs. Anderson
based on her age, risk factors, and current health status? What preventative
services and screenings might she need?
Community and public health nurses (C/PHN) are in a key position to
educate clients like Mrs. Anderson on health promotion and disease
prevention and inform them of U.S. Preventative Services recommendations.
This teaching impacts community health by improving the health of
individuals.
The term adult has many different meanings in society. To children, an
adult is anyone in authority, including a 14-year-old babysitter. As people
age, they tend to redefine the term upward. It is not unusual, for example, to
hear an older person describe a couple in their mid-30s as “kids.” The U.S.
criminal justice system distinguishes between adults and juveniles for
purposes of delimiting types of crimes and possibilities for punishment, and
labor legislation provides different protections for children than for adult
workers. Even hospitals and health care systems vary somewhat as to the
ages at which they distinguish pediatric and geriatric clients from middle-
aged adults.
How would you characterize an adult? Does your definition rest solely
on age or is it influenced by other factors, such as marital status, employment
status, financial independence, amount of responsibility for self and others,
and so on?

For the purposes of this chapter, an adult is defined as anyone 18 years

of age or older. Obviously, there are tremendous differences in health
profiles and health care needs as people age.
As adults enter their middle years (35 to 65), they experience many
normal physiologic changes. However, some changes are the result of
disease, environment, or lifestyle and can be modified through behavior
change.

1801
 Throughout history, the health care needs of women and men have
differed more often than shown similarities (Fig. 21-1). Many health
promotion and health protection programs are designed specifically for
women or for men, as the examples below illustrate.

FIGURE 21-1 Health care needs of men and women of varying

ages are often different.

Mammography screening programs and prenatal clinics are designed

with women's health in mind.
Teaching about testicular self-examination (TSE) and prostate cancer
screening is typically included in health promotion programs for men.
Programs in many areas, such as cardiac rehabilitation, stress
management, and dating violence prevention, may have initially
targeted one gender but are now established as programs for both
genders.

Despite areas of overlap in women's and men's health, morbidity and

mortality statistics, historical development of research foci, and workforce
changes require that the health care needs of women and men be examined
separately. This chapter focuses on the health of women and men across the
adult life span. A physical profile of middle-aged adults is organized by body
systems and can be found on .

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DEMOGRAPHICS OF ADULT
WOMEN AND MEN
Examining mortality statistics provides key information to understanding
changes in the health and well-being of a population. In 2016, a total of
2,744,248 people died in the United States. The age-adjusted death rate was
728.8 per 100,000 for all ages (Kochanek, Murphy, Xu, & Arias, 2017).
Causes of death varied by age, gender, and ethnicity, but the 10 leading
causes of death for all people in rank order are shown in Table 21-1.

TABLE 21-1 The 10 Leading Causes of Death for All Ages in

2017

Source: National Center for Health Statistics (2017).

1803
 Since the beginning of the 21st century, the major causes of death have
remained fairly consistent. This was a major shift from the turn of the 20th
century, when communicable diseases, such as tuberculosis and pneumonia,
were leading causes of death. The shift from communicable to chronic illness
can be attributed to the significant advances in public health, prevention,
technology, pharmacotherapy, and biomedical research (see Chapters 1 and
7).

In 2016, 74% of all deaths in the United States were attributed to the 10
leading causes (Heron, 2018).
Diseases of the heart and malignant neoplasms are the top two causes of
death for both men and women and accounted for 44.9% of deaths in
2016.

Differences included the following:

Cerebrovascular diseases (stroke) were the third leading cause of death

for women.
Unintentional injuries (accidents) were the leading cause of death for all
adults aged 25 to 44 years and the third leading cause of death for men.
Cancer was the leading cause of death in adults aged 45 to 65 years
(Heron, 2018; National Center for Health Statistics [NCHS], 2019).

1804
LIFE EXPECTANCY
Life expectancy is the average number of years that an individual member of
a specific cohort (usually a single birth year) is projected to live. It is another
standard measurement used to compare the health status of various
populations and is typically calculated based on age-specific death rates.
Health statistics often report life expectancy figures at birth and at 65 and 75
years of age (Table 21-2).

TABLE 21-2 Life Expectancy at Birth and 65 Years of Age

According to Sex: United States, Selected Years, 1900–2017

—, data not available.

Reprinted from National Center for Health Statistics (NCHS). (2019). Health, United States 2017.
Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_07-508.pdf

In the United States, life expectancy increased consistently over time

until 2015, when for the first time in 25 years it decreased for both
males and females (Xu, Murphy, Kochanek, & Arias, 2018).
Women have a higher life expectancy than men, but the gap has
narrowed from 7.0 years in 1990 to 5.0 years in 2016.
There also continue to be differences in life expectancy based on race
and ethnicity in the United States. In 2016, individuals of Hispanic
origin had a life expectancy of 81.8 years, whereas the life expectancy
for Whites was 78.5 years and for Blacks was 74.8 years, indicating a
disproportionate burden of morbidity and mortality (NCHS, 2019).

Globally, life expectancy in the United States trails that of many

countries (Table 21-3). Japan reports the highest life expectancy for males

1805
and females. In all countries, disparities exist between male and female life
expectancy. The smallest disparity can be found between women and men
living in Iceland, at 2.6 years (NCHS, 2019).

TABLE 21-3 Life Expectancy at Birth for Selected Countries

by Sex, 2015

Reprinted from National Center for Health Statistics. (2017). Heath, United States, 2017.
Retrieved from https://www.cdc.gov/nchs/data/hus/2017/014.pdf

1806
HEALTH DISPARITIES
The overarching goal of the Healthy People initiative is to eliminate health
disparities and improve the health of all Americans. A health disparity is
defined as a difference in health status that occurs by gender, race/ethnicity,
education or income, disability, geographic location, or sexual orientation
(Orgera & Artiga, 2018). Health disparities occur when one segment of the
population has a higher rate of disease or mortality than another or when
survival rates are less for one group when compared with another (National
Institutes of Health [NIH], 2019a). Often, persons with the greatest health
burden have the least access to health care services, adequate health care
providers, information, communication technologies, and supporting social
services. Interdisciplinary, collaborative, public, and private approaches as
well as public–private partnerships are needed to develop strategies to
address the health disparity goal of Healthy People 2030. Chapter 23
discusses health disparities in more detail.

1807
HEALTH LITERACY
Health literacy is defined as the degree to which individuals have the
capacity to obtain, process, and understand basic health information and
services needed to make appropriate health-related decisions. The ability to
read and understand health information is key to managing health problems.
Low health literacy contributes to health disparities and has been
documented as an increasing problem among certain racial and ethnic
groups, non–English-speaking populations, and persons over 65 years of age
in the United States. Low health literacy is directly associated with (Health
Resources & Services Administration, 2019; NIH, National Library of
Medicine, n.d.):

Poorer health outcomes

Higher use of emergency service
More frequent hospitalizations
Increased risk of death

See Chapter 10 for additional information on health literacy.

1808
MAJOR HEALTH PROBLEMS OF
ADULTS
Morbidity and mortality among adults vary substantially by age, gender, and
race/ethnicity. Several leading causes of death are presented in this section.
Heart disease is the first-leading cause of death in adults and is presented
along with stroke. Malignant neoplasms, chronic lower respiratory diseases
(CLRDs), unintentional injuries, and diabetes mellitus are among the top 10
leading causes of death and are discussed separately. Other selected major
causes of death are covered in detail in other chapters: suicide (Chapter 25),
Alzheimer's disease (Chapter 22), and homicide (Chapter 18).

1809
Coronary Heart Disease and Stroke
Cardiovascular disease (CVD) describes a group of heart and blood vessel
disorders including hypertension, coronary heart disease (CHD), stroke,
arrhythmias, valvular heart disease, peripheral vascular disease, and
cardiomyopathies (World Health Organization [WHO], 2019). Over the last
three decades, cardiovascular mortality in the United States has declined by
about 50%. These gains are attributed to increased use of evidence-based
medical therapies for secondary prevention and reduction in risk factors
associated with lifestyle and environment (Box 21-1). Despite these gains,
approximately one third of all deaths in the United States are still due to
CVD. Currently, an estimated 92.1 million adults are living with one or more
types of CVD and over half of these individuals are 60 years of age or older.
It is estimated that every 36 seconds, an American will die from CVD,
accounting for 2,300 deaths each day (Fig. 21-2; Benjamin et al., 2018;
Centers for Disease Control and Prevention [CDC], 2017a).

BOX 21-1 Evidence-Based Practice

Landmark Research on Cardiovascular Disease
The hallmark Framingham Heart Study
identified major risk characteristics associated
with the development of CVD and the effects of
related factors such as blood triglycerides,
gender, and psychosocial issues. The study
began in 1948 under the direction of National
Heart Institute, now known as the National
Heart, Lung, and Blood Institute (NHLBI). At
that time, the death rates from CVD were
rising, but little was known about the general
causes of heart disease and stroke. The
Framingham Heart Study researchers recruited
2,336 men and 2,873 women between the ages of
30 and 62 in an effort to identify common
factors or characteristics that contribute to
CVD. All participants lived in the town of

1810
Framingham, Massachusetts. Every 2 years,
these individuals were scheduled for an
extensive medical history, physical examination,
and laboratory tests. In 1971, the study enrolled
5,124 of the original participants' adult children
and their spouses (offspring cohort)
(Framingham Heart Study, 2018).
In an effort to reflect the changing demographics that occurred in
the town of Framingham since the original cohort was enrolled,
researchers implemented a new study in 1994. This study included
individuals of Black, Hispanic/Latino, Asian, Indian, Pacific Islander,
and Native American origin (Omni cohort). In 2002, a third generation
(the children of the offspring cohort) was recruited and a second group
of Omni participants was enrolled in 2003. Over the last several years,
investigators expanded their research into the role of genetics and CVD.
The Framingham Heart Study celebrated its 70th anniversary in 2018,
with 15,447 participants covering three generations and 3,698 peer-
reviewed research articles since it began in 1948. Fortunately, findings
from the Framingham Heart Study will continue to make important
scientific contributions about the causes and treatment of CVD and
related health issues (Framingham Heart Study, 2018).
Source: Framingham Heart Study (2018).

1811
 FIGURE 21-2 Heart disease death rates, 2015–2017 adults, ages
35+ by county. (Source: Centers for Disease Control and
Prevention, Division for Heart Disease and Stroke Prevention.
(2019). Quick maps of heart disease, stroke, and socioeconomic
conditions. Retrieved from
http://www.cdc.gov/dhdsp/maps/national_maps/hd_all.htm)

In the United States, racial/ethnic minority populations continue to

encounter more barriers to CVD diagnosis and care, receive lower-quality
treatment, and experience worse health outcomes. Such disparities are linked
to complex factors such as income and education, genetic and physiological
factors, access to care, and communication barriers. Although it appears as
though the disparity gap may be declining, this is likely not due to gains
made by racial/ethnic minority populations, but worsening cardiovascular
health in Whites (Brown et al., 2018). To tackle inequalities in CVD
morbidity and mortality, actions that focus on the social determinants of
health are needed. This includes development and implementation of health
and social policy interventions that improve access to and quality of health
care services and a reduction in poverty and unemployment (Dong, Fakeye,
Graham, & Gaskin, 2018).
According to the American Heart Association (AHA), risk factors for
CVD can be separated into three categories: major risk factors that cannot be
changed, modifiable risk factors, and contributing risk factors (2016).

1812
 Major risk factors that cannot be modified or treated include heredity
(family history, race), increasing age, and gender (male).
Risk factors that can be modified, treated, or controlled include high
blood cholesterol, high blood pressure, smoking tobacco, physical
inactivity, diabetes, and obesity/overweight.
Risk factors that are known to contribute to heart disease are stress,
alcohol consumption, and diet and nutrition.

About half of all Americans (49%) have at least one of the three key risk
factors for heart disease: high blood pressure, high cholesterol, and cigarette
smoking. The likelihood of heart disease or stroke multiplies with the
increasing number of risk factors present (CDC, 2019a).
Stroke ranks fifth among all causes of death in the United States and is a
leading cause of serious physical and cognitive long-term disability in adults
(Box 21-1).

Approximately 795,000 Americans experience a new or recurrent stroke

each year—610,000 of these are first attacks and 185,000 are recurrent
attacks. On average, someone in the United States has a stroke every 40
seconds.
Disparities exist among people who are at risk for having a stroke. For
example, women have a higher lifetime risk of having a stroke
compared with men, with approximately 55,000 more women than men
experiencing a stroke each year.
The risk of having a first stroke is nearly twice as high for Blacks than
Whites, and Blacks are more likely to die following a stroke than are
their White counterparts. The risk for stroke among Hispanics/Latinos
falls between that of Whites and Blacks, with stroke mortality
increasing in this population since 2013.
In the Southeastern United States (the “Stroke Belt”), stroke death rates
are higher than in any other part of the country. Strokes cost the United
States about $34 billion each year. This total includes the cost of health
care services, medications, and missed days of work (Benjamin et al.,
2018; CDC, 2020a).

1813
Cancer
Cancer is a major chronic illness and remains the second leading cause of
death in the United States (Xu et al., 2018).

The National Cancer Institute's (NCI) Surveillance, Epidemiology, and

End Stage Program (SEER) (2020) estimated that, in 2015, there were
approximately 15.1 million Americans living with cancer.
It was estimated that in 2018, 1,735,350 new cancer cases would be
diagnosed, and of these cases, 609,640 persons were expected to die.
Approximately 87% of all cancers are diagnosed in persons 50 years of
age and older, and as individuals age, they are more likely to develop
cancer.
Among ethnic groups, Blacks are more likely to develop and die from
cancer.
Over their lifetime, men living in the United States are more likely to
develop cancer than women.
The Agency for Healthcare Research and Quality estimated the total
expenditures for cancer in 2015 at $80.2 billion (American Cancer
Society [ACS], 2019; NCI, 2020).

Cancer is caused by internal and external factors.

Internal factors are inherited gene mutations, hormones, immune

conditions, and gene mutations that occur from metabolism.
External factors include tobacco and alcohol use, chemicals, radiation,
infectious organisms, and poor lifestyle choices.
These factors can occur in isolation or together to initiate illness.
Screenings can reduce the cancer mortality rate, especially malignancies
associated with the breast, colon, rectum, cervix, and lung (ACS, 2019).

While the lung cancer death rate continues to decline, it remains the
number one cause of cancer deaths among adults in the United States. In
2018, there were an estimated 234,030 new lung cancer cases and 154,050
deaths, attributing to more than 25% of all cancer deaths in the United States
(ACS, 2019).
Cigarette smoking is the predominant risk factor for lung cancer. The
quantity of cigarettes smoked and the number of years a person smoked both
increase an individual's risk of developing lung cancer. Other risk factors
include occupational or environmental exposure to secondhand smoke,
radon, or asbestos; genetic susceptibility (disease at an early age); and a
history of tuberculosis. Annual screening for lung cancer using low-dose
computed tomography scan is recommended for individuals 55 to 74 years of

1814
age who currently smoke or have smoked in the past 15 years and have at
least a 30-pack history. Shared decision-making in screening and smoking
cessation counseling for current smokers are key factors in the success of
screening and prevention (Smith et al., 2018; Wood et al., 2018).
Colon and rectal cancers are the third most common cancers in adults. In
2018, an estimated 97,220 cases of colon and 43,030 cases of rectal cancers
were expected to occur, resulting in 50,630 deaths (ACS, 2019).

The risk of developing colorectal cancer increases with age, and 90% of
all cases are diagnosed in individuals 50 years of age or older.
There are several modifiable factors associated with the increased risk
of colorectal cancer. These factors include obesity, physical inactivity, a
diet high in red or processed meat, alcohol consumption, long-term
smoking, and low intake of whole grains, fruits, and vegetables.
Other risk factors include certain inherited genetic mutations, personal
or family history of polyps or colorectal cancer, and personal history of
chronic inflammatory bowel disease.
The U.S. Preventative Services Task Force (USPSTF, 2016a)
recommends that screening for colon and rectal cancer should begin at
age 50 years for men and women who are at average risk (see
Screenings and Checkup Schedule for Women and Men on ).

1815
Chronic Lower Respiratory Diseases
Chronic lower respiratory disease (CLRD) comprises three major
conditions: chronic bronchitis, emphysema, and asthma. CLRD is the third
leading cause of death in the United States. The term chronic obstructive
pulmonary disease (COPD) includes emphysema and chronic bronchitis.
COPD is a leading cause of death, affecting over 16 million adults in the
United States. The COPD National Action Plan identified educational
interventions to inform the public on ways to prevent, diagnose, and treat this
disease (NIH, National Heart, Lung, and Blood Institute [NHLBI], 2019). By
2020, the annual cost of medical care for adults living with COPD will be
more than $49 billion (CDC, 2018a).

Cigarette smoking is the major risk factor for developing COPD,

accounting for 85% to 90% of cases. Pipe, cigar, and other types of
tobacco smoke also can cause COPD, especially if the smoke is inhaled.
The remaining COPD cases are attributable to environmental exposures
and genetic factors (American Lung Association [ALA], 2020a).
Since 2000, the number of women dying from COPD has surpassed the
number of men. Women are more vulnerable to lung damage from
cigarette smoke and other pollutants because their lungs are smaller, and
research has found that estrogen plays a role in worsening the disease
(ALA, 2020a).
The exact cause of asthma is unknown, but research indicates that both
genetic and environmental factors contribute to its cause. In the United
States, approximately 20.4 million adults have been diagnosed with
asthma and 6.1 million children under 18 years of age have asthma. The
prevalence of asthma is higher in women (10.7%) than in men (6.5%),
respectively (ALA, 2020b; CDC, 2016).

1816
Unintentional Injuries
Unintentional injuries refer to any injury that results from unintended
exposure to physical agents, including heat, mechanical energy, chemicals, or
electricity. They are the fifth leading cause of death overall and the leading
cause of death for persons 44 years of age and younger. The top three causes
of unintentional injuries include motor vehicle crashes, poisoning, and falls.
Approximately 214,000 Americans die from injury each year—one person
every 3 minutes (Fig. 21-3; CDC, 2017a, 2017b).

FIGURE 21-3 Unintentional injuries such as falls are the leading

cause of death for those aged 44 years and younger.

In 2015, 2.8 million people were hospitalized due to injuries and 27.6
million were treated in emergency departments. The costs associated
with fatal injuries were $214 billion, whereas nonfatal injury costs were
over $457 billion.
Males account for the majority of fatal injury costs (78% or $166.7
billion), as well as nonfatal injury costs (63% or $287.5 billion; CDC,
2017a, 2017b, 2020b).
Drugs, both pharmaceutical and illicit, cause the vast majority of
poisoning deaths in the United States, and the number of drug-related
deaths continues to increase. Two out of three deaths from drugs involve
opioids.
Overdose deaths from opioids have increased more than six times since
1999. In 2017, 47,000 people died from an opioid death in the United
States (CDC, 2020c).

1817
 The CDC advocates for preventing opioid overdose by improving opioid
prescribing, reducing exposure to opioids, preventing misuse of opioids, and
improving treatment modalities for opioid use disorder (CDC, 2017c). See
Chapter 25 for more on substance use.
In the United States, motor vehicle accidents are a leading cause of
death. In 2015, more than 2.5 million individuals were treated in emergency
rooms due to injuries from motor vehicle accidents.

The costs of medical care and productivity losses due to motor vehicle
accidents in a 1-year period exceeded 63 billion dollars (CDC, 2020d).
Efforts to decrease motor vehicle injuries are directed toward prevention
of motor vehicle crashes through education and policies related to seat
belts, impaired driving, distracted driving, older adult drivers, teen
drivers, and motorcycle and bicycle safety (2017f).

1818
Diabetes Mellitus
Diabetes mellitus is the seventh leading cause of death in the United States.
This chronic health condition puts individuals at risk for other serious health
conditions, including heart disease, stroke, hypertension, blindness, kidney
disease, and nervous system disease (i.e., neuropathy, which is a loss of
sensation or pain in the feet or hands).

According to the CDC (2017g), over 30 million Americans have type 1

or type 2 diabetes. Of these, 9.2 million have not been diagnosed yet.
Additionally, more than 84 million adults have prediabetes and are at
risk to develop type 2 diabetes.
Risk factors for type 2 diabetes include family history, being
overweight, age >45 years, not getting enough physical activity, and
history of gestational diabetes.
Races/ethnicities at increased risk for developing type 2 diabetes are
African American, Hispanic/Latino, American Indian, and Alaska
Native (Table 21-4; CDC, 2020e, 2020f).
The American Diabetes Association (2018) recommends screening for
diabetes for all people beginning at age 45 years and repeated every 3
years if test results are normal and for asymptomatic adults who are
overweight and/or obese. Individuals with more than one risk factor
may need to be screened more frequently.

TABLE 21-4 Estimated Diagnosed and Undiagnosed Diabetes

Among People Ages 18 Years or Older, United States, 2020
Source: Center for Disease Control (2020e).

1819
Arthritis
Arthritis is a common term used to describe joint pain or joint disease; there
are, in fact, more than 100 types of arthritis conditions, with the most
common being osteoarthritis, rheumatoid arthritis, and psoriatic arthritis
(Arthritis Foundation, n.d.). Over 54 million or 23% of all adults have some
type of arthritis, with the condition occurring more often in women and more
frequently as we age. Symptoms include swelling, pain, stiffness, and
decreased range of motion; however, symptoms come and go and may be
mild, moderate, or severe (CDC, 2019b). Arthritis may cause visible
permanent joint changes such as knobby finger joints or may be less visible
and detected only through x-ray (Arthritis Foundation, n.d.). The disease may
occur with other conditions such as diabetes, heart disease, and obesity
(CDC, 2019b). Arthritis can affect daily life including a person's ability to
work, walk, or climb stairs. Over 140 billion is spent on medical costs related
to this disease each year. Approaches to reducing arthritis pain and managing
independence may include (CDC, 2019b):

Being active
Maintaining a healthy weight
Protecting your joints
Staying educated
Pharmacological and nonpharmacological treatment options

Staying active is an important part of mitigating health issues such as

arthritis. The CDC works with national organizations such as the YMCA to
provide fitness classes that reach over 200,000 adults; efforts to address
health disparities includes bringing classes to low income and underserved
communities (CDC, 2019b).

1820
Obesity
Obesity is defined as having a body mass index (BMI) of 30 or greater and is
recognized as a national health threat and a major public health challenge in
the United States. This condition is a major risk factor for CVD, along with
certain types of cancer, type 2 diabetes, obstructive sleep apnea, and
premature death (CDC, 2020g).

According to the National Health and Nutrition Examination Survey, in

2015–2016, the prevalence of obesity among adults was 39.8%. Middle-
aged adults (40 to 59 years old) had a higher prevalence of obesity at
42.8% than young adults (20 to 39 years old) at 35.7%. The prevalence
of obesity in adults over age 60 years was 41.09% (Hales, Carroll,
Fryar, & Ogden, 2017).
Some groups have higher rates of obesity than others. Adults from
lower socioeconomic and education levels have a higher prevalence of
obesity, as do non-Hispanic Black and Hispanic adults (CDC, 2017c;
Hales et al., 2017).
Additionally, certain geographic regions have higher obesity rates than
others in the United States. The South (32.4%) and Midwest (32.3%)
have the highest prevalence of obesity, and at least 35% of adults in
Alabama, Arkansas, Iowa, Louisiana, Mississippi, Oklahoma, and West
Virginia are obese (CDC, 2019c).

Being obese can have serious health consequences; it is the leading cause
of death in the United States and worldwide (CDC, 2019d), and it is
associated with reduced quality of life and poorer mental health outcomes. In
addition, those that are obese are at increased risk for mortality, hypertension,
elevated LDL, dyslipidemia, stroke, type 2 diabetes, gallbladder disease,
osteoarthritis, CHD, sleep apnea, some cancers, and difficulty with physical
functioning (CDC, 2019d). There are also economic and societal
consequences from obesity, including medical costs associated with related
health issues and productivity concerns related to absenteeism, as well as
premature mortality and morbidity (CDC, 2019d). Healthy behaviors that
include healthy diet patterns and regular physical exercise should be
incorporated into lifestyle habits. Community environment that are safe and
offer healthy food and places for physical activity are also necessary (CDC,
2019d).
Healthy People 2030 has several objectives targeting obesity, some of
which are shown in Box 21-2.

BOX 21-2 HEALTHY PEOPLE 2030

1821
Select Objectives Related to Obesity

Reprinted from U.S. Department of Health & Human Services (USDHHS). (2020). Healthy People
2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives
According to current guidelines, adults should receive a minimum of 150
minutes (2.5 hours) of moderate intensity or 75 minutes of vigorous aerobic
exercise every week, in addition to 2 days muscle-strengthening exercises
(USDHHS, 2018). Community health nurses play an important role in
combatting obesity through educating adults on the importance of
maintaining a healthy weight, or weight reduction if indicated, through
physical activity and proper nutrition.

1822
Substance Use
In 2017, 30.5 million people aged 12 years or older used an illicit drug,
or about 1 in 9 Americans. In 2017, illegal drug use was marked
primarily by marijuana use and the misuse of prescription pain relievers.
Smaller numbers of individuals were current users of cocaine,
hallucinogens, methamphetamine, inhalants, or heroin or were misusers
of prescription stimulants or sedatives (Substance Abuse and Mental
Health Services Administration [SAMSHA], 2017a).
Men are more likely than women to use illegal drugs and have higher
rates of use or dependence on illicit drugs and alcohol than do women
(National Institute of Drug Abuse [NIDA], 2018). Not all people who
abuse illegal drugs, however, develop a substance abuse disorder (see
Chapter 25).

According to SAMHSA (2019), a substance use disorder (SUD) occurs

when the recurrent use of alcohol and/or drugs causes clinically and
functionally significant impairment such as health problems, disability, and
failure to meet major responsibilities at work, school, or home. SUD is a
serious and continuing problem among adult women and men living in the
United States. Women are just as likely as men to develop a SUD (NIDA,
2018).

In 2017, an estimated 19.7 million people aged 12 or older had a SUD

related to their use of alcohol or illicit drugs in the past year in the
United States.
The abuse of opioids, leading to opioid use disorder, has become a
national epidemic and public health concern. Approximately 2.1 million
people had an opioid use disorder, including 1.7 million people with a
prescription pain reliever use disorder and 0.7 million people with a
heroin use disorder (SAMSHA, 2017a).
The medical diagnosis of alcohol use disorder (AUD) refers to a chronic
relapsing brain disease characterized by compulsive alcohol use, loss of
control over alcohol intake, and a negative emotional state when not
using. To be diagnosed with AUD, a person must meet certain criteria as
delineated in the Diagnostic and Statistical Manual of Mental Disorders
(DSM).

Under the current version of the DSM (DSM-V), anyone meeting 2 of

the 11 criteria during the same 12-month period can be diagnosed with AUD.
The severity of AUD is outlined as mild, moderate, or severe based on the
number of criteria met (National Institute on Alcohol Abuse and Alcoholism
[NIAAA], 2017). In the United States, it is estimated that 16 million people

1823
have AUD. Approximately 15.1 million adults in the United States ages 18
and older had AUD in 2015. This includes 9.8 million men and 5.3 million
women. Adolescents can also be diagnosed with AUD. In 2015, an estimated
623,000 adolescents ages 12 to 17 years had AUD (NIAAA, 2018).
Tobacco use is another major public health problem and the leading
cause of preventable diseases and deaths in the United States.

More than 16 million Americans are living with a disease related to

smoking.
Smoking causes cancer, heart disease, stroke, lung diseases, diabetes,
and COPD. Cigarette smoking is responsible for more than 480,000
deaths per year in the United States, including more than 41,000 deaths
resulting from secondhand smoke exposure. This is about 1,300 deaths
every day (CDC, 2020h).
In 2017, an estimated 48.7 million people aged 12 years or older were
current cigarette smokers, including 27.8 million people who smoked
cigarettes daily (NIAAA, 2018). When examining cigarette smoking
based on gender, men (17.5% of males) are more likely to smoke
cigarettes than women (13.5% of females).
The total economic cost of smoking is more than $300 billion a year,
including approximately $170 billion in direct medical care for adults
and $156 billion in lost productivity due to premature death and
exposure to secondhand smoke (CDC, 2020h).
E-cigarettes (also known as e-cigs, e-hookahs, mods, vape pens, vapes,
tank system, and electronic nicotine delivery systems) are used by 2.8%
of adults in the United Sates; the product is largely used by young
adults. The product produces an aerosol by heating liquid, which usually
contains nicotine; users then inhale this aerosol. E-cigarettes are not
considered safe because they contain “harmful and potentially harmful
substances, including nicotine, heavy metals like lead, volatile organic
compounds, and cancer-causing agents” (CDC, 2020h, para. 2). Adults
may use e-cigarettes to reduce craving for regular cigarettes, but the
FDA has not approved e-cigarettes as an aid to quit smoking (CDC,
2020i).

Because of the significance of the problem, 28 of the Healthy People

2030 objectives are related to tobacco use.
The illegal use of prescription opioids, synthetic opioids (fentanyl), and
heroin is a major public health concern in the United States. A serious
national crisis exists due to the abuse and addiction of opioids.

Every day, 130 people die due to opioid overdose in the United States.
In 2017, 47,600 individuals died from an overdose of opioids and an
estimated 1.7 million people experience the disease (NIDA, 2019).

1824
 This rise in opioid overdose deaths is due to increased prescribing of
opioids in the 1990s, the rise in heroin use beginning in 2010, and
synthetic opioid (such as fentanyl) abuse stemming from 2013 (CDC,
2017c, 2019e; NIDA, 2019).
The economic aftermath of prescription opioid misuse in the United
States is estimated at $78.5 billion a year, including the costs of health
care, lost productivity, addiction treatment, and criminal justice
involvement (NIDA, 2019 ).

The full extent of the damage of the opioid crisis goes beyond
economics, influencing family and community life and placing an extreme
strain on community resources, including first responders, emergency rooms,
hospitals, and treatment centers.
In response to the opioid crisis, the USDHHS is focusing efforts on:
1. Improving access to treatment and recovery services 2. Promoting use of
overdose-reversing drugs 3. Strengthening understanding of the
epidemic through improved public health surveillance 4. Providing
support for innovative research on pain and addiction 5. Initiating better
practices for pain management
In 2018, the NIH launched HEAL (Helping to End Addiction Long-term)
Initiative, an aggressive, trans-agency effort to increase scientific solutions to
positively impact the national opioid public health crisis (NIH, 2018).

1825
WOMEN'S HEALTH
Women have not been the focus of medical attention throughout history.
Health benefits achieved by women were incidental compared with those of
men. Advances in women's health are very recent and primarily an advantage
for women living in Western countries, where the women's or feminist
movement has made major inroads (Fig. 21-4).

FIGURE 21-4 Women's health has not historically been the focus
of health care research.

1826
Overview of Factors Influencing Women's Health
Women's rights in the United States started in the second half of the 19th
century and over time addressed issues directly or indirectly impacting the
health of women: voting rights, labor laws, reproductive rights, and violence
against women (International Women's Day, n.d.). This section of the chapter
examines women's health concerns over the adult life span, the major causes
of acute and chronic illness and death, and the issues, trends, and policies
that have affected and currently affect women. For a discussion of how
research in genomics and pharmacogenomics is being applied to women's
health, see Box 21-3.

BOX 21-3 Evidence-Based Practice

Genomics and Pharmacogenomics An
individual's genome consists of their entire set
of DNA, including all genes. Genomics
considers how a person's genes interact with
each other, the individual's environment and
their behaviors, such as diet and exercise, to
influence growth, development, and health
(WHO, n.d.). This is different than genetics,
which considers the function and composition
of a single gene. Discoveries made in the field of
genomics allow health care providers to
translate research to clinical practice. For
example, genomics has increased understanding
of why individuals with the same disease may
not respond similarly or have the same
treatment outcomes, guiding individualized
treatment. It also assists in the identification of
individuals with increased risk for the
development of certain diseases based on gene
mutation, gene interaction, and environment, to

1827
develop individualized prevention and
treatment strategies. These advances in science
and technology have allowed health care to
increase its focus on the delivery of
individualized care and prevention, known as
precision medicine (CDC, 2020n; NIH, 2019b;
NIH, NCI, 2017).
Nurses and other health care providers use genomics routinely in
practice. In the community setting, the nurse may educate women about
breast cancer and risk factors, providing information about genetic
testing for women with a family history. Health care providers partner
with women who have BRCA1 or BRCA2 gene mutations to
individualize breast and ovarian cancer prevention and screening. The
same is true for those with a strong family history of heart disease.
Careful family and personal health histories may guide health care
providers to recommend testing for Familial Hypercholesterolemia
(FH). Individuals with gene mutations causing FH need targeted
treatment to prevent adverse cardiac events. Nurses play a key role in
patient education to assist the individual with FH in reducing or
eliminating modifiable risk factors that could also contribute to
cardiovascular disease.
Another important aspect of genomics is pharmacogenomics, which
considers information about an individual's genome to guide decision-
making in medication and dose selection. The utilization of
pharmacogenomics to guide treatment has become routine for some
disease states and/or medications. Examples of utilizing
pharmacogenomics to guide treatment include:

Avoiding primaquine and other medications known to cause acute

hemolytic anemia in individuals with G6PD deficiency, caused by
an alteration of the G6PD gene.
Choosing an HIV medication other than abacavir for individuals
with an HLA-B*57:01 allele due to increased risk for developing a
severe hypersensitivity reaction.
Adjusting warfarin dose in individuals with CYP2C9 or VKORC1
gene variations to avoid increased bleeding risk (Dean, 2018; FDA,
2018b; NORD, 2017).

Individualizing patient care based on genomics and

pharmacogenetics will continue to increase as the availability of

1828
 genomic data expands. It is essential for nurses to have an
understanding of genomics and pharmacogenomics in order to answer
questions appropriately and provide appropriate and individualized
health promotion and disease prevention education.
Source: Centers for Disease Control and Prevention (2020n); Dean (2018); Food and Drug
Administration (FDA) (2018b); National Institutes of Health (NIH) (2019b); National Institutes
of Health, National Cancer Institute (NIH, NCI) (2017); National Organization for Rare
Diseases (NORD) (2017); World Health Organization (WHO) (n.d.).

Women's health is still overlooked in much of the world. Only in the past
few decades has the health of women been a formidable issue in the United
States, coming not so coincidently with the modern women's feminist
movement that began in the 1960s.

The landmark 1963 publication The Feminine Mystique helped launch

the modern women's movement by critically examining the role of
women in American society (Foster, 2015; Friedan, 2013). The Boston
Women's Health Book Collective's Our Bodies, Ourselves (initially
released in 1973) represented the first book to explore women's health
issues, exclusively written by and for women. In addition, this
publication served as a model for women who wanted to learn about
themselves, communicate their findings with doctors, and challenge the
medical establishment to change and improve the care that women
received (Our Bodies Ourselves, n.d.).
To further expand the dialogue regarding women's health, consumer
activists created the National Women's Health Network in 1975,
primarily to shape health policy and support consumer health decisions
(National Women's Health Network, 2018). These historical
occurrences likely contributed to more female researchers and women
as participants in research.
Feminists paved the way for women to have their voices heard on many
health, social, and political issues. Women sought out higher-education
opportunities in greater numbers and entered workplaces once solely
occupied by men, especially during and after World War II.
These positive changes escalated women toward greater equality, and
with equality came the freedom—and pressure—for women to compete
with men in their social and work settings. Issues related to women's
health were discovered as a result of research that now more regularly
includes women.
The importance of women's health research was reaffirmed in the NIH's
Revitalization Act of 1993, Subtitle B—clinical research equity
regarding women and minorities to “identify projects for research on
women's health that should be conducted or supported by the national
research institutes; identify multidisciplinary research relating to

1829
research on women that should be so conducted or supported …” (NIH,
1993, section 486).

1830
Women's Health Research
In response to changing priorities, researchers have designed and
implemented major studies that focus exclusively on women. Five significant
studies have provided and continue to provide important health information
about women:

The Women's Health Initiative (WHI) was a major research program

addressing the most common causes of death, disability, and poor
quality of life in postmenopausal women—CVD, cancer, and
osteoporosis (WHI, n.d.).
The Women's Health Study (WHS) evaluated the effects of vitamin E
and low-dose aspirin therapy in primary prevention of CVD and cancer
in apparently healthy women (WHS, n.d.).
The Nurses' Health Study (NHS) I involved investigating risk factors for
cancer and CVD, and the NHS II researched diet and lifestyle risk
factors in a population younger than the original NHS cohort (NHS,
2016).
The NHS III is currently investigating women's health issues related to
lifestyle fertility/pregnancy, environment, and nursing exposures (NHS,
2016).

The WHI addressed CVD, cancer, and osteoporosis and was one of the
largest prevention studies of its kind in the United States, starting in 1991
and spanning 15 years. This study was sponsored by the NIH and the
NHLBI, involved 161,808 women ages 50 to 79 years, and was considered to
be one of the most far-reaching clinical trials for women's health ever
undertaken. To date, more than 616 publications have been associated with
findings from this study, which address coronary artery calcium, breast
cancer risk, colorectal cancer, venous thrombosis, peripheral arterial disease
risk, risk of CHD, dementia and cognitive function, and the effects of
estrogen alone in reducing the risk of CHD (National Center for
Biotechnology Information, 2017; WHI, n.d.).
The WHS was a randomized, double-blind, placebo-controlled clinical
trial sponsored by the NHBLI and the NCI. It was the first large clinical trial
to study the use of low-dose aspirin to prevent heart attack and stroke in
women 45 years of age and older. This study began in 1991 and continued
through March 2009 for additional observation and follow-up of the original
28,345 participants. Findings indicated that low-dose aspirin does not
prevent first heart attacks or death from cardiovascular causes in women;
however, stroke was found to be 17% lower in the aspirin group. More than
110 professional articles are associated with this investigation. Recent
publications address the association of dietary fat intake with risk of atrial

1831
fibrillation in women and the novel protein glycan biomarker and future
CVD events (WHS, n.d.).
The NHS (three separate phases) represents the longest running study
related to women's health in the world, investigating factors that influence
the health of women.

The NHS I, a prospective study that began in 1976, enrolled registered

nurses aged 30 to 55 years. Every 2 years, participants received a
follow-up questionnaire with questions about diseases and health-
related topics including smoking, hormone use, and menopausal status.
Later in the study, questions regarding diet and nutrition and quality of
life were added.
The NHS II represented women who started using oral contraceptives in
adolescence, a population with long-term exposure during early
reproductive years. Women, aged 25 to 42 years, were enrolled and
followed forward in time. Every 2 years, participants received a follow-
up questionnaire and were surveyed about diseases and health-related
topics including smoking, hormone use, pregnancy history, and
menopausal status.
The NHS III began recruitment in 2010 and will continue until 100,000
nurses (registered and licensed practical, 22 to 45 years of age) are
enrolled. Also, nurses from Canada are participants and the study aims
to be more representative of the diverse backgrounds of nurses. These
studies are supported by major nursing organizations, with more than
280,000 participants to date (NHS, 2016).

1832
Women's Health Promotion Across the Life Span
What health care needs do women have that are different from those of men?
Is there a need to look at health promotion throughout the life cycle of adult
women? How is the health of an 18-year-old different from that of a 50-year-
old woman? Most of us would have no trouble agreeing that women have
different health care needs that must be considered and that these concerns
vary with age. Knowing what the needs are is essential to knowing how to
help women promote their health.

Healthy People 2030 Goals for Women

As a nation, we have been focusing on improving the health of all citizens
through the Healthy People initiatives, commencing with the 1979 Surgeon
General's report, Healthy People: The Surgeon General's Report on Health
Promotion and Disease Prevention, providing measurable population
objectives. Healthy People 2000 set a standard for change and improvement
in objectives that were met or exceeded in some areas and were far from
being reached in others. In that initiative, objectives in 14 areas focused
specifically on women's health. Healthy People 2010 focused on two
overarching goals: increasing the quality of life and eliminating health
disparities, containing 25 objectives relating to women. Healthy People 2020
reaffirmed the goals of 2010 and added two additional goals: quality of life,
healthy development, along with healthy behaviors across the life span and
creating social and physical environments that promote good health
(USDHHS, 2015). In the nation's fourth generation of health planning, 35
objectives pertain to the health of women (Box 21-4). As the community
health nurse works with women at various stages in the life cycle, the
objectives in Healthy People 2030 can give structure to program planning
and services offered to women in the community at the primary, secondary,
and tertiary levels of prevention.

BOX 21-4 HEALTHY PEOPLE 2030

The Objectives for Women

1833
Reprinted from U.S. Department of Health & Human Services (USDHHS). (2020). Healthy People
2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

Young Adult Women (18 to 35 Years)

Women in the earlier years of adulthood have different tasks to accomplish
and issues to address than women in later adulthood, and the transition from
adolescence to adulthood can be stressful. There are major developmental
tasks that young women need to accomplish such as forming an identity and
the development of intimacy. Behaviors associated with young adulthood
include completing postsecondary education, choosing and establishing a
career (Fig. 21-5), choosing a significant other for the long term, establishing
a household, and planning for children by using a variety of parenting
models (childbirth, adoption, foster parenting). During this time, women also
develop a personal philosophy that encompasses meaningful and comforting
spiritual beliefs that are consistent with day-to-day living (Berk, 2018).

1834
 FIGURE 21-5 Choosing a career path is one developmental task
for young adults.

Women in this age group tend to be healthy. Unfortunately, during this

period, many women engage in health risk behaviors such as physical
inactivity, eating poorly, participating in unprotected sexual intercourse, and
smoking (Box 21-5). Some, if not all, of these behaviors may have been
established in adolescence and represent modifiable behaviors. If not
addressed, poor lifestyle choices can contribute significantly to the leading
causes of morbidity and mortality: diseases of the heart and vascular systems,
cancers, chronic respiratory diseases, and diabetes (CDC, 2019f). The
majority of health concerns for many women in this age group are related to
eating disorders, reproductive health and sexually transmitted infections
(STIs), physical activity, mental health and mood disorders, and substance
use.

BOX 21-5 What Do You Think?

Fad Diets Each year, approximately 45 million
Americans begin a diet. Fad diets have been
around for centuries and don't seem to be going
anywhere. Every year new diets promise results,
but do they work and are they safe?
In 2018, the ketogenic diet (keto) made its way back into mainstream.
This is a high-fat, low-carbohydrate diet that eliminates sugar,
grains/starches, fruits, beans/legumes and encourages high-fat foods such
as eggs, nuts, meats/fish, full-fat dairy and cheeses, and healthy oils. Low-

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carb vegetables are also encouraged. The goal is to reach ketosis by
replacing dietary carbs with fats. Benefits may include weight loss and
decreased glucose and insulin levels. There are conflicting studies
reporting benefits and risks of the ketogenic diet. While individuals
adhering to this diet lose weight, once carbohydrates are re-introduced, the
resulting side effect is often weight gain. Research has shown both
increase and decrease in LDL cholesterol, as well as the development of
insulin resistance, and nonalcoholic fatty liver disease.
The paleolithic diet is known by a few different names and continues
to be a popular option among individuals trying to lose weight. This is a
low-carbohydrate, high protein diet that encourages high consumption of
lean meats and vegetables, moderate consumption of fruits, nuts, and
seeds, and abstinence from dairy, legumes, and grains. While it has many
of the same attributes of keto, it is higher in protein and lower in fat.
Evidence suggests that maintaining a low carbohydrate diet, such as the
paleo or ketogenic diet, long term may increase mortality from
cardiovascular disease, stroke, and cancer, when compared to higher
carbohydrate diets. However, the source of carbohydrate intake, whole-
food versus highly processed, must be considered and whole-food sources
recommended as an individual's main carbohydrate intake.
The plant-based, or vegan, diet has gained momentum in recent years
and eliminates all animal products including meat, eggs, and dairy. It is
rich in fruits, vegetables, nuts, seeds, legumes, and plant proteins. While
there are variations of veganism, such as whole-food plant-based or raw,
there are many vegan “junk foods” or processed vegan replacement foods
that can cause more harm than good. Adherence to a plant-based diet that
is not heavily based on processed vegan foods may reduce weight and help
manage or eliminate chronic disease.
Other recent dieting trends include intermittent fasting, juicing,
detoxing, and gluten-free diet. Whether individuals ask about the health
benefits or adverse effects of diets they are following or considering, it's
important to encourage them to research potential nutritional deficiencies
certain diets may cause. This allows for intentional monitoring for dietary
deficiencies and supplementation if needed. For example, individuals
following a ketogenic diet may not be consuming sufficient amounts of
fiber or vitamins and minerals found in fruits and vegetables. Vegans may
need to supplement or be intentional about consuming vitamins B12 and
D3, omega-3 fatty acids, iron, and calcium.
Do you know someone who seems to always be trying the latest diet?
Is that person successfully losing weight or in a constant weight
loss/weight gain cycle? As a C/PHN, how would you approach this
subject?

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 Source: Gunnars (2018); Kosinski and Jarnayvaz (2017); Mauer (2018); Mazidi, Katsik,
Mikhailidis, and Banach (2018); T. Collin Campbell Center for Nutrition Studies (2018).

Eating Disorders
Eating disorders are complex, chronic illnesses primarily affecting young
women. There is no single cause of these disorders; however, several things
may contribute: culture, personal characteristics, emotional disorders,
stressful events, biology, and families. The three most common are anorexia
nervosa, bulimia nervosa, and binge eating.

Anorexia nervosa is characterized by marked by weight loss,

emaciation, a disturbance in body image, and a fear of weight gain.
Persons affected lose weight either by excessive dieting or by purging
themselves of ingested calories. This illness is typically found in
industrialized nations and usually begins in the teen years. Young
women are 10 to 20 times more likely than young men to experience
anorexia. Refusal to maintain body weight can be life threatening due to
electrolyte disturbances, anemia, and secondary cardiac arrhythmias.
Low body weight can impair insulin production, leading to amenorrhea
(absent menstrual periods) and decreased bone density (National
Institute of Mental Health, 2016, 2018; Office on Women's Health,
2018a).
Bulimia nervosa is characterized by recurrent episodes of binge eating,
self-induced vomiting and diarrhea, misuse of laxatives or diuretics,
excessive exercise, strict dieting or fasting, and an excessive concern
about body shape or weight. Females in cultures where emphasis is
placed on a certain ideal of beauty, individuals who have been sexually
abused or come from families with a history of eating disorders, and
individuals with low self-esteem and a history of not being “in control”
or with communication and emotional difficulties are at greater risk (
Office on Women's Health, 2018b; SAMHSA, 2017b).
Binge eating is the most common eating disorder in the United States,
with typical onset in late adolescence and early 20s. It is characterized
by repeated episodes of uncontrolled eating including eating large
amounts quickly, when not hungry, and until comfortably full. Many
individuals with this disorder have difficulty expressing their feelings,
have difficulty controlling impulses and stress, and feel depressed about
overeating. Obesity is common because purging is not a characteristic
of this disorder. This disorder results in increased risk for type 2
diabetes, high cholesterol, osteoarthritis, kidney disease or renal failure,
heart disease, and hypertension (Office on Women's Health, 2018c;
SAMHSA, 2017b).

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 In general, females have a higher rate of eating disorders than males.
However, millions of men and boys battle all forms of this illness. The
community health nurse can play a vital role in identifying affected persons
and refer these individuals to appropriate health care providers, mental health
counselors, and self-help groups. Screening tools that may help identify
individuals requiring referral for further assessment are available (National
Eating Disorder Association, 2018).

Reproductive Health
During the reproductive years, it is important for both women and men to be
as healthy as possible (Fig. 21-6). During this time, healthy habits can be
initiated, and unhealthy habits resolved to ensure the best health during the
years individuals focus on having children. Preconception health is important
for all women of reproductive age, not just those planning to become
pregnant, because it focuses on getting healthy and staying healthy (CDC,
2020j).

FIGURE 21-6 Good health is important during pregnancy.

Although preconception care is addressed in Healthy People 2030, many

of the preconception objectives are related to family planning and maternal
health. The CDC has developed a checklist for women of reproductive age to
commit to healthy preconception activities including (CDC, 2020j):

Make a plan and take action

See a health care provider
Take 400 μg of folic acid every day
Stop smoking, using drugs, and drinking excessive amounts of alcohol
Avoid toxic substances
Reach and maintain a healthy weight

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 Get help for violence
Learn family history
Get mentally healthy
When ready, plan pregnancy

Community health nurses have been at the forefront of maternal and

child health care for decades, and they must continue to strive to incorporate
components of preconception care into their practices. Nurses must also
advocate for clients to influence public policy, which has the potential to
improve access to care for many women and improve pregnancy outcomes.
Sexual health and STIs are important health concerns for young women.
Sexual activity typically commences in adolescence and continues
throughout the life span. STIs are epidemic in the United States, especially
among young adults (see Chapter 8).

Human papillomavirus (HPV) is the most common STI in the United

States. Approximately 79 million Americans are infected with HPV,
resulting in 10,800 cases of cervical cancer and 300,000 high grade
cervical lesions annually. Gardasil 9 is a two or three dose vaccine that
can prevent 90% of cervical cancers, as well as anogenital warts.
Gardasil 9 is now approved for individuals 9 to 45 years old (CDC,
2019g; FDA, 2018a).
Chlamydia and gonorrhea are also common STIs affecting women.
Rates for both these STIs have increased in women in recent years.
Chlamydia is the most reported nationally notifiable disease in the
United States, with more than 1.7 million cases in 2017.
The rate of gonorrhea is lower than chlamydia, but in 2017, there were
555,608 cases reported, making it the second most nationally reported
notifiable disease in the United States. Both chlamydia and gonorrhea
are underdiagnosed, which can have deleterious consequences for
women. If treatment is delayed, women can develop pelvic
inflammatory disease, chronic pelvic pain, ectopic pregnancy, and
infertility (CDC, 2017d, 2018b). See Chapter 8 for more information on
communicable diseases.

Routine screening recommendations for STIs in women include the

following:

HPV: screen women 30 to 65 years old every 5 years with high-risk

HPV testing (alone or with cytology screening; USPSTF, 2018a)
Chlamydia and gonorrhea: annual screening for women under age 25
years or older women with risk factors (CDC, 2017d; USPSTF, 2016b)
HIV: screen individuals aged 15 to 65 years; annual screening if high
risk; younger or older depending on risk factors (USPSTF, 2018b)

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 Community health nurses working with adult women should provide
factual information to increase women's knowledge of STI risk. This
information should be a part of frank discussions regarding condom use,
sexual partners (male and female), type of sexual activity (oral, anal,
vaginal), life-threatening consequences of an undiagnosed STI, and
undesirable pregnancy outcomes. Outside of abstinence, condom use is the
first line of prevention against STIs. See Chapter 8 for more on
communicable diseases.

Adult Women (35 to 65 Years)

Women in the adult age group of 35 to 65 years have established themselves
into patterns of living that have served them well or ill. During this period,
the results of years of choices may present themselves in the form of chronic
illnesses. Nevertheless, many women in this age group have time to change
health habits to possibly reverse encroaching chronic illnesses (Fig. 21-7).
For other women, lifestyle choices and undetected diseases have shortened
their life spans, and large numbers of women in this age group are dying
prematurely.

FIGURE 21-7 Menopause is transitional period in a woman's life,

and healthy diet and exercise are important.

Adult women demographics are shifting. An increasing number of

educated women are having children, and they are having them later in life;
they are also spending more time in the work force before they have children.
Births within the United States are decreasing; however, foreign-born births
are increasing. In the United States, one in four mothers is solo mother,
raising children on their own. Typical stereotypes are also shifting as
working women face pressure to be more involved as mothers, while men are

1840
more involved in childcare and housework than in the past (Pew Research
Center, 2020a). Women in the developmental stage between 35 and 65 years
of age may face many challenges including:

Caring for aging parents

Supporting young adult children
Family–work role conflict
Economic burden for single mothers
Gender gap
Parenting pressure (Pew Research Center, 2020b)

Menopause and Hormone Replacement Therapy

Perimenopause, or menopausal transition, is the period of time leading
up to the last menstrual cycle and is characterized by cycle changes and
irregularity. Women typically begin to notice symptoms of
perimenopause in their 40s. Menstrual flow may be light or heavy, and
spotting may occur, depending on varying estrogen and progesterone
levels. Women may also have vasomotor symptoms such as hot flashes
(flushes) or night sweats and climacteric symptoms such as experience
sleep disturbances and vaginal and urinary tract changes (American
College of Obstetricians and Gynecologists [ACOG], 2018a; Martin &
Barbieri, 2019). The average length of perimenopause is 4 years but
may last up to 10 years.
Menopause is a time that marks the permanent cessation of menstrual
activity (last menstrual period). The average age is 51 years (range = 45
to 58); however, it can occur earlier (Office on Women's Health, 2018d).
Natural menopause is defined as cessation of menstrual periods for 12
consecutive months, with no other apparent cause.
Menopause symptoms differ among women and may last months
to years. They range from hardly noticeable in some women to
very severe in others. Symptoms include nervousness or anxiety,
hot flashes (flushes), chills, excessive sweating (often at night),
excitability, fatigue, mood disorders (apathy, mental depression,
crying episodes), insomnia, palpitations, vertigo, headache,
numbness, tingling, myalgia, urinary disturbances, and vaginal
dryness (ACOG, 2018a; Office on Women's Health, 2018d).
According to the Study of Women's Health Across the Nation
(SWAN), hot flashes and some of the other menopausal symptoms
last an average of 7.4 years, persisting 4.5 years once menopause is
reached. However, these symptoms may persist for longer,
particularly in African American women and those who are
overweight or obese (Santoro, 2016).

1841
 The Endocrine Society recommends diagnosis of menopause based on
the cessation of menstruation for 12 consecutive months. Recommendations
for women in the menopausal transition include discussions about
menopausal symptoms, osteoporosis, cancer screening, and assessment for
CVD; along with a determination of the need for appropriate menopausal
hormone therapy (MHT) (Stuenkel et al., 2015). For women under age 60,
or who are <10 years past onset of menopause, with bothersome menopausal
symptoms, MHT may be an appropriate treatment option. Health care
providers must take patient risk for CVD, venous thromboembolic events,
and breast cancer into account when considering initiation or continuation of
MHT and should use a shared decision-making approach (Martin & Barbieri,
2019). At this time, ACOG recommends against the use of MHT as primary
or secondary prevention of heart disease or osteoporosis (ACOG, 2018b).
Women who are not candidates for oral MHT may be able to use transdermal
routes or nonhormonal therapies to relieve symptoms, depending on risk
factors and contraindications.

Some women choose to use bioidentical hormone therapy—chemically

similar hormones derived from plants—that may (e.g., micronized
estradiol and progesterone) or may not be approved (e.g., Triest, Biest,
pregnenolone) by the Food and Drug Administration (FDA).
Current evidence does not support the use of bioidentical hormone
therapy over conventional MHT (ACOG, 2018c; Martin & Barbieri,
2019).
Women may also choose natural products (e.g., phytoestrogens, black
cohosh, DHEA, dong quai, vitamin E) for symptomatic relief. Women
choosing natural or herbal supplements should be counseled on lack of
evidence supporting efficacy and long-term safety, as well as potential
side effects and drug interactions (National Center for Complementary
and Integrative Health, 2018).
Other complementary health approaches women may choose for
menopausal symptom relief includes hypnotherapy, meditation, yoga,
and acupuncture.

Osteoporosis
A gradual loss in bone density is known as osteoporosis. Typically,
bone mass stops increasing around age 30 years. As women age, bones
may weaken and easily fracture as estrogen levels decrease.
In the United States, 1 in 4 women over the age of 65 years has
osteoporosis (CDC, 2020k). Therefore, it is important for women to
build strong bone early. Bone density is influenced by many factors
such as heredity, race/ethnicity, physical activity, and nutrition. It is

1842
 important for women of all ages to maintain a healthy diet that is rich in
calcium and vitamin D, engage in physical activity, and avoid smoking.
There are several classes of medications that can be used to treat
osteoporosis: bisphosphonates (helps build bone mass), selective
estrogen receptor modulators (slows rate of bone loss), calcitonin (slows
rate of bone loss), and teriparatide (helps build up new bone).
The USPSTF recommends screening for osteoporosis in women over
the age of 65 years, or in postmenopausal women under age 65 years
with increased risk for osteoporosis-related fractures (USPSTF, 2018b).
See Chapter 22 for more on osteoporosis in older women.

Heart Disease
Heart disease is the number one killer of women, causing the death of
295,995 females in 2016 (Xu et al., 2018). The most common heart
problem, CHD, is underdiagnosed, undertreated, and under-researched
in women.
In addition, women have a higher mortality rate after heart attack and
poorer outcomes than do men, and this may be related to delayed
diagnosis and treatment.
Risk factors for heart disease in women are age, family history,
race/ethnicity, physical inactivity, sleep apnea, obesity, diabetes
mellitus, high blood pressure, high cholesterol, and cigarette smoking
(Office on Women's Health, 2018e).

Family history, race/ethnicity, and advancing age cannot be changed, but

women can make lifestyle changes to alter other risk factors. The remaining
risk factors are issues that the community health nurse can discuss with
female clients in this age group. Community health nurses can help raise
awareness regarding heart disease when working with women at the
individual, family, or aggregate levels. Some important facts that can be
shared are as follows:

Heart disease accounts for 1 in 5 female deaths in the United States

(CDC, 2019c).
In the United States, approximately 1 in 16 Black, White, and Hispanic
women over the age of 20 years have CHD (CDC, 2019c).
The average age for first heart attack in females is 72.0 years (Benjamin
et al., 2018).
In all age groups, mortality rate for women following a heart attack is
higher than in men (Office on Women's Health, 2018d).
Almost two thirds of women who suddenly die from heart disease have
had no previous symptoms (CDC, 2019c).

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 Heart disease is sometimes thought of as a “man's disease,” but about
the same number of women and men die each year of heart disease
(CDC, 2019c).
Women may have atypical heart symptoms or less acute chest pain,
which may delay them from seeking care (Office of Women's Health,
2019).
MHT may increase risk of heart attack, stroke, and blood clots (Office
of Women's Health, 2018f).
Nine out of 10 women have at least one risk factor for heart disease
(NIH, NHLBI, 2019).

An excellent lay resource is “Go Red for Women,” a public awareness

program of the AHA to help improve knowledge (AHA, 2018). Also, Well-
Integrated Screening and Evaluation for Women across the Nation
(WISEWOMAN), a CDC program that helps women with little or no health
insurance reduce their risk for heart disease, stroke, and other chronic
diseases (located in 21 sites across 19 states), can be helpful. The program
assists women ages 40 to 64 in improving their diet, physical activity, and
other behaviors (Fig. 21-8). This program also provides cholesterol tests and
other screening (CDC, 2020K, 2020L ).

FIGURE 21-8 A healthy diet is an important part of health

promotion.

Cancer
Cancer is the second leading cause of death for women, estimated to kill
286,010 females in the United States in 2018. The majority of cancers
(87%) occur in persons 50 years of age and older.

1844
 An estimated 38% of women in the United States will develop cancer in
their lifetime. To help address this disparity, community health nurses
can provide more opportunities for education and screening for this
population. Screening has reduced the deaths for cancers of the breast,
colon, rectum, and cervix (ACS, 2019).
Breast cancer is the most common cancer among women; however,
more women die of lung cancer. In 2018, it is estimated that 40,920
deaths related to breast cancer will occur (SEER, n.d.a).

Overall, the death rates from breast cancer have declined since 1990, and
the biggest decline was among women under 50 years of age (Table 21-5).
This can be attributed to early detection and improvements in treatment. The
sooner breast cancer is discovered, the more successfully it is treated. By
obtaining regular clinical breast exams and mammograms, eating a diet low
in fat and high in fruits and vegetables, breast-feeding (if possible), and
avoiding prolonged use of MHT, a woman is doing what she can to promote
breast health.

TABLE 21-5 Breast Cancer Death Rates Among All Women:

2013–2017

Source: Cancer Statistic Center (2018); Surveillance, Epidemiology, and End Stage Program (SEER)
(n.d.a).

Although breast self-examination (BSE) is no longer a routine screening

recommendation, it is important that women are familiar with their
breasts. This allows them to recognize any overt changes in their
breasts, especially changes related to size, shape, symmetry, and nipple

1845
 discharge. The community health nurse has many resources available to
provide information and to teach women breast awareness in their
homes, small groups in clinics, or in various other community settings
to enhance knowledge of breast health (ACS, 2020a). See Chapters 11
and 12 for more on breast cancer screening.

Breast cancer screening is important for early detection when tumors are
likely to be smaller and confined to the breast. Early detection is associated
with better prognosis for survival. The USPSTF (2016c) published the
following breast cancer screening recommendations for women of average
risk:

Women, age younger than 50 years: should be an individual decision

and the patient's context (risk for disease) should be taken into account
(Grade C).
Women, aged 50 to 74 years: biennial screening with mammography
(Grade B).
Women, aged 75 years and older: evidence is insufficient to assess the
benefits and harms of screening mammography (Grade I; USPSTF,
2016c).
Women who have a first-degree relative with breast cancer (mother,
sister), have a breast cancer gene (BRCA1 or BRCA2), or have had
previous breast cancer are at a higher risk for developing the disease
than other women in the general population. Therefore, these
individuals need to consult their physicians regarding timelines for
screenings (ACS, 2020a).

Cervical cancer screening has improved early detection and prevention

of cervical cancer dramatically. Both the incidence and the death rates for
cervical cancer have declined in recent decades because of treatment of pre-
invasive cervical lesions. The major risk factors for this disease are infection
with certain types of HPV, unprotected intercourse at an early age, and
multiple sex partners. In 2018, it is estimated that 13,240 new cases of
invasive cervical cancer will be diagnosed in the United States, contributing
to 4,170 deaths among women from this disease. The 5-year survival rate for
this cancer, if prompt treatment is initiated, is 66.2% for all stages and 91.7%
for local infiltration, making it one of the most successfully treated cancers
(SEER, n.d.b). The USPSTF published the following cervical cancer
screening recommendations:

Women younger than 21 years: recommend against screening (Grade D)

Women age 21 to 29 years: every 3 years with cervical cytology (Grade
A)
Women age 30 to 65 years: every 3 years with cervical cytology alone,
or every 5 years with high-risk human papillomavirus testing (hrHPV),

1846
 or every 5 years with hrHPV and cytology combination (Grade A)
Women older than 65 years: recommend against screening with
adequate screening previously and not at high risk (Grade D) (USPSTF,
2018c)

C/PHN can continue to improve screening and early diagnosis through

education and advocating for low-cost screening, which will allow at-risk
low-income and rural women access to regular cervical cancer screenings. In
addition to screening, educating women about the HPV vaccine is an
important strategy to reduce the incidence of cervical cancer. The Gardasil 9
vaccine protects against 9 HPV virus types that may cause cervical cancer
and anogenital warts. It is started as early as age 9 and given as two (age 9 to
13) or three doses (age 14 and older) over 6 months. Previously, the HPV
vaccine was only available for individuals age 9 to 26; however, in 2018, the
FDA approved the expanded use of Gardasil 9 to also cover males and
females age 27 to 45 years (FDA, 2018a; Merck Sharp & Dohme
Corporation, 2018).

Ovarian cancer contributes to more deaths than any other cancer of the
female reproductive system and accounts for 5% of cancer deaths
among women. In 2018, a total of 22,240 cases were anticipated and
14,070 deaths were expected.
The primary risk factor for this disease is heredity, or a strong family
history of breast or ovarian cancer. The 5-year survival rate is 47.4%
compared to cervical (66.2%) and breast (89.9%) cancers.
The USPSTF recommends against routine screening for ovarian cancer
in women who do not have symptoms. However, women considered at
high risk should receive a pelvic exam, a transvaginal ultrasound, and a
blood test for the tumor marker CA 125. Therefore, C/PHNs need to
continue to stress the importance of early detection (SEER, n.d.c; Torre
et al., 2018; USPSTF, 2018d).

Myalgic Encephalomyelitis/Chronic Fatigue

Syndrome
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a
chronic and debilitating disease characterized by fatigue lasting for 6 or
more months, worsening of symptoms after exertion and unrefreshing
sleep. Other symptoms may include cognitive impairment, orthostatic
intolerance, frequent sore throat, headache, painful muscles, and joint
pain. It is estimated that between 836,000 and 2.8 million persons in the
United States have ME/CFS, with women affected up to four times
more than men.

1847
 Symptoms may last for months or years, waxing and waning and are
difficult to validate objectively, but they are subjectively debilitating.
Because the cause is unknown, there is no specific treatment and no
prevention suggestions.
Treatment is focused on supportive care for the associated pain,
depression, and insomnia. The Solve ME/CFS Initiative provides
support and information for women and is one of seven organizations
that contributed to Impact of Chronic Overlapping Pain Conditions on
Public Health and the Urgent Need for Safe and Effective Treatment, a
report that raises awareness of chronic pain conditions that
disproportionately impact women.

The community health nurse can assess activity level and degree of
fatigue, emotional response to the illness, and coping ability. Emotionally
supportive family members and health care providers are helpful. Referring
women to mental health counseling or a local support group is useful for
many women and within the role of the community health nurse (CDC,
2019h; Chronic Pain Research Alliance, 2015; Institute of Medicine, 2015;
Solve ME/CFS Initiative, 2018).

1848
MEN'S HEALTH
Gender is among the numerous factors that influence health. More male
neonates die at birth, and men are more likely to die earlier from a chronic
illness than women (Fig. 21-9). This is evidenced by the difference in life
expectancy between men and women in the United States; women survive an
average of 5 years longer than men (CDC, 2017e; Xu et al., 2018).

FIGURE 21-9 Men have different health care needs at various

stages of life.

1849
Overview of Factors Influencing Men's Health
Masculinity is an influencing factor in men's health. Men are socialized to be
independent and conceal their vulnerability. Therefore, even when they are
aware of personal physical or mental health problems, they are less likely to
access the health care system. How the male identity is maintained can
include activities that are hazardous to their health, and the result is a high
death rate from unintentional injuries among young men. Examples of these
activities include substance use, use of firearms, excessive alcohol
consumptions, and smoking (CDC, 2017e; Xu et al., 2018).

1850
Men's Health Promotion Across the Adult Life
Span
In the early years of young adulthood (between 18 and 35 years), men
continue to grow and mature. Adult men aged 35 to 65 years have reached
maturity, the peak of their physical and intellectual development, and their
greatest earning power. What specific needs do men in these age groups
have? Are their needs being met through provided services?

Healthy People 2030 Goals for Men

Healthy People 2030 addresses men's health through family planning, STD,
LGBT, and adult health issues such as mental health, substance abuse and
opioids, tobacco, nutrition, physical activity, chronic diseases, and cancer
(Box 21-6).

BOX 21-6 HEALTHY PEOPLE 2030

The Objectives for Men

Reprinted from U.S. Department of Health & Human Services (USDHHS). (2020). Healthy People
2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objective

Young Adult Men (18 to 35 Years)

The young adult male has many tasks to accomplish including:

1851
 Acquisition of training/education leading to a personally and financially
rewarding career
Selecting a compatible companion and establishing a life together (Fig.
21-10)
Practicing and internalizing a belief and value system that brings
comfort and meaning to existence
Actively planning for having (or not having) children
And participating in the betterment of the greater community

FIGURE 21-10 Choosing a significant other is a developmental

task of young adulthood.

Young men may choose work that involves physical labor, office work,
or a variety of other endeavors, including active duty military. They may also
be veterans of military service.
Young men engage in risk taking behaviors without thinking about the
consequences. Depending on his attitudes and practices before a man enters
young adulthood, he may or may not be enticed to experiment or continue
with the use of tobacco, alcohol, or illicit drugs. Experimentation or usage of
these substances can occur while in college, the military, or working at a full-
time job. In addition, young men respond to challenges such as drag racing
and exceeding speed limits. This is an important age group for the C/PHN to
reach with health information because decisions made in these formative
years affect how young men live the rest of their lives. The nurse can meet
with young adult men in work settings, college campuses, military bases,
health clubs and bars, and at single-adult groups sponsored by religious
communities and other organizations.
Another issue to address during the early years is the young man's
attitudes and beliefs toward sex and sexual experimentation. Young men may
question their sexuality as they mature. During this stage, some men come to

1852
the realization that they are homosexual—a person who has sexual interest in
or sexual intercourse exclusively with members of his or her own gender.
Some men who have sex with men (MSM), women, or both often do not
consider themselves to be bisexual. When taking a sexual history,
community health nurses must ask men if they have sex with women, men,
or both, and they should be aware of issues affecting the lesbian, gay,
bisexual, and transgender (LGBT) population.
Transgender, another term associated with sexuality, describes
individuals who experience and/or express their gender differently and often
does not correspond with the person's apparent or birth gender. An example
is when a presumed male chooses to put on makeup and clothes that a female
would traditionally wear. Some transgender individuals define themselves as
female to male or male to female and may take hormones and/or undergo
medical procedures to enhance or make permanent their gender selection,
including gender reassignment surgery. Others prefer to simply be called
male or female—the gender they present to others, whether or not they have
undergone permanent gender reassignment.
Sexual experimentation, whether heterosexual or homosexual, can place
young men at risk for diseases that affect long-term health or is life
threatening. Men who are sexually active can reduce the possibility of being
infected with an STI by limiting the number of sexual partners and using
condoms consistently and correctly. Condoms also serve as a form of birth
control for men. Monogamy, having sex with only one partner and abstinence
can further reduce or eliminate the chance of contracting an STI. Public
health nurses can serve as a resource for young men and can help them
obtain free or low-cost condoms and treatment for STIs.

Human Immunodeficiency Virus

From 2012 through 2016, the rates of diagnoses of HIV infection in the
Northeast and the Midwest decreased. The rates in the South and the West
remained stable. In 2017, rates were 16.1 in the South, 10.6 in the Northeast,
9.4 in the West, and 7.4 in the Midwest (CDC, 2017f). Because the
percentage of persons diagnosed with HIV varies by geographic region, it is
important that prevention, testing, and treatment interventions be tailored for
each area's distinctive needs.
https://www.cdc.gov/hiv/statistics/overview/geographicdistribution.html

Despite advances in the prevention and treatment of human

immunodeficiency virus (HIV), the disease continues to
disproportionately impact men in the United States.
In 2016, the rate of HIV infected men was 570.1 per 100,000 compared
to 169.9 in females. Of the 754,218 infected males in 2016, 72% of
infections were attributed to male-to-male sexual contact (CDC, 2017f).

1853
 The highest rate of new infection was seen in blacks/African
Americans, followed by Hispanics/Latinos.
HIV new infection was most prevalent in persons aged 25 to 29 years
followed by those persons aged 20 to 24 years (CDC, 2019i).
When examining trends in the disease based on race/ethnicity and age,
the burden of the disease is highest among men of color and young
adults.

Alcohol and illicit drug use are known to decrease social inhibitions and
increase the risk for HIV transmission through risky sexual behaviors (e.g.,
lack of condom use) and the sharing of needles or other injection equipment
(CDC, 2019i). Community health nurses must be able to talk openly and
nonjudgmentally with men about their use of substances and their sexual
relationships. These conversations can be challenging, but they have to occur
if the number of HIV infections is to be reduced.

Testicular Cancer
The risk for testicular cancer is a health problem that young men should
be aware of even before early adulthood. The disease occurs most often
in men between 20 and 34 years of age.
A few risk factors have been identified that increase a young man's
chance of developing testicular cancer including a personal history of an
undescended testicle, abnormal testicular development, family history
of testicular cancer, race/ethnicity (White), and age, (ACS, 2018).
It is a rare form of cancer and is not on the list of objectives for men in
Healthy People 2030. However, if detected early, this cancer is highly
curable.
According to the Testicular Cancer Society (2020), it may be beneficial
to the overall health of a young man to know how to perform a testicular
self-exam. For more information on TSE, visit the following Web site of
the Testicular Cancer Society:
https://testicularcancersociety.org/pages/self-exam-how-to

The choices a young adult man makes during these years establish
healthy eating, work, rest, and exercise habits that will benefit him for a
lifetime. A man should follow the dietary food guidelines that are
recommended by U.S. Department of Agriculture (2016). Establishing a
pattern of rest that allows his body to recover and refresh from a day full of
meaningful activities will help him look forward to each day. He should
establish an exercise routine that meets his personal needs, fits his skills and
talents, and includes some physical activities that involve his family (Fig. 21-
11). These choices provide him with the knowledge that he is doing
everything he can to keep himself healthy and to prevent the two major

1854
killers of men—heart disease and cancer. Typically, young adult clients have
few interactions with health care providers in any given year. It is important
for people in this age group to have regular health checkups, be assessed for
early signs of disease, and engage in health promotion activities.

FIGURE 21-11 Adult men are encouraged to maintain good health

through eating a healthy diet and getting regular exercise.

Adult Men (35 to 65 Years)

Men in the developmental stage between 35 and 65 years of age face many
challenges including:

Caring for their own families and children

Caring for aging parents and in-laws
Economic burdens of putting children through college
Adjusting to the reality that their career path is probably set, and many
life choices have been made

The term “midlife” is applied to the first half of this age period, 35 to 49
years during which many men experience a “midlife crisis.” This period of
time can be a difficult stage of life due to:

Reappraisal of values, priorities, and personal relationships

Doubt and anxiety realizing that his life is half over
Beliefs he has not accomplished enough
Struggles to find new meaning or purpose in his life
Boredom with his personal life, job, or partners
Desires to make life changes in personal life, job, or partners

1855
 In fact, men in midlife are at higher rates for suicide behavior than the
general population (SAMHSA, 2018).
The later years in this stage, ages 50 to 64, involve preparation for
retirement. In anticipation of retirement, these years are marked by:

Expanded social relationships

Pursuit of new hobbies to fill increased leisure time
Finishing a career and accumulation of the best retirement benefits
Making life altering decisions
Potential health problems
Loss of loved ones, particularly a spouse or long-term companion

Successful navigation of this stage can be fulfilling but may require a

man to enhance his self-care skills. This includes having a positive attitude
toward aging, one that examines the benefits of maturity, finds a balance
between work and home, and maintains a healthy lifestyle by eating balanced
meals and obtaining regular exercise. The community health nurse can
provide anticipatory guidance to men approaching this stage and provide
them with information on ways to manage life more effectively.

Reproductive Health
As mentioned earlier in this chapter, during the reproductive years, both
women and men should strive to be as healthy as possible. During this stage,
especially when a man has decided that his family is complete (Fig. 21-12),
he may choose a permanent form of birth control through a surgical
procedure called vasectomy. A vasectomy entails:

FIGURE 21-12 Reproductive health is an important consideration

for men.

Removal of all or a segment of the vas deferens

Sperm cannot be released

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 Routinely conducted on an outpatient basis
Minimally invasive
Takes about 30 minutes (CDC, 2017g)

Compared to tubal ligation (a surgical form of contraception for women),

vasectomy is equally effective in preventing pregnancy, but vasectomy is
simpler, faster, safer, and less expensive. A vasectomy is not protective
against STIs and almost all can be reversed (NIH, 2016). Because these
methods, however, are intended to be irreversible, all women and men should
be counseled about the permanency of these procedures (CDC, 2017g).
Erection problems are common among men of all ages but especially in
men as they age. Erectile dysfunction (ED), sometimes called impotence, is
the repeated inability to get or keep an erection firm enough for sexual
intercourse. The word impotence may also be used to describe other
problems that interfere with sexual intercourse, such as lack of sexual desire
and problems with ejaculation or orgasm. Using the term erectile dysfunction
makes it clear that these other issues are not involved (AUA, 2018; Urology
Care Foundation, 2018). Because an erection requires a specific sequence of
events, ED can occur when any of the associate events are disrupted. The
sequence includes nerve impulses in the brain, spinal column, and areas
around the penis, as well as response in muscles, fibrous tissues, veins, and
arteries in and near the corpora cavernosa. Damages to nerves, arteries,
smooth muscles, and fibrous tissues, often as a result of disease, are the most
common causes of ED. Comorbidities such as diabetes, kidney disease,
chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and
neurologic disorders are primary health risk factors for ED (AUA, 2018;
Urology Care Foundation, 2018).
Lifestyle choices that contribute to heart disease and vascular problems
also increase the risk of ED. Smoking, being overweight, and lack of
exercise are possible causes of ED. Surgery (especially radical prostate and
bladder surgery for cancer) can injure nerves and arteries near the penis,
causing ED. Injury to the penis, spinal cord, prostate, bladder, and pelvis can
lead to ED by harming nerves, smooth muscles, arteries, and fibrous tissues
of the corpora cavernosa. In addition, many common medicines—
antihypertensive, antihistamines, antidepressants, tranquilizers, appetite
suppressants, and cimetidine—can produce ED as a side effect. In diagnosing
ED, the medical provider will do a thorough health history including a
lifestyle assessment. Specific questions related to the cardiovascular system
and the nature of ED will be addressed (AUA, 2018; Urology Care
Foundation, 2018).
Drugs for treating ED can be taken orally, injected directly into the penis,
or inserted into the urethra at the tip of the penis. Current medical treatment
consists of approved sildenafil citrate (Viagra), the first pill to treat ED. Since

1857
then, vardenafil hydrochloride (Levitra [oral], Staxyn [sublingual]), tadalafil
(Cialis), and avanafil (Stendra) have been created and belong to a class of
drugs called phosphodiesterase (PDE) type 5 inhibitors. These medications
are currently the first line of therapy for treating ED. The drugs work by
relaxing smooth muscles in the penis during sexual stimulation and allow
increased blood flow. They can be taken as needed before sexual activity, up
to once a day. Low-dose daily dosing rather than “on-demand” dosing has
been found to be beneficial for some couples (Urology Care Foundation,
2018).

Cardiovascular Disease
Heart disease is the leading cause of death in men across most racial/ethnic
groups. Despite a decline in the overall death rate from CVD, the burden of
disease among men remains high.

In 2013, CVD caused 310,000 deaths in men (CDC, 2020m).

Approximately 70% to 89% of sudden cardiac events occur in men, and
50% of these men have no previous symptoms of disease.
The average age for a first heart attack among men is 66 years.
About 8.5% of White men, 7.9% of Black men, and 6.3% of Mexican
American men have some coronary disease.
The rate of a first cardiovascular event rises from 3 per 1,000 men at 35
to 44 years of age to 74 per 1,000 men at 85 to 94 years of age.
It is interesting to note, if all forms of major CVD were eliminated, life
expectancy among all persons would increase by almost 7 years (CDC,
2020m).

Major risk factors for heart disease in men include hypertension,

hyperlipidemia (high LDL), tobacco use, diabetes, obesity/overweight, lack
of physical activity, excessive alcohol consumption, stress, and low daily
fruit and vegetable consumption (Box 21-7). When working with adult men,
the community health nurse should educate men about the importance of
modifying factors that increase their risk of developing CVD (CDC, 2020m).
C/PHNs should discuss the signs and symptoms of a heart attack and how to
access emergency medical treatment with adult males.

BOX 21-7 Evidence-Based Practice

Church-Based Blood Pressure Interventions for
Young Black Males Hypertension is a
significant disorder among Black males in the
United States who experience early-onset and

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 multiple comorbidities. Black males are less
likely to engage in healthy lifestyles and seek
medical advice and treatment. Interventions
directed at young black males to decrease the
incidence and severity of hypertension are
limited.
A community-based participatory research study was conducted
(Carter-Edwards et al., 2018) in the southeastern United States to
explore using the church as a venue to offer blood pressure
interventions for young black men. Focus group participants consisted
of 19 men, 9 were aged 18 to 35 years and 10 were aged 36 to 50. Focus
group questions explored lifestyle and self-management behaviors
related to hypertension. The analysis of the focus group data revealed
that most lifestyle behaviors were perceived to be manageable although
participants admitted to added stress in managing busy work and
family-related activities. Interestingly, another major theme generated
was understanding hidden sodium.
Although the findings confirm persistent challenges of engaging
young black men for blood pressure interventions, the results imply that
programs should utilize the church infrastructure as a means to
disseminate information and implement health care interventions.
Prayer, supportive family systems, church leaders, mentors, and peers
may help young black men increase their knowledge and achieve
optimal lifestyles related to their blood pressure (Carter-Edwards et al.,
2018).
Nurses were not included in the study, yet community health nurses
would be an invaluable resource, as they can form partnerships to
educate young black males on healthy lifestyles. Nurses are in a key
position to recognize concerns touching the health and well-being of
patients, determine health configurations across patient populations,
connect patients with community resources and social services, and
develop comprehensive interventions (Bachrach & Thomas, 2016).
Source: Bachrach and Thomas (2016); Carter-Edwards et al. (2018).

Prostate Health
Prostate health is another concern that may occur later in this life stage. The
prostate is a doughnut-shaped gland located at the bottom of the bladder,
about halfway between the rectum and the base of the penis. The prostate
encircles the urethra. The walnut-sized gland produces most of the fluid in

1859
semen. Men can experience infection (prostatitis), prostate enlargement
(benign prostatic hyperplasia [BPH]), and prostate cancer (ACS, 2020b).

BPH is very common among men.

The primary risk factor for developing BPH is age. Nearly 50% of men
over 50 years of age report symptoms that are related to prostate gland
enlargement.
Symptoms of BPH are caused by an obstruction of the urethra and
gradual loss of bladder function, which results in incomplete emptying
of the bladder. The most commonly reported symptoms of BPH involve
lower urinary tract symptoms (LUTS), such as hesitant, interrupted, or
weak urinary stream, urgency or leaking of urine, and more frequent
urination, especially at night.
Men often report the symptoms of BPH before the physician diagnoses
it through a digital rectal examination (DRE).
Treatment for BPH can include medication or surgery to reduce the size
of the prostate (Urology Care Foundation, 2019).

Prostate cancer is the most frequently diagnosed cancer in men and the
second leading cause of cancer death.

According to the ACS, 1 man in 7 will get prostate cancer during his
lifetime and 1 man in 38 will die from the disease.
However, most prostate cancers grow slowly and do not cause any
health problems in men who have them.
More than 2.9 million men in the United States who have been
diagnosed with prostate cancer at some time in their lives are still alive
today.
Prior to age 40, prostate cancer is very rare, but the chance of having
prostate cancer rises rapidly after age 50.
About 6 cases in 10 are diagnosed in men 65 years of age and older.
Age is the strongest risk factor for prostate cancer, but family history
and ethnicity also need to be considered.
Prostate cancer occurs more often in Black men than in men of other
races and occurs less often in Asian and Hispanic/Latino men.

The reasons for these racial and ethnic differences are not clear. Starting
at age 50, all men should talk to their health care provider about the pros and
cons of screening for prostate cancer. This discussion should start at age 45 if
a man is Black or has a father or brother who had prostate cancer before age
65. Men with two or more close relatives who had prostate cancer before age
65 should talk with their health care provider about screening for prostate
cancer at age 40 (ACS, 2020b; CDC, 2019j). The effectiveness of the
screening test, prostate-specific antigen (PSA), has been brought into

1860
question, and the USPSTF (2015) has outlined a framework for further study
and review.
Treatment for prostate cancer depends on the man's age, overall health
status, and stage of disease (Tabayoyong & Abouassaly, 2015).

Treatment options include surgery to remove all or part of the prostate

(prostatectomy), radiation, and hormone therapy.
Surgery, radiation, and hormone therapy all have the potential to disrupt
sexual desire and performance, temporarily or permanently.
Urinary dysfunction and incontinence are common side effects that
occur after surgery or radiation.
Rather than immediate treatment, watchful waiting or active
surveillance is an option that may be appropriate for older men with
limited life expectancy and/or less aggressive tumors (Filson, Marks, &
Litwin, 2015).

A community health nurse can reinforce or clarify information shared

with the man by his health care provider, discuss his treatment options with
him and his family, and provide the support they may need if prostate cancer
is diagnosed.

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ROLE OF THE COMMUNITY
HEALTH NURSE
The community health nurse works with adults in all age groups using the
three levels of prevention—primary, secondary, and tertiary—as a guide.
Interventions are conducted at the individual, family, group, and aggregate
levels to make progress toward the Healthy People 2030 objectives (Box 21-
8).

BOX 21-8 Levels Of Prevention Pyramid

Breast Cancer SITUATION: Breast cancer.
GOAL: Using the three levels of prevention, avoid or promptly diagnose
and treat negative health conditions and restore the fullest potential.

Client teaching by the community health nurse is a major factor in

preventing and managing chronic diseases. The challenge to the nurse is to

1862
be prepared to discuss issues, backed up with knowledge of and access to the
appropriate community resources, to meet client needs. What the nurse can
accomplish can be quite dramatic in terms of reducing days in the hospital
because of chronic disease, improving quality of life for the chronically ill
person, and preventing a combination of unhealthy habits from becoming
causative factors in new cases of chronic disease. A nursing care plan matrix
can guide the community health nurse in discussing areas of health
promotion and protection with the client. An example of a nursing care plan
matrix for young adults can be found in Box 21-9.

BOX 21-9 Nursing Care Plan Matrix for

Health Promotion, Young Adults: 18 to
35
Community health nurses can use this matrix to individualize teaching,
services, and/or care to young adult clients. Use the questions to
stimulate the development of an individualized approach that is client
focused and client driven with the community health nurse acting as the
catalyst. In any or all of these areas, the community health nurse may
(1) discuss issues and commend the client for positive attitudes and
behaviors (e.g., when the client is making healthful decisions, such as
condom use for his/her health and the health of significant others); (2)
discuss the issues and guide the client to resources that will enhance
more positive behaviors and decisions (e.g., flu shot clinic or healthy
lifestyle program for adults); or (3) discuss the issues and inform the
client that immediate changes must be made to protect the health of self
or others and inform/utilize the appropriate resources as soon as
possible (e.g., follow-up for symptoms related to suspected STI).

1. Life partner. Ascertain whether the client is looking for a life

partner or is choosing to live a single life. Discuss how the
single life is satisfying for the client and ways to make it richer.
Discuss settings in which client can meet others (male or female,
based on sexual preference) with similar interests, philosophy,
and outlook, such as work settings, school settings, faith
communities, recreational communities, and the like.
Discuss what the client is looking for in a potential life partner,
expectations for the relationship, what the client contributes,
how the client compromises and resolves conflict, and other
issues. If in a relationship, what is good, what needs improving,
and how to initiate change.
2. Life's work. How is the client preparing for his/her life's work
(education, formal training, on the job training)? Will the life's

1863
 work provide resources for client's life plans? Will the work
choice provide long-term satisfaction? Is the work choice a
“stepping stone” to another work role? How will/does he/she
handle work and rearing children? What needs changing or can
be improved in the work/children arrangement?
3. Planning for children. What knowledge does he/she have about
family planning? What methods fit best with his/her philosophy,
religious beliefs, and lifestyle? What are the long-term effects of
the choices? How many children is the client planning to rear?
Has he/she thought through the ramifications of this number? If
choosing not to have (or unable to have) children, how will
he/she deal with this? Does he/she want alternative suggestions
for raising a child (adoption, foster parenting) or information
about interacting with children (volunteering)?
4. Maintaining physical and mental health. In this area, the
community health nurse needs to explore all areas of health
promotion and protection. This will include discussions
regarding primary and secondary prevention. Primary prevention
discussions could include:

Diet and nutrition

Physical and leisure activities
Safe sex practices
Periodic health examinations
Personal safety—seat belts, protective helmets, dating violence,
etc.
Immunizations
Regular use of sunscreen
Stress reduction activities
Secondary prevention discussions could include:
Screening for sexually transmitted infections
Testicular self-examination
Smoking cessation
Pelvic exams and Pap smears
Counseling and support at times of stress

5. Developing a life's philosophy. Discuss client's personal life

satisfaction, which may include religiosity and spirituality, living
in congruence with cultural/ethnic/family beliefs and
expectations, and coming to a comfortable level of satisfaction
with life choices, having few regrets.

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Primary Prevention
Primary prevention activities focus on education to promote a healthy
lifestyle. Much of the community health nurse's time is spent in the
educator role.
When working with individuals, the C/PHN should encourage routine
health examinations, healthy eating habits, adequate sleep, moderate
drinking, and no smoking. Among aggregates, the community health
nurse focuses on community needs for services and programs that will
keep that population healthy, such as providing flu vaccine clinics,
teaching sexual responsibility, and preventing STIs.

The community health nurse may collaborate with community leaders

and other stakeholders in designing programs, work with committees to
secure funding, or approach the state legislature to lobby for needed changes
to state laws and policies governing the health of adults. At other times, the
nurse works with small groups of adults who could benefit from making
healthy choices in diet, relaxation, and physical activity. Likewise, it is not
unusual for the C/PHN to work with an individual to promote healthy living.
An example of available resources on smoking cessation to those working
with the veteran population is shared in Box 21-10.

BOX 21-10 Population Focus

Public Health and the Veteran Population The
Office of Patient Care Services within the
Veterans Health Administration provides a
public health focus on health promotion and
disease prevention for the veteran population.
The mission is accomplished through education
and outreach, public health policy development,
population-based surveillance, performance
measurement and improvement, clinical
guidelines, and research. Current focus areas
for the veteran population include reducing
complications from military exposures,
hepatitis C, HIV/AIDS, influenza, women's

1865
health issues, and tobacco cessation. The
veteran population is disproportionately
affected by smoking-related illnesses. Many
veterans began using tobacco during military
service or deployment. The U.S. Department of
Veterans Affairs Mental Health Web site
“Tobacco and Health” was developed
specifically for the veteran population to
provide evidence-based information and helpful
resources for veterans interested in improving
their health by quitting the use of tobacco. The
Web site is resource rich and can be accessed by
any veteran or health care professional at
http://www.mentalhealth.va.gov/quit-
tobacco/index.asp. Two particularly meaningful
resources for the veteran population are the
SmokefreeVET (a text messaging program
utilizing daily advice and support) and Stay
Quit Coach (a mobile app to help Veterans deal
with issues arising in tobacco cessation).
—Cory, VA Staff Nurse
Source: Veterans Health Administration, U.S. Department of Veterans Affairs (2019).

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Secondary Prevention
Secondary prevention focuses on screening for early detection and
prompt treatment of diseases. Throughout the life span, screening tests
can help adults identify disease early (see Screenings and Checkup
Schedule for Women and Men on ).
A significant amount of the community health nurse's time is spent in
assessing the need for planning, implementing, or evaluating programs
that focus on the early detection of diseases.
This is followed with teaching to prevent further damage from the
disease in progress or to prevent the spread of the disease, if it is
communicable. Examples of secondary prevention programs include
establishing mammography clinics, teaching breast and TSE, and
screenings—blood pressure, blood glucose, BMI, and cholesterol.
Wherever adults gather in groups, this is a good place to provide both
primary and secondary health care and prevention services.

1867
Tertiary Prevention
The tertiary level of prevention focuses on rehabilitation and preventing
further damage to an already compromised system. Many adults with
whom a community health nurse works have chronic diseases,
conditions resulting from another disease, or long-standing injuries with
resulting disability.
Ideally, negative health conditions can be prevented. If not, the next best
thing is for them to be diagnosed early, without damage to an
individual's health. But if negative health conditions have not been
treated or brought under control, then the individual is at a tertiary level
of prevention. At this level of prevention, the nurse focuses on
maintaining quality of life.

Depending on the client's age, tertiary prevention can be simple or very

complex. A 19-year-old man who breaks his leg while skiing needs
information about using crutches safely, a reminder to eat protein foods for
bone healing, and an appointment to return to his health care provider if he
experiences various symptoms and to get the cast removed. He generally
needs no additional help from others. Tertiary prevention in this case is
uncomplicated. On the other hand, a 62-year-old woman who is 70 lb
overweight with out-of-control blood glucose levels, symptoms of congestive
heart failure, and difficulty walking more than 20 ft has much to accomplish
in order to feel healthy. Can the nurse help the woman lose weight? Will
weight loss bring her diabetes under control and alleviate congestive heart
failure symptoms? With some weight reduction, will she be able to walk
more easily? Or, will the woman feel better with physical therapy and a
different medication regimen? Is there a quicker, safer, and better approach?
On assessment, the nurse discovers that the woman has been as much as 80
lb overweight for 40 years. Will this information alter the nurse's approach to
helping this woman? What additional information does the nurse need?
Caring for people at the tertiary level of prevention can become quite
complicated because many body systems may be involved. In addition, all
people function within many social systems, which may include family
expectations, roles people have within the family, expected behaviors,
community system knowledge and involvement, personal expectations,
motivation, and support. Working at the tertiary level involves all of the
nurse's skills in addition to community resources and a client who can be or
wants to be motivated.

1868
SUMMARY
The 20th century saw a shift in the leading causes of death, from
communicable to noncommunicable diseases. Currently, the five
leading causes of death in adults are diseases of the heart, malignant
neoplasms, unintentional injuries, CLRDs, and cerebrovascular diseases
—none of which are communicable.
The health care needs of adults are of great concern. Many needs are the
same for both women and men, but the important differences were
addressed in this chapter.
Adults have health care needs that change as they age. Diet and
exercise, obesity, substance use, safety, and healthy lifestyle choices are
issues that adults must consider throughout their lives.
Genomics refers to how a person's genetic makeup and environment
predispose an individual to the development of disease. Understanding a
person's genetic risk and environmental factors that may further
influence and increase risk allows community health nurses to provide
targeted education on disease prevention. Heart disease and cancers
remain important concerns for both men and women, and health
decisions made as a young adult can have a major impact on persons as
they age.
Chronic illness is an issue of increasing concern for both men and
women as life expectancies increase. C/PHN should use the three levels
of prevention to promote health across the life span. Primary prevention
activities focus on education to promote a healthy lifestyle. Secondary
prevention focuses on screening for early detection and prompt
treatment of diseases.
The C/PHN role at this stage is to assess needs; to plan, implement, or
evaluate programs that focus on the early detection of diseases; and to
educate clients to prevent further damage from or spread of disease. The
tertiary level of prevention focuses on rehabilitation and prevention of
further damage to an already compromised system. At this level of
prevention, the nurse focuses on maintaining quality of life.

1869
ACTIVE LEARNING EXERCISES
1. Using journals or online sources, select three articles that relate to a
preventable chronic disease. For each article, summarize the content,
identify the likely cause, and describe how the disease may have been
prevented.
2. You are asked to offer a weight control program for 12 young adults
who are residents in an apartment complex that has monthly
programs related to health and wellness. The ages of the intended
participants range from 20 to 30. What steps would you take to
develop a successful program? What would be important to
emphasize with this age group? What resources (e.g., smartphone
apps, online information) might be useful to them in adhering to a
healthy diet and exercise program?
3. Apply “Assess and Monitor Population Health” (1 of the 10 essential
public health services; see Box 2-2 ) as follows: Using nursing and
other health care databases, research a chronic disease associated with
men or women aged 35 to 65. In a small group discussion with your
classmates, identify selected concerns and discuss both personal
responsibility and societal responsibility regarding management of
this health problem.
4. In a small group, determine screening recommendations for a male
and female at 50 years of age. Which recommendations are similar?
Which are different?
5. Complete a health history on an adult, including medical, family,
social history, and environmental history. Based on the information
collected, determine the individual's personal risk factors. Which risk
factors are modifiable? Which are not modifiable? Which chronic
diseases is he or she is at risk for developing? What education would
you provide to help the individual reduce his or her risk?

thePoint: Everything You Need to Make the

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1870
REFERENCES
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detailedguide-toc
American Cancer Society (ACS). (2019). Cancer facts and figures 2019.
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org/research/cancer-facts-and-statistics/annual-cancer-facts-and-
figures/2019/cancer-facts-and-figures-2019.pdf
American Cancer Society (ACS). (2020a). American cancer society
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https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-
detection/american-cancer-society-recommendations-for-the-early-detection-
of-breast-cancer.html
American Cancer Society (ACS). (2020b). Prostate cancer. Retrieved from
https://www.cancer.org/cancer/prostate-cancer.html
American College of Obstetricians and Gynecologists (ACOG). (2018a). The
menopause years. Retrieved from
https://www.acog.org/store/products/patient-
education/pamphlets/womenshealth/the-menopause-years
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stat facts: Cervical cancer. Retrieved from
https://seer.cancer.gov/statfacts/html/cervix.html
Surveillance, Epidemiology, and End Stage Program (SEER). (n.d.c). Cancer
stat facts: Ovarian cancer. Retrieved from
https://seer.cancer.gov/statfacts/html/ovary.html
T. Collin Campbell Center for Nutrition Studies. (2018). Living a whole-
food, plant-based life. Retrieved from https://nutritionstudies.org/whole-
food-plant-based-diet-guide/
Tabayoyong, W., & Abouassaly, R. (2015). Prostate cancer screening and the
associated controversy. Surgical Clinics of North America, 95(5), 1023–
1039. doi: 10.1016/j.suc.2015.05.001.
Testicular Cancer Society. (2020). Testicular self-exam. Retrieved from
https://testicularcancersociety.org/pages/self-exam-how-to
Torre, L. A., Trabert, B., DeSantis, D. E., Miller, K. D., Samimi, G.,
Runowicz, C. D., Guaden, M. M., … Siegel, R. L. (2018). Ovarian cancer
statistics, 2018. CA: A Cancer Journal for Clinicians, 68(4), 284–296.
Urology Care Foundation. (2018). What is erectile dysfunction? Retrieved
from https://www.urologyhealth.org/urologic-conditions/erectile-dysfunction
Urology Care Foundation. (2019). What is Benign Prostatic Hyperplasia
(BPH)? Retrieved from https://www.urologyhealth.org/urologic-
conditions/benign-prostatic-hyperplasia-(bph)
U.S. Department of Agriculture. (2016). MyPlate. Retrieved from
https://www.choosemyplate.gov/MyPlate
U.S. Department of Health and Human Services (USDHHS). (2015). Healthy
People 2020: Disparities. Retrieved from
https://www.healthypeople.gov/2020/about/foundation-health-
measures/Disparities
U.S. Department of Health and Human Services (USDHHS). (2018). Active
adults. In Physical Activity Guidelines for Americans (2nd ed., pp. 55–65).
Washington, DC: U.S. Department of Health and Human Services. Retrieved
from https://health.gov/paguidelines/second-
edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf#page=55

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U.S. Department of Health & Human Services (USDHHS). (2020). Healthy
People 2030: Browse objectives. Retrieved from
https://health.gov/healthypeople/objectives-and-data/browse-objectives
U.S. Preventative Services Task Force. (2016a). Final update summary:
Colorectal cancer screening. Retrieved from
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/color
ectal-cancer-screening
U.S. Preventative Services Task Force. (2016b). Final update summary:
Chlamydia and gonorrhea: Screening. Retrieved from
https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSum
maryFinal/chlamydia-and-gonorrhea-screening?ds=1&s=chlamydia
U.S. Preventative Services Task Force. (2016c). Final recommendation
statement: Breast cancer: Screening. Retrieved from
https://www.uspreventiveservicestaskforce.org/Page/Document/Recommend
ationStatementFinal/breast-cancer-screening1
U.S. Preventative Services Task Force. (2018a). Final update summary:
Human immunodeficiency virus (HIV) infection: Screening. Retrieved from
https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSum
maryFinal/human-immunodeficiency-virus-hiv-infection-screening
U.S. Preventative Services Task Force. (2018b). Final recommendation
statement: Osteoporosis to prevent fractures: Screening. Retrieved from
https://www.uspreventiveservicestaskforce.org/Page/Document/Recommend
ationStatementFinal/osteoporosis-screening1#consider
U.S. Preventative Services Task Force. (2018c). Final update summary:
Cervical cancer screening.Retrieved from file:///Users/joey-
stanleyhotmail.com/Downloads/cervical-cancer-final-rec-statement.pdf U.S.
Preventative Services Task Force. (2018d). Final update summary: Ovarian
cancer. Retrieved from
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/ovari
an-cancer-screening
Veterans Health Administration, U.S. Department of Veterans Affairs.
(2019). Tobacco and health. Retrieved from
https://www.mentalhealth.va.gov/quit-tobacco/
Women's Health Initiative (WHI). (n.d.). About WHI. Retrieved from
https://www.whi.org/about/SitePages/About%20WHI.aspx
Women's Health Study (WHS). (n.d.). Overview of women's health study
(WHS) study design. Retrieved from
http://whs.bwh.harvard.edu/images/WHS%20website-
Overview%20of%20study.pdf
Wood, D. E., Kazerooni, E. A., Baum, S. L., Eapen, G. A., Ettinger, D. S.,
Hous, L., … Hughes, M. (2018). Lung cancer screening, version 3.2018:
Clinical practice guidelines in oncology. Journal of the National

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10.6004/jnccn.2018.0020.
World Health Organization (WHO). (2019). Cardiovascular disease.
Retrieved from https://www.who.int/cardiovascular_diseases/about_cvd/en/
World Health Organization (WHO). (n.d.). Human genomics in global
health. Retrieved from
https://www.who.int/genomics/geneticsVSgenomics/en/
Xu, J. Q., Murphy, S. L., Kochanek, K. D., Bastian, B., & Arias, E. (2018).
Deaths: Final data for 2016. National Vital Statistics Reports, 67(5).
Hyattsville, MD: National Center for Health Statistics.

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1883
CHAPTER 22
Older Adults
“In the end, it's not the years in your life that count. It's the life in your years.”

—President Abraham Lincoln (1809–1865)

KEY TERMS
Age dependency ratio Ageism
Aging in place Alzheimer's disease (AD) Arthritis Assisted living Beta-
amyloid Case management Chronic conditions Continuing care retirement
communities (CCRCs) Custodial care Elder abuse
Geriatrics Gerontological Hospice
Long-term care Nursing home Osteoporosis Palliative care Polypharmacy
Respite care Senility
Tau protein Universal design

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Describe the global and national health status of older adults.
2. Identify and refute at least three common misconceptions about older
adults.
3. Describe characteristics of healthy older adults.
4. Provide an example of primary, secondary, and tertiary prevention
practices in the older adult population.
5. Identify four chronic conditions most commonly found in the older adult
population.
6. Describe initial steps for reporting elder abuse.
7. Describe various types of living arrangements and care options as older
adult's age in place.
8. Describe the importance of integrating palliative care into aspects of
care for older adults.

1884
INTRODUCTION
Ms. Barbara is still in the apartment she and her husband shared for many
years after they retired. At 94, Ms. Barbara tends her parakeet, Bert, and
visits her neighbors regularly. Because she does not drive anymore, she
orders her groceries online for delivery. Her apartment has a universal design
with safety bars and a pull string for quick assistance. She loves card games
and plays bridge and Scrabble regularly with others in the retirement
community. Her health has had its ups and downs, but with the support of an
automated pill box and frequent visits from her daughter, Ms. Barbara is able
to remain independent in her apartment.
Older adults constitute a large and rapidly growing population group in
the United States, one that you will join eventually. Perhaps your parents or
grandparents are part of that group now. Improved medical care, advances in
public health standards, and a focus on prevention have contributed to
dramatic increases in life expectancy in the United States. A child born in
2016 could expect to live 78.6 years, about 30 years longer than a child born
in 1900 (Administration for Community Living, 2019b). A second reason for
the huge growth in the number of older adults began in 2011 as the baby
boomers (people born after World War II between the years of 1946 and
1964) reached age 65. One out of four of these baby boomers will live past
age 90 (Administration for Community Living, 2019b). Older adults
represent 15.2% of the U.S. population or about one in every seven
Americans (over 50 million); this number is expected to double by 2060,
when older adults will outnumber young children.
Racial and ethnic minority populations will increase to approximately
28% of older adults by 2030 (U.S. Department of Health and Human
Services, 2020b). The health status of racial and ethnic minorities of all ages
lags far behind that of nonminority populations. For a variety of reasons,
older adults may experience the effects of health disparities more
dramatically than any other population group.
Looking forward to these changing health needs of the nation, Healthy
People 2030, the road map for health in the United States, lists five
overarching goals, all of which focus on healthy aging:
1. Attain health and wellbeing, free from preventable disease, disability,
injury, and premature death.
2. Eliminate disparities, and achieve health equity for all.
3. Create environments that promote full potential for health for all.
4. Promote healthy development and healthy behaviors across all life
stages 5. Engage leadership, constituents, and the public to take action

1885
 to improve health for all (ODPHP, 2020).
The future older population is expected to be better educated than the
current one. The increased levels of education may accompany better health,
higher incomes, more wealth, and consequently a higher standard of living in
retirement.
Baby boomers bring much to the conversation about retirement,
including an interest in the solvency of Medicare and Social Security
programs and an interest in aging in place in their communities. At the end
of the 2008 recession, which impacted many retirement plans, about one half
of working adults aged 50 to 64 years reported that they were not prepared to
retire and were delaying retirement, according to a national survey by the
Pew Research Center's (2016).
In addition to financial preparation for retirement and older age, many
older adults view marriage through a different lens than older generations
before them. Given that many baby boomers are divorced or have never been
married, they have a different opinion about the definition of family,
including how obligated they feel about taking care of an older family
member (Reuters, 2017). Single adults may not have the same preparation
for retirement that married adults do.
Another factor affecting the health of the current generation of older
adults is ever-rising health care costs in the United States (Fig. 22-1). These
costs have a disproportionately greater impact on older adults because the
cost of providing health care for an American 65 years or older is three to
five times greater than the cost for someone younger (Peterson-Kaiser Health
System Tracker, 2016).

FIGURE 22-1 Share of total health spending by age group and

share of the population. (Peterson-Kaiser Health System Tracker.
(2016). How do health expenditures vary across the population?

1886
 Reprinted with permission from the Kaiser Family Foundation.
Retrieved from https://www.healthsystemtracker.org/chart-
collection/health-expenditures-vary-across-population/?
sf_data=results&_sft_category=spending&sf_paged=2#item-
whites-have-higher-health-spending-in-most-age-categories-than-
people-in-other-groups_2016)

The growth of the aging population presents opportunities for public

health nurses to work with communities to strengthen and expand programs
and services targeted to seniors, to advocate for the needs of the aging
population with government agencies and other organizations, and to assure
access to quality health care services that address their unique and complex
problems (United Nations, 2017).
This chapter first examines the characteristics of the aging population in
the United States and the global challenge of an aging society. Ageism is
discussed in the context of misconceptions about older adults. Next, the
primary, secondary, and tertiary health needs of older adults are explored.
Diseases common among older adults are reviewed, with a focus on
Alzheimer's and other dementias. Elder abuse is reviewed with a focus on
financial abuse and abuse reporting. Finally, population-based health services
and nursing interventions applied to the health of the aging population are
discussed in light of cost containment and comprehensive care.

1887
GERIATRICS AND
GERONTOLOGY
Nurses trained in the specialty of gerontological nursing are needed to care
for our aging population. Gerontological nursing encompasses all aspects of
the aging process, including economic, social, clinical, psychological, and
spiritual factors. Gerontological nursing focuses on promoting and improving
the health of older adults. This holistic approach includes evaluating the
impact of these factors on the older adult and society. Health is defined by
the person and may include the ability to age in place or sustain maximum
functioning.
In contrast, geriatrics is a medical specialty. Like other medical
specialties, geriatrics focuses on abnormal conditions and the treatment and
cure of those conditions. A geriatrician is a medical doctor with specialized
training in geriatrics.
A C/PHN works with older adults at the individual, family, and group
levels. In one instance, the nurse may work to promote and maintain the
health of a vigorous 80-year-old man who lives alone in his home. However,
a community/public health perspective must also concern itself with the
aggregate of older adults. There are many groups of seniors with whom the
nurse may choose to work, such as those who attend a memory day care
center, those who belong to a retirement community, those who live in a
nursing home, or members of a caregiver support group. Other groups
include residents of a senior citizens' apartment building; those with
cognitive, vision, or hearing impairments; homeless men and women; and
veterans. Work with clients can also involve political advocacy. The
possibilities for C/PHNs to work with older adults are vast and ever
expanding.

1888
HEALTH STATUS OF OLDER
ADULTS
People are living longer as a result of improved health care, eradication and
control of many communicable diseases, use of antibiotics and other
medicines, healthier dietary practices, safer global water supplies, regular
exercise, and accessibility to a better quality of life via education and social
services. Increased life expectancy reflects, in part, the success of public
health interventions. However, community/public health programs must now
respond to new challenges, such as the following: the growing burden of
chronic illness, physical and cognitive impairments, increasing concerns
about future caregiving, coordinating care across providers and settings, and
rapidly rising health care costs.
Chronic diseases, often referred to as chronic conditions, affect older
adults at a disproportionately higher rate. They contribute to disability,
diminish quality of life, and increase health care costs. Two out of three older
Americans have multiple chronic conditions, with treatment for this group
resulting in 66% of the U.S. health care budget (Centers for Disease Control
and Prevention [CDC], 2017a).
C/PHNs have the opportunity to address key challenges faced by the
older population. They can work to meet the long-term needs of individuals
with cognitive and physical impairments, coordinate care across providers,
oversee the adequacy of services, and support family caregivers in the plan
of care. In this way, C/PHNs can help older adults live in the communities, a
more cost-effective and desirable outcome.

1889
Global Demographics
The unprecedented growth in the number of older adults is not limited to the
United States but is happening worldwide. In 2010, an estimated 524 million
people were aged 65 years or older—8% of the world's population. By 2050,
this number is expected to nearly triple, to about 1.5 billion, representing
16% of the world's population (United Nations, 2017).
Life expectancy at birth around the world now is 67. A child born in
Myanmar or in Brazil can expect to live 20 years longer than one born 50
years ago. And in Iran, only 1 person in 10 is currently older than 60 years,
but in 35 years' time, this will change to 1 in 3 (Beard et al., 2016).
Although more developed countries have the oldest population profiles,
the vast majority of older people—and the most rapidly aging populations—
are in less developed countries. Between 2010 and 2050, the number of older
people in less developed countries is projected to increase more than 250%,
compared with a 71% increase in developed countries (United Nations,
2017).
Because of this demographic shift, along with altered societal
expectations, changes in attitudes and social policies worldwide are needed.
Many countries have few or no social programs, pensions, or health care
services available for their older adult populations.

1890
National Demographics
As a result of demographic transitions, including declining infant and
childhood mortality, lower fertility rates, and improvements in adult health,
the shape of the global age distribution is changing. The age distribution in
developed countries, such as the United States, includes a larger proportion
of older adults than does the age distribution in less developed countries.
By 2025, the United States is expected to have 80% more older adults
than in 2000, but the number of working-age adults will grow by only 15%
(Ortman, Velkoff, & Hogan, 2014). This is often represented by an age
dependency ratio. By looking at Figure 22-2, you can see that over the
years, an increasing number of younger, working-age adults are needed to
provide support for older adults (15 working-age persons for 1 older adult in
1960 vs. 23 in 2015). However, the age dependency ratio does not take into
consideration that many older adults may still be working or have other
sources of income.

FIGURE 22-2 World Bank, Age Dependency Ratio: Older

Dependents to Working-Age Population for the United States
[SPPOPDPNDOLUSA]. (Retrieved from FRED, Federal Reserve
Bank of St. Louis;
https://fred.stlouisfed.org/series/SPPOPDPNDOLUSA, January 24,
2019. FRED® and the FRED® logo are registered trademarks of
the Federal Reserve Bank of St. Louis. Used with permission.
FRED® chart provided courtesy of the Federal Reserve Bank of
St. Louis. © 2019 Federal Reserve Bank of St. Louis. All rights
reserved.)

Despite the overall trend toward increased life expectancy, disparities

exist among various subgroups in the population. Life expectancy is highest
for White Americans and lowest for Black Americans, who have the highest

1891
death rates of any of the racial and ethnic groups in the United States. The
Hispanic, Black, and Asian populations have been expanding and are
projected to grow substantially through 2025 (U.S. Census Bureau, 2015).
Although the older population is not expected to become majority–minority
in the next four decades, it is projected to be 42% minority in 2050, up from
20% in 2010 (U.S. Census Bureau, 2015).
The health status of racial and ethnic minorities of all ages lags behind
that of nonminority populations. For a variety of reasons, older adults may
experience the effects of health disparities more dramatically than any other
population group (Box 22-1). To help address these health disparities, the
Racial and Ethnic Approaches to Community Health (REACH) (CDC,
2020b) program supports community-based coalitions in the design,
implementation, and evaluation of innovative strategies to reduce or
eliminate health disparities among racial and ethnic minorities. The goal of
REACH is to achieve health equity, eliminate disparities, and improve the
health of all groups (CDC, 2020b).

BOX 22-1 Evidence-Based Practice

Health Risks Faced by Older Adults Below are
three examples of research findings related to
health risks faced by older adults that are
relevant to community/public health nurses
(C/PHNs).
Suicide Assessment of older adults
for suicide risk is an important
consideration for community health
nurses and C/PHNs. Although
suicide attempts are less frequent in
older adult populations, the
completion rate is high, with 25% of
older adults, both male and female,
succeeding. Nurses need to

1892
understand the known risk factors
for suicide, such as depression,
anxiety, and bipolar disorder.
However, many older adults may not
have diagnosable symptoms and may
not be assessed for mental illness.
C/PHNs need to understand the
losses that may contribute to suicidal
ideation, such as the loss of a spouse
or friend or physical problems with
vision, hearing, or untreated pain.
They should also know of key
supports for older adult: supportive
family and friends, spiritual
practices, and connection to the
community. This article discusses
assessment, screening, and reducing
risk by connecting clients to
resources.
Health Complications Related to
Homelessness The proportion of
homeless who are older adults is
increasing by virtue of the aging of

1893
the general population. According to
the research study indicated below,
conducted in Oakland, California,
one half of single homeless adults are
aged 50 years or older and have the
kinds of chronic conditions that
typically occur in housed adults aged
75 years or older. This study
considers participants who stayed in
four primary environments:
unsheltered, shelters, and homeless
hotels, with family or friends, and in
rentals following a period of
homelessness. Nearly 40% had
problems with at least one activity of
daily living, and 25% had cognitive
impairment. Many had vision and
hearing problems and urinary
incontinence. This study highlights
the needs of older homeless adults
who do not have supportive living
environments to meet their needs.

1894
 Chronic Illness and Functional
Disabilities Consider the influence of
Programs that offer All-Inclusive
Care for the Elderly (PACE) sites in
communities and what occurs after a
PACE site closed. PACE activities
are organized around a day center
that provides medical and social
services to avoid institutionalization
of older people with chronic illnesses
and functional needs. Outcomes of
PACE site closures lead to higher
numbers of emergency department
visits, hospitalizations, and nursing
home placements. C/PHNs need to
learn about comprehensive
programs such as PACE, which can
be effective in reducing health care
costs.
Source: Diggle-Fox (2016); Brown et al. (2017); Meunier et al. (2016).

Growth in the number of older adults will significantly affect health care
resources, housing options for older adults, and national longevity statistics.
As the number of older people increases, so, too, will their need for
assistance with activities of daily living (ADLs) and other services,
especially those persons with Alzheimer's and other dementias. Many will
serve as caregivers to family members who need assistance in attending to

1895
ADLs such as dressing, eating, toileting, and bathing, and researchers are
seeking effective methods for providing respite to caregivers and reducing
costs. Laws pertaining to health care and social services are being passed to
better address the needs of older adults, most of whom will remain in the
community. The Administration on Community Living, along with the
National Family Caregivers Support Project Program (NFCSP), provides
grants to states and territories to provide five types of services
(Administration for Community Living [ACL], 2019a):

Information to caregivers about available services

Assistance to caregivers in gaining access to the services
Individual counseling, organization of support groups, and caregiver
training
Respite care
Supplemental services, on a limited basis

These services are designed to work with other state-and community-

based services to provide a coordinated set of supports. Studies have shown
that these services can reduce caregiver burnout and stress and keep them
healthy, delaying the need for costly assisted living or nursing home care
(Administration for Community Living, 2019b).
Many older adults live in poverty; over 4.5 million older adults (9%)
were below the federal poverty level in 2016. This poverty rate represents a
statistically significant increase from the poverty rate of 8.5% in 2013
(Kaiser Family Foundation, 2018). However, in 2017, the Supplemental
Poverty Measure (SPM) from the U.S. Census Bureau, which was adjusted
for regional costs of living and nondiscretionary expenses, revealed a poverty
level for older adults of 14.1% (over 5% higher than the official 9% rate).
This increase is mainly due to adding medical out-of-pocket expenses, which
were not included in the original poverty level calculations (U.S. Census
Bureau, 2018).
The education level of the older population is rising. Between 1970 and
2016, the percentage of older persons who had completed high school
increased from 28% to 85%. In 2014, about 28% had a bachelor's degree or
higher. Considerable racial and ethnic differences were found in the
proportion completing high school (i.e., 90% of non-Hispanic Whites, 80%
of Asians, 77% of African Americans, 71% of American Indian/Alaska
Natives, 54% of Hispanics). In comparison, only 30% of older Whites and
9% of older African Americans had high school diplomas in 1970
(Administration for Community Living, 2019b). With higher levels of
education come broader health consumerism and improved quality of life.

1896
DISPELLING AGEISM
Ageism is negative stereotyping of older adults and discrimination because
of older age. These stereotypes often arise from negative personal
experiences, myths shared over time, and a general lack of current
information. A majority of older adults report having experienced ageism in
the form of being patronized, ignored, or treated as if they were incompetent
(Applewhite, 2016).
By becoming more aware of the myths and realities of older age,
C/PHNs can improve the health and quality of life of the growing population
of older adults. C/PHNs must guard against ageism in their practice by
dispelling common myths and misconceptions (Table 22-1).

TABLE 22-1 Myths About Older Adults

The aging process among older adults is individual, subtle, gradual, and
lifelong. One can see remarkable differences among individuals in the rate of
aging. Even in a single individual, various systems of the body age at
different rates. Therefore, chronologic age cannot readily be a reliable
indicator of health needs. Methods for calculating your “real” or biological
age can give you a better picture of your body's true state of health (see
http://www.biological-age.com/about.html for a calculator you can use for
yourself and your clients). For information on how to make a healthy
transition into older age, see Box 22-2.

1897
BOX 22-2 Levels of Prevention Pyramid
SITUATION: Making a healthy
transition into a satisfying old age GOAL:
Using the three levels of prevention,
prevent or delay chronic diseases,
promptly diagnose and treat conditions,
and restore the fullest possible potential.
Transitioning to Older Age

1898
MEETING THE HEALTH NEEDS OF
OLDER ADULTS
Many factors contribute to healthy aging, including a lifetime of healthy
habits and circumstances, a strong social support system, and a positive
emotional outlook. Most people recognize a healthy older person when they
meet one.
What is healthy old age? Would you consider Minerva Blackstone in Box
22-3 to have a healthy old age? The vast majority (94%) of older adults in
the United States, even those with chronic diseases or other disabilities, are
living outside institutions and are relatively independent. Good health in the
older adult means maintaining the maximum possible degree of physical,
mental, and social vigor. It means being able to adapt, to continue to handle
stress, and to be active and involved in life and living. In short, healthy aging
is being able to function, even when disabled, with the assistance of others as
needed.

BOX 22-3 STORIES FROM THE

FIELD
Minnie Blackstone I am a public health nurse
(PHN) and live next door to Minerva
Blackstone, affectionately called Minnie by her
friends. Minnie is a lively 87-year-old woman
who enjoys life. Every day, except in bad
weather, she walks a half mile to visit her
granddaughter Karen. There, she works on the
quilt she is making for Karen. Twice a week,
Minnie takes the city bus to the senior citizens'
center to join her friends in an exercise class.
Minnie has noticed that her vision and her
hearing are not what they used to be. She can
no longer crochet in the evening with low

1899
 lighting but has found a bright magnifying
lamp to help her continue her hobby. As for her
hearing, Karen has set up an appointment with
the audiologist. Do you know how much
hearing aids will cost Minnie? Will Medicare
pay for them?
Minnie is a happy person but is not content unless she is up on the
latest political developments. She never misses the news and talks about
current events at every chance. She has a good appetite and generally
sleeps well. Minor arthritis does not hamper her activities nor does the
hypertension that she controls by independently taking her medication
daily. Right now Minnie is enjoying a healthy old age. What planning
needs to be made for Minnie when and if her arthritis or other chronic
conditions disable her?

Carole, District PHN

Wellness among the older population varies considerably. It is influenced

by many factors, including personality traits, life experiences, current
physical and cognitive health, current societal supports, and personal health
behaviors Areas of focus for Healthy People 2030 for older adults
(USDHHS, 2020a) include the following:

Increase physical activity for those who have reduced physical and
cognitive function
Reduce pressure ulcer–related hospital admissions
Reduce emergency department visits due to falls
Reduce inappropriate medication use
Reduce hospital admissions due to diabetes
Reduce hospital admissions for pneumonia
Reduce hospital admissions for urinary tract infections

In 2016, the category dementias, including Alzheimer's disease (AD),

was added to Healthy People 2020 topics and objectives and is in the
objectives for Healthy People 2030 (USDHHS, 2020a). This chapter
discusses AD in depth (see Diseases and Conditions Common in Old Age).
Important steps for the care of those with dementia and their caregivers
include earlier diagnosis, reduction of severity of both cognitive and
behavioral symptoms, and supporting caregivers (Healthy People 2020,
2020b; USDHHS, 2020a).

1900
 Other actions that can increase healthy aging include addressing health
disparities among older adults, encouraging people to plan for end-of-life
care and communicate their wishes through advance directives, improving
oral health and increasing physical activity among seniors by promoting
environmental changes, increasing adult immunization levels, and preventing
falls. Some older adults demonstrate maximum adaptability, resourcefulness,
optimism, and activity. Others, often those from whom we tend to draw our
stereotypes, have disengaged and present a picture of dependence and
resignation. Most older adults are somewhere in between these two extremes.
Although the level of wellness varies among older adults, that level can be
raised.
The goals in community health nursing are to maximize the wellness
potential of older adult clients and to support their highest level of functional
ability. Nurses must analyze and build on an older person's strengths rather
than focus on the difficulties or deficits.

1901
LEVELS OF PREVENTION
Older adults, like any age group, have certain basic needs: physiologic and
safety needs, as well as the needs for love and belonging, self-esteem, and
self-actualization. Their physical, emotional, and social needs are complex
and interrelated. The following sections discuss these needs according to
primary, secondary, and tertiary prevention activities.

1902
Primary Prevention
Primary prevention activities involve those actions that keep one healthy.
Such primary prevention activities as health education, follow-through of
sound personal health practices (e.g., flossing, seat belt use, exercise),
recommended routine screenings, and maintenance of an appropriate
immunization schedule ensure that older adults are doing all that they can to
maintain their health.

Nutrition and Oral Health Needs

People who have maintained sound dietary habits throughout their life have
little need to change in old age. Adults aged 80 years and over had the lowest
rate of obesity, 26.7%, from 2013 to 2016 (Healthy People, 2020b). The U.S.
Department of Agriculture (USDA, n.d.) replaced the food pyramid with
MyPlate as a visual to guide the food intake of Americans. Tufts University
has modified MyPlate for older adults (Fig. 22-3). The modifications include
an emphasis on drinking plenty of fluids, including water, tea, and coffee,
and consuming a diet high in fiber. Although multivitamins are not meant to
replace food as a source of nutrients, taking them as a supplement to food to
achieve recommended intakes may be a good idea (Tufts University, 2015).

1903
 FIGURE 22-3 MyPlate for older adults. (Reprinted with
permission. Available at https://hnrca.tufts.edu/myplate/(“My Plate
for Older Adults” Copyright 2016 Tufts University, all rights
reserved. “My Plate for Older Adults” graphic and accompanying
website were developed with support from the AARP Foundation.
“Tufts University” and “AARP Foundation” are registered
trademarks and may not be reproduced apart from their inclusion in
the “My Plate for Older Adults” graphic without express
permission from their respective owners.)

It is generally believed that older people need to maintain their optimal

weight by eating a diet that is low in fats, moderate in carbohydrates, and
high in proteins with a daily calorie count of 1,200 to 1,600 (Fig. 22-4).
Older adults need less vitamin A but more calcium and vitamin D (for
healthy bones), more folic acid, and more vitamins B6 and B12 (for cognitive
health) than younger adults. Many communities offer meals to seniors, either
at senior centers or by way of Meals on Wheels, through grants provided by
the Older Adult Nutrition Program (Administration for Community Living,
2020).

1904
 FIGURE 22-4 Healthy nutrition for older adults. Preparing and
eating meals should be an uncomplicated, natural process, best
shared with others.

Oral health is integral to general health and wellbeing throughout one's

life. Major advances in the field of oral health—including community water
fluoridation, advanced dental technology, better oral hygiene, and more
frequent use of dental services—have had a substantial impact on the number
of older adults who retain their natural teeth. The percentage of older adults
who have lost all their natural teeth has declined to 18%, surpassing the
Healthy People 2020 target of no more than 20% (CDC, 2017b). The
percentage of adults aged 65 or over with a dental visit in the past year was
60.6% (CDC, 2017b). Healthy People 2030 guidelines addresses oral health
and maintenance, with a focus for older adults on receiving treatment for root
decay (USDHHS, 2020a).

1905
 Poor oral health has been associated with peripheral vascular disease,
diabetes, and risk for death caused by pneumonia in nursing homes
(Almirall, Serra-Prat, Bolibar, & Balasso, 2017). Even those with dentures
must be vigilant in maintaining oral health, as they are still at risk from
inflammatory processes leading to diseases such as pneumonia. Many older
adults, especially those who are disadvantaged or have limited incomes, have
decreased nutritional and fluid intake, changes in gums, and increased
periodontal disease, as well as a higher incidence of dry mouth.
Fluid intake and oral hygiene are appropriate topics for anticipatory
guidance from C/PHNs working with older adults. Take the time to assess
the older adult's oral cavity, including mucosa, denture fit, and any
complaints about chewing or swallowing.
In addition to maintaining a healthy diet, older adults are cautioned to
limit the use of alcohol. Any person can have a problem with alcohol, and it
is not unusual for older adults to have an alcoholic drink. Use of alcohol can
lead to falls or car crashes (National Institute for Aging [NIA], 2020a). As
with all adults, older persons should avoid tobacco, drink fluoridated water
or use fluoride toothpaste, practice good oral hygiene, and have regular
dental checkups (CDC, 2017b). They should also avoid the habitual use of
laxatives, instead adding more fluids, fiber, and bulk to their diet with fresh
fruits and vegetables. Also, inadequate fluid intake can contribute to bowel
and bladder problems. Increased physical activity and exercise help maintain
regularity of bowel function in older adults.

Exercise Needs
Older adults need to exercise; in fact, they thrive when exercise is
incorporated into their daily routine (National Institute on Aging, 2020b).
Research demonstrates that exercise and increased physical activity have
multiple benefits for the older adult, including:

Arthritis relief, restoration of balance and reduction of falls,

strengthening of bone, proper weight maintenance, and improvements in
glucose control, cognitive and brain function, and overall mortality
(Macera, Cavanaugh, & Belletiere, 2017)
A healthy state of mind, improved sleep, and reduced risk of heart
disease (Roitto et al., 2018)
Decreased incidence of osteoporotic fractures due to a reduced risk of
falling, with an exercise routine that includes activities to improve
strength, flexibility, and coordination, even among the very old

The C/PHN should explore the kinds of activity that appeal to older
adults, including walks. A wide variety of activities are appropriate for and
benefit older adults:

1906
 In one study, older adults who were informed about the benefits of
walking walked more than those who were reminded of the negative
consequences of not walking (Notthoff & Carstensen, 2017).
Exercise may occur with others in connection with such activities as
homemaking chores, gardening, hobbies, or recreation and sports.
Resistance training (with small dumbbells or resistance bands), along
with either Tai Chi or regular walking, has been shown to increase
muscle strength, stability, and functional ability among seniors
(Healthfinder.gov, 2020).
Physical disabilities need not be a barrier to exercise, as there are
specialized exercise programs (e.g., chair aerobics, wheelchair fitness).

Sleep
Sleep is another area of focus in Healthy People and is important to older
adults for the following reasons:

In older adults, adequate sleep is necessary to fight off infection and

support the metabolism of sugar to prevent diabetes or to work
effectively and safely.
Sleep timing and duration affect a number of endocrine, metabolic, and
neurological functions that are critical to the maintenance of individual
health.
Untreated, sleep disorders and chronic short sleep are associated with an
increased risk of depression, heart disease, high blood pressure, obesity,
diabetes, and all-cause mortality (Gulia & Kumar, 2018).

Some changes in sleep are natural with aging, such as:

Decreased slow-wave or deep sleep due to the body producing lower

levels of growth hormone
Altered circadian rhythms (the internal clock that tells one when to
sleep and when to wake up), causing the older adult to want to go to
sleep earlier in the evening
Nighttime wakefulness and interrupted sleep due to pain, the need to
void, medications, and snoring, which may worsen with age (Gulia &
Kumar, 2018)

The C/PHN can assess and help older adults having sleep challenges by:

Asking them to keep a sleep journal

Investigating their nighttime voiding patterns
For men, assessing for the possibility of an enlarged prostate, which can
cause problems with complete bladder emptying and may need
treatment

1907
 Objectives for Healthy People 2030 focus on reduction of accidents due
to driving while drowsy, providing treatment for those with obstructive sleep
apnea, and sufficient sleep (USDHHS, 2020a).

Economic Security Needs and Poverty

Economic security is a major need for older adults. Many older adults work
beyond retirement age for reasons of enjoyment and purpose, but they may
also be concerned about having financial stability through the rest of their
lives. Factors affecting economic security in older adults include the
following:

Having to spend retirement resources caring for elderly parents or

grandchildren
Limited income and reliance on Social Security and Supplemental
Security Income, with half of all people on Medicare in 2016 having
incomes of <$26,200 (Kaiser Family Foundation, 2018)

Fearing the potential cost of major illness and wanting to avoid being a
burden on family or friends, many older people conserve their limited
finances by practices that may threaten their health:

Adopting frugal eating patterns

Skipping or taking only partial doses of medications
Limiting the use of home heating and cooling
Spending little on themselves, in general

For older adults today who have lived many years past retirement
without sufficient financial security to maintain them throughout these
additional years, fears are not unfounded. More than a quarter of Hispanic
older adults and nearly a quarter of Black older adults lived in poverty in
2016, compared with around 1 in 10 White adults aged 65 or older (Kaiser
Family Foundation, 2018).
Many older adults are not aware that there are important preventive
health measures and community-based programs that can maximize function
and help older adults maintain health at a higher level (U.S. Preventive
Services Task Force [USPSTF], 2018b). C/PHNs should be familiar with and
share with their clients local support services that may provide housing, food,
and utilities for older people in need, which can do much to help relieve the
source of that stress and anxiety.

Psychosocial and Spiritual Needs

1908
All human beings have psychosocial needs that must be met for their lives to
be rich and fulfilling. Typically, aging is seen as a time of loss and decline,
and much research focuses on the physiological and psychological impact of
multiple losses and decline. However, some research indicates that older
adults actually pay attention to and remember positive information and
memories more than younger people do (American Psychological
Association, 2020). There may be biological and psychological reasons for
this:

The amygdala in the brain reacts to emotions, and biological research

indicates that older adults may not react at a brain level to negative
information in the way the younger adults do (Mather, 2016), meaning
that they may be more likely to gather and hold onto only their good
memories.
For many, old age may be a time of life reflection, review, and
reevaluation of what gives meaning and satisfaction in life. Knowing
that they have limited time, older adults may choose to focus on positive
emotions.

However, with a lack of healthy relationships with other people, life can
be very lonely and diminished in quality for older people.
Holistic nursing is a hallmark of community and public health nursing.
This means a focus on the body, mind, and spirit. The word spirit comes
from the Latin meaning “breath” and refers to the core of an individual, the
part that gives meaning to life (New World Encyclopedia, n.d.). Although
related, religion and spirituality are distinct concepts:

A spiritual component exists in all people but not everyone is religious.

Religion is generally recognized to be the practical expression of
spirituality or the organization, rituals, and practice of one's beliefs.
Religion includes specific beliefs and practices, whereas spirituality is
far broader.

According to the Pew Forum, belief in God continues to be very

important to older adults, including the younger baby boomers, even though
religious practices vary (Pew Research Center, 2018). Whereas other sources
of wellbeing decline, religion may become more important over time.
Individuals within different cultures have varying philosophies and practices
of spirituality but derive similar positive outcomes.
Faith-based nursing is one of the community nursing roles that
epitomizes this holistic approach of caring for one's clients, many of whom
are older adults. See Chapter 29 for an in-depth discussion of faith
community nursing.

1909
Coping With Multiple Losses and Suicide
Older adults may experience multiple losses, including loss of income and
purpose from a career once practiced, loss of the economic stability of
employment, and loss of space due to replacement of a larger residence,
where the older adult may have raised a family. The loss of a spouse after 50
years of marriage may have a huge impact on the remaining partner. Short-or
long-term declines in health may result in pain or limited mobility and may
necessitate multiple moves, such as a move to a child's home, a move to an
assisted living facility, and a move to a skilled living facility. Repetitive
losses occur as significant others, relatives, friends, and acquaintances die.
There is no right or wrong way to grieve, but there are healthy and unhealthy
ways to cope with the pain. Assisting older adults with handling these losses
is an important role of the public health nurse. To do this, C/PHNs need to be
aware of some of the facts about grief.
As Kübler-Ross (1969) stated in her classic work, there are five stages of
grief: denial, anger, bargaining, depression, and, finally, acceptance.
Inadequate coping with the compounding losses can make an older person
believe that life holds no meaning. Depression may be a difficult problem for
older adults. Social and emotional withdrawal can often occur, as can
suicide.

Among the risk factors for suicidal behavior in older adults are the loss
of a spouse; having other mental disorders, such as dementia and
depression; physical illnesses or decline; and social isolation.
Although older populations have a much lower rate of suicide attempts
than younger age groups do, the rate of completed suicide is high
(Conejero, Olie, Courtet, & Calati, 2018). The rates of suicide may be
underreported, given the negative stigma around suicide, especially in
older adults.

Community health nurses should be observant of risk factors and be

prepared to ask questions, including whether the client is suicidal, as older
adults are not likely to talk about the subject (Diggle-Fox, 2016). Asking
someone whether he or she is suicidal does not put the idea in the person's
head. This is a myth. Most people are grateful that they have been asked. If
you think someone is suicidal, do not let them be left alone; seek further
services for the older adult.
Older adults who have maintained good health and developed a
supportive system of family and friends have more fulfilled lives (Fig. 22-5).
Churches, universities, and senior service programs often have volunteers
who regularly meet with isolated seniors either in their homes or long-term
care facilities, increasing social support for those who have no family
members nearby.

1910
 FIGURE 22-5 A supportive system of family and friends helps
older adults meet their psychosocial needs.

Explore the senior services available in your community on the Internet.

Good examples are the local Area Agency on Aging (AAA), the local health
department, senior community centers, and the YMCA. Some counties have
a senior resources guide. The Eldercare Locator, available at
https://eldercare.acl.gov/Public/Index.aspx, can provide current information
on local caregiver services and resources.

Maintaining Independence
The need for autonomy—to be able to assert oneself as a separate individual
—is important for all people. Independence helps to meet the need for self-
respect and dignity. Older adults need to have their ideas and suggestions
heard and acted upon, and they ought to be addressed by their preferred
names in a respectful tone of voice. Respect for the older adult is not a strong
value in American society, but it is highly valued in Asian, Italian, Hispanic,
and Native American cultures. Older people represent a rich resource of
wisdom, experience, and patience that is often unacknowledged in the United
States.
Older adults who are in poverty, minorities, or veterans and who
experience poorer health need support at home to remain independent.
Communities work with local, state, and federal agencies to create programs
to provide support to older adults who need assistance but want to remain in
their home communities. A good example of a program supporting older
veterans at home is the Veteran in Charge program in Colorado Springs,
Colorado. This program allows veterans to receive community-based
services to continue living in their homes as long as possible and gives them
control of the who, what, when, and how much related to the care
(https://www.theindependencecenter.org/veterans/).

1911
Interaction, Companionship, and Purpose
Baby boomers, who started to reach the retirement age of 65 in 2011, have
changed the face of aging. Nearly 75% of boomers feel that full-time
retirement is not for them. This may be, in part, because they are not
financially prepared to live another 20 years past retirement (AARP, 2016).
As the largest and healthiest aging cohort, they may also be the most
engaged.
However, not everyone will be employed after the age of 65. Some may
be challenged with physical or mental impairments or caring for spouses or
parents. A new phrase in our language is “Grand families.” It is possible that
grandparents and even great grandparents may be cutting into their own
finances to care for grandchildren whose parents may have been deployed or
are struggling with substance abuse.
Programs exist to support older adult caregivers. Examples include the
federally supported Foster Grandparents and Senior Companions programs,
which engage millions of Americans in service (Fig. 22-6). These older
adults work part-time offering companionship and guidance to handicapped
children, the terminally ill, and other people in need (Corporation for
National & Community Service, n.d.).

FIGURE 22-6 Volunteering can be a rewarding experience for

older adults.

In cases where family and social networks have weakened, C/PHNs and
others can help to improve their psychosocial health by working at
individual, family, and community levels. The problem is of greatest
significance for women, who outnumber men considerably in the later years
and who more frequently live alone. Take time to explore skills that older

1912
adults can do from home: letter writing, volunteer phone calling, or crafting
for others who are ill.

Safety and Health Needs

Safety issues are a major concern for older adults and the C/PHNs who work
with them. Several areas of focus are discussed here: personal health and
safety, home safety, and community safety.
Personal health and safety includes three major areas: immunizations,
home safety and prevention of falls, and drug safety (Box 22-4).

BOX 22-4 C/PHN USE OF THE NURSING

PROCESS

Nursing Care Plan For Community Older Adults:

Example of Risk For Falls: Ms. Belmont Ms.
Belmont lives with the companionship of an
elderly Dalmatian dog. She goes out with her
daughter occasionally for lunch and for
appointments. Generally she and her dog are at
home. At 94 years old, she states that she isn't as
strong as she used to be and has mentioned
concern that she may trip over her dog.
Problem Statement
Fall prevention

Desired Outcomes
No falls
No fall-related injuries
Can demonstrate preventive measures (take up any loose rugs, remove
electric cords, etc.)
Implements strategies to prevent falls at home (e.g., coaches the dog
verbally to stay in front of her walker, locks the cellar door to remind
herself to avoid the stairs)

1913
Contributing Factors
Altered mobility and physical impairments: osteoporosis, neuropathy,
impaired balance
Sensory and cognitive impairments: profound hearing loss, macular
degeneration, mild cognitive impairment
Sleep problems
Home safety: dog in the way
Environmental concerns: bathroom and bedroom setup, distance to
kitchen

Immunizations

1914
Older adults are at increased risk for many vaccine-preventable diseases.
Preventable illnesses cause substantial morbidity and mortality in older
patients, who tend to have more medical comorbidities and are at higher risk
for complications. Acute respiratory infections, including pneumonia and
influenza, are the eighth leading cause of death in the United States,
accounting for 56,000 deaths annually (CDC, 2019a).
Nonetheless, vaccination rates in the United States do not meet targets
for vaccination against flu and pneumonia, such as the Healthy People 2020
target of 90%. Healthy People 2030 objectives target a reduction in hospital
admissions due to pneumonia by older adults (USDHHS, 2020a). Although
influenza does kill an estimated 36,000 people per year, in older adults, it is
the exacerbating effect it has on other conditions (e.g., pneumonia,
congestive heart failure, or chronic obstructive pulmonary disease [COPD])
that is of greatest concern (National Foundation for Infectious Diseases,
2018).
Racial and ethnic disparities exist among older adults receiving influenza
and pneumonia vaccines; therefore, it is important to engage in outreach
efforts to these populations, such as culturally targeting communication,
reaching out to those providers serving this population, and offering
vaccination clinics in underserved sections of the community. The CDC
regularly updates immunization guidelines for older adults (CDC, 2020c).
Attempts to improve immunization coverage involve changing provider
knowledge, attitudes, and behavior through reminders and standing orders, so
that “missed opportunities” when seeing clients are prevented. Additional
opportunities for vaccinating people exist beyond the primary care setting, as
C/PHNs are well aware. Regardless of the site, a method for tracking and
communicating vaccinations is needed so that vaccination information may
be documented and shared with the elder's primary care provider.
Shingles is caused by the varicella–zoster virus (VZV); this is the same
virus that causes chickenpox. Anyone who has had chickenpox can develop
shingles because VZV remains in the nerve cells of the body after the
chickenpox infection clears, and VZV can reappear many years later causing
shingles. Shingles is a very painful localized skin rash, often with blisters.
The disease most commonly occurs in people 50 years or older, people who
have medical conditions that keep the immune system from working
properly, or people who receive immunosuppressive drugs. A new shingles
vaccine called Shingrix (recombinant zoster vaccine) was licensed by the
U.S. Food and Drug Administration (FDA) in 2017. The CDC recommends
that healthy adults aged 50 years or older get two doses of Shingrix, 2 to 6
months apart (CDC, 2018a ). Shingrix provides strong protection against
shingles, and C/PHNs should advise clients about this vaccine.

Fall Prevention

1915
According to the CDC STEADI fact sheet, every 20 minutes an older adult
dies from a fall, and one in five falls causes a serious injury, such as a head
trauma or a fracture. Furthermore, fewer than half of fallers talked to the
primary provider about the fall. Medicare costs for fall injuries total over $31
billion dollars annually (CDC, 2019b). In fact, falling once can double your
chances of falling again. In 2017, medical costs for falls exceeded 50 billion
dollars, with Medicare and Medicaid responsible for 75% of these costs
(CDC, 2017c). Although not all falls cause serious injuries, effects from
falls, such as decreased mobility and excessive bleeding due to taking
medications such as blood thinners, lead to additional concerns (CDC,
2017c).
Environmental hazards (e.g., lack of nonslip surfaces and handrails) and
host conditions (e.g., poor vision, problems with balance) are often the
causative factors in falls. Falls are a preventable problem. The CDC STEADI
initiative has a toolkit that includes screening tools and other clinician and
patient resources to guide you in preventing falls in older adults (2019b).
We have all heard stories about older adults who have fallen and
fractured a hip and who were not wearing technology that could have helped
them call for assistance, such as a pendant alert. Today, more than in any
other time, older adults can be safer and more comfortable at home or in a
facility as the result of smart home technology and wearable monitoring.
Smart homes may include environmental, activity, and physiological sensors,
with more affordable systems being developed in a rapidly expanding market
(Boxes 22-5 and 22-6; Majumder et al., 2017). Smart homes have been
purported as a method to safeguard senior safety through alerts and
notification related to falls, first aid, and detection of unattended cooking
(Wong, Skitmore, & Buys, 2017). One study looked at the use of smart home
technologies in older individuals in Hong Kong. Seniors reported concerns
related to confidence in the use of machines specifically, technical problems,
and the inability to fix a problem. However, seniors did like automation
processes such as reminders, because this reduced the need for outside
assistance (Wong et al., 2017).

BOX 22-5 Guidelines for Assessing the

Safety of the Environment
Illumination and Color Contrast
Is the lighting adequate but not glare producing?
Are the light switches easy to reach and manipulate?
Can lights be turned on before entering rooms?
Are night-lights used in appropriate places?

1916
 Are there working flashlights close by (bedroom, kitchen, bath,
living room)?
Is color contrast adequate between objects such as a chair and
floor?

Hazards
Are there throw rugs, highly polished floors, or other hazardous
floor coverings?
If area rugs are used, do they have a nonslip backing and are the
edges tacked to the floor?
Are there cords, clutter, or other obstacles in pathways?
Is there a pet that is likely to be running underfoot?

Furniture
Are chairs the right height and depth for the person?
Do the chairs have armrests?
Are tables stable and of the appropriate height?
Is small furniture placed well away from pathways?

Stairways
Is lighting adequate?
Are there light switches at the top and bottom of the stairs?
Are there securely fastened handrails on both sides of the stairway?
Are all the steps even?
Are the treads nonskid?
Should colored tape be used to mark the edges of the steps,
particularly the top and bottom steps?

Bathroom
Are grab bars placed appropriately for the tub and toilet?
Does the tub have skid-proof strips or a rubber mat in the bottom?
Has the person considered using a tub seat?
Is the height of the toilet seat appropriate?
Has the person considered using an elevated toilet seat?
Does the color of the toilet seat contrast with surrounding colors?
Is toilet paper within easy reach?

Temperature

1917
 Is the temperature of the room(s) comfortable?
Can the person read the markings on the thermostat and adjust it
appropriately?
During cold months, is the room temperature high enough to
prevent hypothermia?
During hot weather, is the room temperature cool enough to
prevent hyperthermia?

Overall Safety
How does the person obtain objects from hard-to-reach places?
How does the person change overhead light bulbs?
Are doorways wide enough to accommodate assistive devices?
Do door thresholds create hazardous conditions?
Are telephones easily accessible, especially for emergency calls?
Would it be helpful to use a cordless portable phone or a cellular
phone?
Would it be helpful to have some emergency call system available?
Does the person wear sturdy shoes with nonskid soles?
Are smoke alarms present and operational?
Is there a carbon monoxide detector (if the house has gas
appliances)?
Does the person keep a list of emergency numbers by the phone?
Does the person have an emergency exit plan in the event of fire?

Bedroom
Is the height of the bed appropriate?
Is the mattress firm at the edges to provide enough support for
sitting?
If the bed has wheels, are they locked securely?
Would side rails be a help or a hazard?
When side rails are in the down position, are they completely out
of the way?
Is the pathway between the bedroom and bathroom clear of objects
and adequately illuminated, particularly at night?
Would a bedside commode be useful, especially at night?
Does the person have sufficient physical and cognitive ability to
turn on a light before getting out of bed?
Is furniture positioned to allow safe use of assistive devices for
ambulation?
Is a telephone situated near the bed?

1918
 Kitchen
Are storage areas used to the best advantage (e.g., are objects that
are most frequently used in the most accessible places)?
Are appliance cords kept out of the way?
Are nonslip mats used in front of the sink?
Are the markings on stoves and other appliances clearly visible?
Does the person know how to use the microwave oven and other
appliances safely?

Assistive Devices
What assistive devices are used?
Is a call light available, and does the person know how to use it?
Would the person benefit from any assistive devices that are not
being used?
Are assistive devices being used safely and properly, or do they
present additional hazards?

Source: Miller (2019).

BOX 22-6 QSEN: Focus on Quality

Safety for Older Adults
Safety: Minimizes risk of harm to patients and providers through both system
effectiveness and individual performance (Cronenwett et al., 2007, p. 126).

(See https://qsen.org/competencies/pre-licensure-
ksas/#quality_improvement for the knowledge, skills, and attitudes
associated with this QSEN competency.) Nurses must deliver safe and
effective care. Not only must they be vigilant in the safety of the care they
provide, they are also tasked with proving a safe environment for the patient.
In the community setting this can be difficult, because patients and families
may need assistance or education regarding home safety. C/PHNs may be
able to identify issues or concerns based on home visits and discussions with
patients and their families and are positioned to provide support and
education.
For example, a C/PHN working in a metropolitan city makes a home
visit to Margaret, a 90-year-old woman living alone, following her
hospitalization for a fall. The nurse discovers that despite using a walker,
“Maggie” is spry, alert, and attentive. In the 900-square-foot home, the nurse
notes many small rugs scattered around and furniture cluttered within every

1919
room, limiting walking space. Maggie states that she has lived in this house
for 70 years and is not moving. The daughter is present for the home visit,
and the son lives two blocks away; both check in on their mother daily.

1. What risks are presented in this situation?

2. How would you address safety for the patient and her family?
Source: Cronenwett et al. (2007); Dolansky and Moore (2013).
Risk factors for falls include (CDC, 2017c, para, 4) the following:

Difficulty with walking and balance

Vitamin D deficiency
Medications that effect balance such as tranquilizers, sedative, or
antidepressants
Vision problems
Poor footwear
Hazards such as throw rugs, clutter, and uneven steps

Medications
Medications are often prescribed to control the effects of chronic conditions.
A significant safety issue for the older adult arises from the use of
prescription and over-the-counter (OTC) drugs. Problems can arise from a
single difficulty or a combination of issues such as:

Number of medications taken daily

Absorption rate of medications
Drug interactions
Side effects

In addition, the more medications taken daily, the higher the rate of
nonadherence to the schedule (Chou, Tong, & Brandt, 2019). This problem is
compounded when older adults have visual or cognitive impairments. Older
adults often have multiple chronic diseases for which they take prescription
medications. It is not unusual for older people to be taking four to six
medications daily. The use of multiple drugs, called polypharmacy, is
defined as using from 5 to 10 prescription drugs (Golchin, Frank, Vince,
Isham, & Meropol, 2015). For example, an older adult with two chronic
diseases, such as heart failure and COPD, is likely to take more than five
medications.
Older adults often receive multiple prescriptions from multiple providers
and sometimes from multiple pharmacies, including mail-order pharmacies.
They are less likely to see the pharmacist in person, and these circumstances
put older adults at risk of receiving the same or similar medications in error.
For example, an older adult living in the community has arthritis and heads

1920
to the pharmacy for pain management. Many of the pain medications the
older adult considers contain acetaminophen (Tylenol). However, this older
adult is already taking prescribed pain medication that contains
acetaminophen and thus is at risk of overdosing.
Medication side effects or drug interactions can lead to falls and further
disability. Older adults need education about the drugs they take and their
possible effects. They also need proper supervision of their overall
medication intake, including complementary and alternative therapies (e.g.,
herbal treatments) and OTC drugs. It is also important for all seniors to keep
a list of their current medications and doses and to have this available in the
event of an emergency. This is an area in which the community health nurse
can intervene very effectively (Box 22-7).

BOX 22-7 Preventing Polypharmacy in

Older Adults Below are some strategies
you can use to help patients reduce the
risk of polypharmacy.
Recommendations
Use the correct medication, at the correct dose, and for the shortest
duration.
AMOR
Assess medications and review for interaction.
Minimize nonessential medications.
Optimize by noting duplication.
Reassess patient for function, cognition, clinical status, and
medical adherence.
Start low and go slow is recommended for medication
prescriptions of older adults.

Nurse's Role
Look for duplications in drugs—same category or drug
classification.
Are the medication dosages therapeutic?
Are there any interactions such as drug–drug, drug–food, or drug–
disease?
Are any nondrug therapies being used?
Source: Smith and Kautz (2018).

1921
 Research evidence indicates that polypharmacy in older adults is being
addressed by the use of appropriate screening tools such as the Beer's criteria
and STOPP Screening tool (https://consultgeri.org/try-this/general-
assessment/issue-16). C/PHNs can help by doing a thorough medication
review with older adults (Box 22-7).

Safety in the Community

Safety can involve many things, such as pedestrian and driving issues, crime
and fear of crime against older adults, and environmental factors such as sun
exposure, pollution, heat, and cold.
Because of age-related changes in vision, hearing, and mobility and the
effects of polypharmacy, older adults are at risk in the community as
pedestrians and as drivers. Automobile crashes and pedestrian injuries can be
life-threatening events when elders are involved. As pedestrians, older adults
must be increasingly vigilant to traffic patterns, sidewalk irregularities, and
the possibility of being a victim of street crime.
Often out of necessity and pride, older people may drive longer than their
abilities permit. The C/PHN may recommend resources for families who
need to talk about driving safety https://www.aarp.org/auto/driver-safety/we-
need-to-talk/ (AARP, n.d.).
Although many older adults are fearful of being victims of crime, rates of
nonfatal violent crime and property crime against the elderly are lower than
in all younger age groups. See Box 22-8 for actions the C/PHN can take to
assist elders with a fear of crime.

BOX 22-8 Simple Steps to Prevent

Crime and Identity Theft
Never open the door automatically; always keep doors and
windows locked.
Use neighborhood watch to keep an eye on your neighborhood.
Don't leave notes on the door when going out.
Let someone know when you are away and cancel deliveries.
Keep the lights on at night and use a timer.
Keep an inventory of serial numbers and photographs of valuable
items; keep copies in a safe place.
Ask for proper identification of delivery persons or strangers. Do
not let a stranger in your home.
Never give out information on the phone letting someone know
you are alone.

1922
Use direct deposit as much as possible, and keep valuables in a
safe deposit bank box.
Be wary of unsolicited offers to fix your home. It could be a scam.
If it happens, report it to the police right away.

1923
Secondary Prevention
Secondary prevention focuses on early detection of disease and prompt
intervention (see Chapter 1). Much of the C/PHN's time is spent in educating
the community on preventive measures and positive health behaviors. This
includes encouraging individuals to obtain routine screening for diseases
such as hypertension, diabetes, or cancer, which, if identified early, can be
treated successfully. Many nurses, working in collaboration with community
agencies, are in positions to establish screening programs based on the
desires and demographics of the community and agency focus, making them
accessible to the population being served.
Older adults need to be encouraged to follow the routine health screening
schedule prescribed by their clinic or health care provider. See Chapter 21 for
information on adult screenings (see
http://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html for a
recommended immunization schedule for older adults).

Diseases and Conditions Common in Old Age

Four of five older adults experience at least one chronic condition, and many
suffer multiple chronic conditions as they progress into older age.
Cardiovascular disease, cancer, diabetes, and obesity are common to all
adults and are discussed in depth in Chapter 21. AD is covered in this chapter
as a disease of older adults, as well as arthritis, sensory loss, depression, and
osteoporosis. Common chronic conditions seen in older adults are as follows:

Alzheimer's disease
Arthritis
Cardiovascular disease
Depression
Diabetes
Hearing loss
Obesity
Osteoporosis

The prevalence of chronic disease and resulting disability in older adults

require health promotion behaviors and guidance. Chapter 21 covers
appropriate preventive services recommended for older adults (see
Screenings and Checkup Schedule for Women and Men in on of
Chapter 21).

Alzheimer's Disease

1924
 Alzheimer's disease (AD) is the most common form of dementia in
older adults, first described in 1907 by Dr. Alois Alzheimer, who
depicted many of the symptoms that are now known as Alzheimer's
dementia. AD is the sixth leading cause of death and the only disease
among America's top 10 that cannot be prevented or cured.
Ethnically diverse older adults face a higher risk: African Americans are
twice as likely and Hispanics one and one-half times more likely to
develop AD than Whites (Mayeda et al., 2016).

Although much is still unknown about this devastating age-related

disease, the Alzheimer's Association (AA, 2020a) annually releases a report
of the current scientific findings. To identify AD, a comprehensive
examination is needed (see Box 22-9). AD causes more deaths than breast
and prostate cancer combined. Yet less than half of those diagnosed with AD
or their caregivers report being told of their diagnosis, in contrast to 90% of
persons with any of the four most common types of cancer being told.

BOX 22-9 Annual Cognitive Assessment

Although there is no single test to
identify Alzheimer's disease (AD) (AA,
2020b), annual cognitive assessment
recently became a mandatory
component of the Annual Wellness Visit
(AWV) required for all Medicare and
Medicaid enrollees (Borson et al., 2013;
Scott & Mayo, 2018). It is recommended
that health care providers offer a
comprehensive examination during this
AWV (Wiese & Williams, 2015). A
complete health and family history—
including cognitive, behavioral, and
psychiatric, physical exam, lab tests,
neurologic, functional, and mental status

1925
 assessments—are essential. A
comprehensive assessment is needed
because many conditions, including
some that are treatable or reversible
(e.g., thyroid disease, depression, brain
tumors, drug reactions), may cause
dementia-like symptoms.
C/PHNs are well positioned to initiate a discussion about memory
with their clients and family members as the first step of assessment for
cognitive decline, followed by a brief 5-minute screening using one of
several methods recommended by an AA workgroup (Cordell et al.,
2013; Scott & Mayo, 2018), such as Borson's (2013) MiniCog, which
involves a clock-drawing test and recall of three words. Another tool is
the Quick Dementia Rating Scale (Galvin, 2015), which asks family
members 10 questions regarding the client's functional ability; the
patient's responses give a clear indication of dementia risk. If an AD
diagnosis is given, the nurse can provide anticipatory guidance on
managing potential behavior changes and help the family to plan for
future care needs. Early and accurate diagnosis could save up to 7.9
trillion in care costs by 2050 (AA, 2020b).

Dr. Lisa Wiese, Assistant Professor, Florida Atlantic University

Between 2017 and 2025, every state is expected to see at least a 14% rise
in the AD prevalence (AA, 2020b). Because of this growth, Healthy People
2020 designated dementias, including AD, as a focus area ( Healthy People 2020,
2020c ). Healthy People 2030 guidelines highlight the need for early
identification, reduction in preventable hospitalizations, and communication
with a provider regarding care and treatment (USDHHS, 2020a).
The occurrence of AD is not a normal development in the aging process.
Damage to the brain from AD can begin 20 years prior to the onset of
symptoms (AA, 2020b). One of the major contributors to AD is the slow
accumulation of “plaques and tangles” that interfere with brain function. A
concentration of tau proteins result in tangles and block the transport of
essential nutrients inside the neurons. Plaques result from an excess amount
of beta-amyloid, which are thought to interrupt the neuronal communication
at brain synapse. The increased presence of tau proteins and beta-amyloid
activates the production of microglia, which are charged with clearing these

1926
toxins. Unfortunately, the microglia are overwhelmed by the amount of
proteins and debris left by dying cells, and a harmful chronic inflammatory
response ensues. The result is even more cell death and brain atrophy.
Another contributor to decreased brain function is the consequent decreased
ability of the brain to metabolize its main fuel, glucose. Persons with diabetes
and cardiovascular disease were recently found to have a higher risk for AD
and related dementias (ADRD). This led to the additional findings that a
combination of a person's health, environmental factors, and lifestyle choices
in addition to age-related and genetic factors influence the onset and
progression of AD (AA, 2020b).

There is a simple means of describing the difference between the

normal forgetfulness of aging and AD. We may forget where we have
placed our keys, but upon finding them, we remember why we needed
the keys, whereas a person with AD loses immediate recall.
People in the preclinical Alzheimer's stage eventually notice that they
are forgetting recent activities or events, or names of familiar things or
people (AA, 2020b).
In the mild stage, persons may be able to work, drive, and participate in
well-known activities but may become lost or forget commonly used
words. A typical sign of Alzheimer's is the difficulty in creating new
memories, as the limbic system where memories are stored is often the
area affected first by beta-amyloid plaques and neurofibrillary tangles.
As the disease advances, the symptoms become serious enough to cause
people with AD or their family members to recognize that things are
“not right” and that help is needed. The moderate stage is characterized
by struggles to complete routine tasks, wandering, and behavior and
personality changes. Persons may become agitated, experience paranoia,
and begin to lose the ability to complete ADLs.
Persons in the severe stage of Alzheimer's dementia become bedbound
and cannot communicate in words that can be understood by others
(AA, 2020b).
On average, a person with AD lives 4 to 8 years after diagnosis but can
live as long as 20 years, depending on other factors (AA, 2020b).
Contrary to the myth, persons with AD are still the same person they
once were, but their current reality is different.

Several medications have been approved for use with persons diagnosed
with Alzheimer's dementia. Medications called cholinesterase inhibitors are
prescribed for mild to moderate AD. Memantine is prescribed for moderate
to severe stages, often in combination with donepezil. However, these drugs
only delay the progression of symptoms for a limited time. At best, available
medications “turn back the clock somewhat” with the disease worsening at a

1927
slower rate, or the drugs control some of the client's behaviors that jeopardize
safety, thereby promoting caregiver management.
How does this disease impact the role of the C/PHN? First, the C/PHN
can conduct family teaching regarding health behaviors that may reduce the
risk of ADRD, such as staying active, exercising, healthy eating habits,
adequate sleep, and managing cardiovascular risk factors (diabetes, smoking,
obesity, and hypertension (AA, 2020b)). The C/PHN can stress the
importance of completing the Medicare Annual Wellness Visit, including
routine cognitive screening to detect early signs and symptoms of MCI,
which provide the opportunity to investigate other possible causes of decline.
Early detection benefits also include the following:

Effective management of coexisting conditions

Appropriate use of available treatment regimens and holistic modalities
Pursing health-promoting activities; brain games, exercise, improved
nutrition, and sleep patterns
Coordination of care between all members of the health care team,
including providers and caregivers
Encouraging the client and family to participate in activities that bring
joy/are meaningful
Accessing support services, day centers, and caregiver support groups

Learning about the illness and ADRD management that will decrease
care costs is essential, where nearly one in every five Medicare dollars is
spent. Average per person Medicare spending for those with ADRD is three
times higher than average per person spending across all other seniors.
Medicaid payments are 19 times higher (AA, 2020b). These 2018 figures did
not include caregivers, who provide 83% and over 18 billion hours of unpaid
care to those with ADRD, valued at $232 billion (Black et al., 2018).

The person with dementia often exhibits depression, agitation,

sleeplessness, and anxiety, which disrupt the caregiver's normal routine,
greatly adding to caregiver stress. Caregiver burden is multiplied by
new or worsening illness, creating a further demand on health care
resources. Caregivers experience twice the rate of anxiety and
depression as other caregivers (Zhu et al., 2015).
In many situations, the main caregiver is an aged spouse. The C/PHN
can make a difference in health outcomes for both the person with
ADRD and their caregiver by helping to connect families to community
resources (Box 22-10).

BOX 22-10 C/PHN Use of the Nursing

Process Resources for Managing

1928
Alzheimer's Disease Assessment
Mr. and Mrs. Boxwell are in their early 80s and have lived modestly on
a fixed income since Mr. Boxwell's retirement. However, their budget
has been strained this year as they have had $300 to $400 a month in
out-of-pocket expenses for prescription medications. Mrs. Boxwell
confessed to you (the C/PHN visiting them after receiving a referral
from the senior center) that during some months, they will skip
medication doses to “make ends meet.” Mrs. Boxwell is diabetic, Mr.
Boxwell has heart failure, and they both take medications for
hypertension. They live in a small, older home, and their older model
car is seldom driven as they report “the traffic is getting worse” and
they have “come close to having a car crash two times” lately. They are
receptive to your suggestions and are trying to stay healthy and
independent.

Problem Statements
1. Health status altered as a result of insufficient finances to purchase
needed medications for chronic diseases 2. Altered safety and
diminished driving skills Plan and Implementation

Problem Statement 1
The C/PHN will explore the clients' eligibility for Medicare Part D and
Medicaid. It is possible that these clients are eligible, yet unaware of
these programs. The nurse will look at Benefits CheckUp, a service of
the National Council of Aging that has information on benefits
programs for older adults (benefitscheckup.org).
The C/PHN will consult with the clients' primary health care
provider and ask for a change in prescriptions from brand names to
generic. Also, ordering some medications in larger doses that come in
scored tablets may be less expensive, and the client can safely break the
larger pills in half. Mrs. Boxwell will check with her present distributor
of diabetic supplies about getting larger quantities, generic brands of
syringes, alcohol pads, etc.

Problem Statement 2
Mr. Boxwell will look into selling the car and exploring the bus
schedule and other senior shuttle services that can be used to travel to
the doctor and grocery store. Mr. and Mrs. Boxwell's daughter spends a
day with them monthly and takes them wherever they want to go, as
long as it is “a fun outing,” and they will look into coordinating errands
with her.

1929
 Evaluation
The couple is eligible for Medicare Part D, and this will help defray the
out-of-pocket costs for medications. They have reduced medication
costs as much as possible and report not missing any prescribed
medications.
They sold their car and are negotiating the bus in good weather and
using a taxi in the winter or when it is raining (they figured they save
$1,000 a year in auto insurance, auto maintenance, and gasoline,
whereas the bus and taxi cost them about $22 a month).
Because the couple is receptive to the help you have provided, you
initiate a discussion regarding their long-term plans for housing needs as
they get older. They are not opposed to a senior housing option and have
been talking about it with their daughter. They are going to talk with a
realtor about selling their house, explore some senior apartments with
their daughter on her monthly visits, and review their budget.

Arthritis
Arthritis encompasses more than 100 diseases and conditions that
affect joints, surrounding tissues, and other connective tissues and is the
leading cause of disability for adults in the United States (CDC, 2018b).
Types of arthritis include osteoarthritis (OA), rheumatoid arthritis (RA),
gout, and fibromyalgia. With OA, the number of cartilage cells
diminishes, cartilage becomes ulcerated and thinned, and subchondral
bone is exposed. The bony surfaces rub together resulting in joint
destruction with subsequent pain and stiffness (National Institute of
Arthritis and Musculoskeletal and Skin Diseases [NIAMS], 2019).

Gentle exercise is helpful for clients with OA, following treatment for
pain. Acetaminophen is the first drug of choice; however, clients often find a
combination of medications and daily routines that helps them the most. The
nurse can best assist these clients by assessing the safety of a particular
regimen and suggesting treatment changes as new research becomes
available: new medications, surgical options for joint replacement, and
dietary changes, such as vitamins and foods high in essential fatty acids
(NIAMS, 2017).
RA is a progressive chronic condition that begins during young
adulthood and becomes disabling as the disease continues, attacking tissues
of the joints and causing systemic damage in the later years (NIAMS, 2017).
This form of arthritis is an autoimmune disease that causes inflammation,
deformity, and crippling. RA is treated with anti-inflammatory agents,
corticosteroids, antimalarial agents, gold salts, and immunosuppressive

1930
drugs. Joint discomfort is often relieved by gentle massage, heat, and range-
of-motion exercises.
The C/PHN needs to be aware of the major differences between these
two prevalent forms of arthritis. Recommended treatments, including
physical therapy, diet, and medication, change as more evidence-based
research is conducted on arthritis (NIAMS, 2017).

Depression
Depression is not a normal part of growing older, yet it is common among
older adults (CDC, 2017d). Health care providers can miss depression and
mistake it for a natural response to grief/loss or illness.
The nurse needs to keep in mind the many potential causes of depression.
Medical conditions, such as stroke, cancer, vitamin B12 deficiency, diabetes,
chronic pain with dependence on prescription painkillers, or insomnia, may
lead to depressive symptoms. Many prescription drugs can trigger or
exacerbate depression. These include blood pressure medications, sleeping
pills, calcium channel blockers, ulcer, and pain medications. Screening for
depression is within the scope of responsibility of the C/PHN. The Geriatric
Depression Scale (GDS) is available and revised for 2019
(https://consultgeri.org/try-this/general-assessment/issue-4.pdf).
C/PHNs can help elders prevent the overwhelming signs and symptoms
of depression related to losses by working with community groups. Through
senior centers, adult housing units, senior day care centers, or men's and
women's groups at religious centers, the C/PHN can meet with seniors to
offer support, teach strategies to improve the quality and quantity of support
systems, invite mental health speakers to discuss the topic of depression
prevention, and generally assess the holistic health status of the elders in that
setting.

Osteoporosis
Osteoporosis is a disease of aging bone in which the amount of bone is
decreased and the strength is reduced. Osteoporosis means “porous bone,”
meaning that the condition enlarges the holes, and the bones become brittle.

Researchers estimate that one in five women in the United States has
osteoporosis and that half of the women over 50 will have a fracture of
the hip, wrist, or vertebrae; it is considered a major public health threat
for approximately 44 million U.S. adults over age 50 (International
Osteoporosis Foundation, n.d.).

Proper diet and weight-bearing exercise throughout life are now

recognized as the most effective measure to maintain bone health. There is

1931
growing evidence that calcium and vitamin D supplementation can help
lower rates of fractures and reduce bone loss in the elderly. Higher protein
intake may also help prevent bone loss (International Osteoporosis
Foundation, n.d.). There are many FDA-approved drugs to treat osteoporosis
that can be prescribed by a primary care provider. Therefore, identification of
risk factors and regular screenings is essential to prevent the progression of
this debilitating disease (International Osteoporosis Foundation, n.d.).

Sensory Loss
Older adults complain about losing their “taste buds” and have deficits in
smell. This is why it is not unusual for older adults to over-salt their food or
reach for sweet foods they can taste.

The prevalence of hearing loss (as high as 75%) and vision impairments
(18%) is high in adults >70 years old (Correia et al., 2016). Most
hearing loss happens slowly over time, and the older adult may not
recognize their hearing problem. These losses of hearing and vision are
correlated with depression, social isolation, physical function, cognitive
impairment, and quality of life (Contrera, Wallhagen, Mamo, Oh, &
Lin, 2016).

C/PHNs can assess for hearing and vision loss using simple tests. For
vision, a simple reading of text from a book or newspaper with glasses can
suffice. Problems like macular degeneration or glaucoma can cause blindness
and need medical care, while presbyopia can be solved with drugstore
readers. For hearing, check to see if the older adult uses well-fitted hearing
aid, and that they have a good supply of batteries. A family member may be
able to supply information about how well the older adult is hearing, but a
referral to a clinic may be helpful. Cost for hearing aids is significant in the
decision for improvement of hearing. Some amplification help can be found
with smartphone application or necklace type amplifiers. But these and
hearing aids are not yet paid for by Medicare (Contrera et al., 2016) and can
be quite expensive. Medicaid will pay for some hearing solutions, should the
older adults have dual eligibility.

1932
Tertiary Prevention
Tertiary prevention involves follow-up and rehabilitation after a disease or
condition has occurred or been diagnosed and initial treatment has begun.
Chronic diseases that are common among older adults, such as heart failure,
stroke, diabetes, cognitive impairment, or arthritis, cannot always be
prevented but can frequently be postponed into the later years of life through
a lifetime of positive health behaviors. However, when they occur, the
debilitating symptoms and damaging effects can be controlled through
healthy choices encouraged by the C/PHN and recommended by the primary
care practitioner.

Although many older adults are considered generally healthy, 80% have
at least one chronic condition and 50% have at least two (National
Council on Aging [NCOA], 2018).
A small proportion suffer more disabling forms of disease, such as
COPD, cerebral vascular accidents (CVAs), cancer, or DM, with some
requiring extensive care and ongoing medical management.

Heart disease and cancer pose their greatest risks as people age, as do
other chronic diseases and conditions, such as stroke, chronic lower
respiratory diseases, AD, and diabetes. Influenza and pneumonia also
continue to contribute to older adult deaths among older adults, despite the
availability of effective vaccines. While the risk for disability from disease
clearly increases with advancing age, poor health is not the inevitable
outcome of aging. Many older adults manage chronic conditions well
throughout the remainder of their lives.

1933
HEALTH COSTS FOR OLDER
ADULTS: MEDICARE AND
MEDICAID
As the number of older adults grows, so do costs for health care (see Chapter
6 Medicare and Medicaid). Older adults generally pay about 13% of health
care from out of pocket, and the rest comes from insurances, especially
Medicare. There is a concern that older adults, especially those with low
incomes, will have much higher out-of-pocket costs (Hatfield, Favreault,
McGuire, & Chernew, 2018). See Figure 22-7 for total federal outlays for
Medicare spending in 2017. With the addition of Social Security, Medicaid,
ACA, and CHIP, half of the pie is spent annually (Kaiser Family Foundation,
2017).

FIGURE 22-7 Total Federal outlays for Medicare Spending in

2018. (Reprinted with permission from the Kaiser Family
Foundation. Retrieved from https://www.kff.org/medicare/issue-
brief/the-facts-on-medicare-spending-and-
financing/#:~:text=Medicare%20spending%20was%2015%20perc
ent,same%20as%20the%202018%20projection)

1934
 Medicare or Medicaid does not cover all health care costs for older
adults. It is predicted that by 2050, the numbers of older adults, especially
those over 85 years of age and those with cognitive impairment, will need
support with ADLs. Most of care is done by informal unpaid caregivers. This
is often done at a heavy physical and financial cost, including lost
opportunities for employment, health insurance, and retirement savings.
Services for older adults are very expensive.

1935
Medicare
Although Medicare does cover many services for older adults, there can be
significant out-of-pocket costs. Some are surprised that Medicare does not
cover long-term or custodial care, most dental care and dentures, eye
examinations for prescribing glasses, and hearing aids and examinations
(Medicare.gov, n.d.).
Medicare Part A covers inpatient care and rehabilitation expenses,
hospice care services, and some home health care services. Hospitalizations
and rehospitalizations are a significant expense for the Medicare program. A
major theme of health care reform was the prevention of hospitalizations by
providing more supportive care at home.
Medicare Part B covers outpatient and primary care visits. When
enrolling for Medicare Part B, older adults will pay 20% of the monthly
expenses. Medicare premiums for medical insurance (Part B) are $11,608 per
person per year for most beneficiaries and are higher for those with incomes
above $85,000 (Medicare.gov, 2018). See Chapter 6 for more details on
Medicare.

1936
Medicaid
Although the majority of people enrolled in Medicaid are children and
families, most Medicaid spending goes for services provided to people aged
65 years and over and people with disabilities (Kaiser Family Foundation,
2018) (see Fig. 22-7).
Most people believe that Medicaid is a program for the poor, whereas
Medicare is for those who are financially secure. In FY 2010, 14% of all
Medicaid beneficiaries—9.6 million—were “dual eligible” seniors and
younger persons with disabilities who are covered by Medicare as well. One
of every five Medicare beneficiaries is a dual eligible client. Dual eligible
beneficiaries are very poor, and many have high health and long-term care
needs. Medicaid assists them with their Medicare premiums and cost sharing
and covers full Medicaid benefits for a large majority of them—most
importantly, long-term services and supports at home or in a care facility,
which Medicare does not cover (Kaiser Family Foundation, 2018). See
Chapter 6 for more details on Medicaid.

1937
ELDER ABUSE
Elder abuse or mistreatment (i.e., abuse and neglect) is defined as
intentional actions that cause harm or create a serious risk of harm to a
vulnerable elder by a caregiver or another person who stands in a trust
relationship with the older adult.
Signs of elder abuse may be missed by professionals working with older
adults because of lack of training on elder mistreatment or lack of reporting.
In addition, older adults themselves may be unwilling to speak up for fear of
retaliation, physical inability to report, cognitive impairment, or they do not
want to get the abuser (90% of whom are a family member) in trouble. See
Chapter 18 for comprehensive discussion of all types of elder abuse and
mistreatment.
It is notable that financial abuse often accompanies one of the other
forms of abuse (see Box 22-11). The financial abuse of seniors is a growing
problem, often called the “crime of the 21st century.” A senior can be
financially stable and living independently and may suddenly become
destitute and forced out of the home as a result of financial abuse. The most
common perpetrators of elder abuse are spouses or partners of elders, often
in a relationship with long-term domestic violence. Family members account
for 76% of reported mistreatment. Abusers, particularly adult children, are
often dependent on the victim for financial assistance, housing, or because of
personal problems such as mental illness, alcohol, or drug abuse (NIA,
2020c).
Various state, local, and county agencies investigate and enforce elder
abuse laws. The first agency to respond to a report of elder abuse in most
states is APS. In some states, certain professionals are required or
encouraged to report elder abuse; there are generally doctors and nurses,
psychologists, police officers, social workers, and employees of banks and
other financial institutions. In 2017, APS in Texas received funding to
improve elder abuse reporting by using telehealth to connect virtually with
clients who were reported to the state as suspected victims of elder abuse. In
the first 8 months, 300 clients were referred for assessments by a team of
physicians that provided mental health assessments, guardianship filings,
employee misconduct reviews, and other medical assessments. This approach
reaches older adults in rural and hard-to-reach areas (Burnett, Dyer, Clark, &
Halphen, 2018).

BOX 22-11 What Do You Think?

1938
Mrs. Stetson's Story The C/PHN has been
visiting Mrs. Stetson for a wound dressing for the
past few weeks. After Mr. Stetson passed away,
her son, John, offered to help her with the
finances. She was no longer able to see well
enough to do the bank deposits. John took her to
the bank to be added as a signer on the account.
When Mrs. Stetson's daughter from out of town
arrived several months later for a visit, she
wanted to do some Christmas shopping with her
mother for the grandchildren. Upon arrival to
the bank with her daughter, Mrs. Stetson found
that her checking account and substantial
amount of her savings were drained. She shared
this information with the C/PHN. What should
the C/PHN do? Review the steps for reporting
elder abuse in your state: What is your
professional responsibility?

1939
APPROACHES TO OLDER ADULT
CARE
As we noted in the introduction to this chapter, the United States and the
world is experiencing unprecedented growth in the number of aging older
adults. Current costs of care in facilities, price of long-term care insurance,
and the limits on amounts of support in community services will demand
new or improved models of care. Case management can focus on primary,
secondary, and tertiary services to enhance the quality of care by decreasing
fragmentations, maximizing resources, and providing the highest quality of
care possible.

1940
Case Management and Needs Assessment
Case management involves assessing needs, planning and organizing
services, and monitoring responses to care throughout the length of the
caregiving process, condition, or illness. Nurses have stepped into the case
management role to coordinate and manage patient care across the
continuum of health services. Following the nursing process, nurses as case
managers assure quality outcomes and cost containment as well as
coordination of care. They work with the health care team including social
work as each discipline has “…different training, different skills, and see
patients from a different perspective” (Christie 2018, para, 4).
Social workers use case management to address their clients' social
needs, including their financial problems. Provisions of the Affordable Care
act support homeand community-based services by providing Medicaid
coverage for home services coordinated by a case manager. This funding is
available through states who opt in to the ACA Community First Choice
(Medicaid.gov, 2015). When covered by a community program like the First
Choice option, case managers and C/PHNs can support the family members
of an older adult who will be paid for caregiving for their family member, a
great cost saving when compared with a nursing home.
The C/PHN is part of the case management team and should be prepared
to assess the needs of older adults with valid instruments:

The Older Americans Resources and Services Information System

(OARS), developed by Duke University Center for the Study of Aging
and Human Development (Duke University, 2014), utilizes two sections
of one tool—OARS Multidimensional Functional Assessment
Questionnaire (OMFAQ)—to determine levels of functioning in five
areas (mental health, physical health, economic resources, social
resources, and ability to perform ADLs).
The Katz Index of ADLs is based on an evaluation of the functional
independence or dependence of clients with respect to bathing, dressing,
toileting, and related tasks (Katz, 1963).
The Lawton Instrumental ADLs Scale looks at an older adult's ability to
perform such activities as using the telephone, shopping, doing laundry,
and handling finances (Graf, 2008).
Times Up and Go Test (TUG) is a measurement of the time in seconds
for a person to rise from sitting from a standard armchair, walk 10 ft,
turn, walk back to the chair, and sit down. The person wears regular
footwear and walking supports (cane, walker). The test is predictive of
falls in older adults (Kang et al., 2017).
Cognitive Screens: to screen for the need for further testing, should the
client or family be worried. Open this link and try the MiniCog

1941
(https://consultgeri.org/try-this/general-assessment/issue-3.1).
Vision and hearing screens: The test is familiar to older adults. A simple
test of reading with corrective lenses if used will suffice to know if the
older adult can read directions, pill bottles. This would not screen for
eye problems like macular degeneration. For hearing, the Whisper Test
may be used, with hearing aids if the older adult uses them
(https://geriatrics.ucsf.edu/sites/geriatrics.ucsf.edu/files/2018-
06/whispertest.pdf).
Spiritual assessment: Spiritual needs can be assessed using many
different instruments or questionnaires. Try FICA (Faith, Importance,
Community, Address) for example (Dameron, 2005).

1942
HEALTH SERVICES FOR OLDER
ADULT POPULATIONS
How well are the needs of older adults being met? To answer this question,
other questions must be raised. Do health programs for older adults
encompass the full range of needed services? Are programs both physically
and financially accessible? Do they encourage clients to function
independently? Do they treat older people with respect and preserve their
dignity? Do they recognize older adults' needs for companionship, economic
security, and social status? If appropriate, do they promote meaningful
activities instead of overworked games or activities such as bingo,
shuffleboard, and ceramics? Are health care services and other social
services provided based on evidence and research? Effective services for
older adults should be comprehensive, coordinated, and accessible and
demonstrate evidence-based quality.

1943
Criteria for Effective Service
Several criteria help to define the characteristics of an effective community
health service delivery system. Four, in particular, deserve attention. In order
to be effective, it should be comprehensive. Many communities provide some
programs, such as limited health screening or selected activities, but do not
offer a full range of services to more adequately meet the needs of their
senior citizens (see Box 22-12). A comprehensive set of services should
provide the following:

BOX 22-12 What Do You Think?

Services in your Community Have you wondered
whether or not you should intervene if you see an
older adult in a situation where they might need
help? Or perhaps a neighbor will tell you about
someone who might be in trouble. As a nurse, these
kinds of situations come to our attention regularly.
Silver Key SOS of Colorado Springs, Colorado
offers an SOS (Senior Outreach Service). Anyone
can contact Silver Key if there is a concern about
an older person who may need help
(https://www.silverkey.org/services/senior-
assistance/silverkey-sos/). The reporting person
need not be identified to the referred older adult.
Once notified, a case manager will contact the
older person and connect them with appropriate
services, if the older adult is willing. Services
include counseling for many problems, community
resources, treatment for depression or misuse of
drugs or prescriptions, teach your peers and family
to recognize some warning signs: confusion,

1944
physical problems, signs of home/person neglect,
social isolation, and economic problems.
Look for these kinds of services in your community. Do they exist under
city services? Perhaps the County Health Department? How would you go
about connecting families or older adults to services?

1. Affordable housing options

2. Adult day and memory care programs 3. Access to high-quality health
care services (prevention, early diagnosis and treatment,
rehabilitation) 4. Health education (including preparation for
retirement) and centralized resources for information 5. In-home
services that promote aging in place 6. Recreation and activity
programs that promote healthy nutrition and socialization 7.
Specialized transportation services 8. Safe and outdoor spaces that
promote activity and enjoyment

A second criterion for a community service delivery system is

coordination. A good example of efforts toward effective and coordinated
services is the Age Friendly Cities and Communities programs (AARP,
2019a). Communities that apply for Age-Friendly demonstrate that the
community addresses the above listed services. In 2018, 301 communities
are designated age-friendly (AARP, 2020a).
A coordinated information and referral system provides another link.
Most communities need this type of information network, which contains a
directory of all resources and services for the older adult and includes the
name and telephone number of a contact person with each listing. An
example of this network is 2-1-1. This number connects the caller to services,
and many communities have their own. San Diego 2-1-1 is a good
illustration (https://211sandiego.org/).
A third criterion is accessibility. Too often, services for seniors are
inconveniently located or are prohibitively expensive. Some communities are
considering multiservice community centers to bring programs and services
for low-income elderly closer to home. The Program of All-Inclusive Care of
the Elderly (PACE) is one example of this (National PACE Association,
2020). Comprehensive services are offered to eligible nursing home patients,
including personal, health care, and housing. Other services such as
transportation, in-home services (home health aides, homemakers, grocery
and meal delivery) may further solve accessibility problems for many older
adults.
Finally, an effective community service system for older people should
promote quality programs. This means that services should truly address the
needs and concerns of a community's senior citizens and be based on

1945
evidence of good outcomes. A range of housing types, from luxurious
retirement communities with all amenities for the active and wealthier senior
to secure and more modestly priced or low-income apartments for
independent senior living, are being built in most communities. However,
affordable rental apartments and homes for older adults and low-income
families are in short supply in many communities, putting some older adults
in homeless situations. Age-friendly communities are focusing on this
problem with an array of solutions, including “tiny houses,” “granny flats,”
and redesigning current homes to universal design, that is, usable by anyone
of any age, whether a disability or not (e.g., wider door frames, less steps
up).

1946
Services for Older Adults by Level of Care
Required
There is increased emphasis on providing needed services for older people at
home, the essence of aging in place. Today's emphasis on cost control gives
added support for providing services at home. Given the increase in
longevity, the potential for cost savings appears significant if care for
dependent older people can be supported where they live (see Table 22-2).

TABLE 22-2 Senior Residential and Home Health Care

Service Comparison

Maintaining functional independence should be the primary goal of

services for the older population. Assessment of needs, ability to function,
and the use of assessment tools to form the basis for determining appropriate
services is necessary. Although many well older people can assess their own
health status, some are reluctant to seek help. Therefore, outreach programs
serve an important function in many communities, as they locate people in
need of health or social assistance and refer them to appropriate resources.

1947
 Independent living is a general term for any housing arrangement
designed exclusively for seniors. Types of independent living facilities
include subsidized senior housing, retirement communities, Continuing
Care Retirement Communities, and age-restricted apartments (55+). The
senior housing industry is rethinking these older models to come up
with intergenerational community models, as baby boomers tend to be
less interested in senior-only communities.
The concept of continuing care retirement communities (CCRCs),
sometimes referred to as total life care centers, allows older people to
“age in place,” with flexible accommodations designed to meet their
health and housing needs (AARP, 2019b). CCRCs are the most
expensive long-term care solution available to seniors; however, they
provide all levels of living, from total independence to the most
dependent.
Assisted living communities provide care to residents who need support
with ADLs (these could include eating, dressing, bathing, mobility,
toileting, grooming, and assistance with medications). These
communities typically provide cooked meals in a shared dining hall,
housekeeping, laundry, and transportation. Some communities include
additional services such as salon/barbershops, art/activities, or a theater
(Dementia Care Central, 2019).
Memory care units are for individuals with dementia who require skilled
care and supervision. These units or living spaces provide 24/7
supervision by staff who are specifically trained to care for patients with
memory loss (Dementia Care Central, 2019).

Residents entering CCRCs sign a long-term contract that provides for

housing, services, and nursing and dementia care. Many seniors enter into
CCRC contracts while they are healthy and active, knowing they will be able
to stay in the same community and receive nursing care should this become
necessary. Currently, CCRCs are redesigning their homes and apartments to
fit the needs of the baby boomers, who want more of a village feel.
Dedicated memory care units in long-term and assisted living are part of the
redesign. Older adults who invest in a CCRC need to have financial means to
support the entrance and monthly fees. Entrance fees can be as high as
$1,000,000 (AARP, 2019b).

The growing Village Concept is a relatively new, self-supporting

solution for independent living in which older adults live in their own
homes, in a neighborhood, or in some cases high rise city apartment
buildings. Neighbors share services such as transportation, grocery
shopping, or helping with household chores provided by village
providers, either professional or volunteer. The village encourages
socialization with a wide offering of activities among the members, and

1948
 some hold wellness activities. This option requires a membership fee,
on average, about $450 a year to provide services (AARP, 2017b).

Older adults who remain in their homes or apartments may rely on smart
home technology to improve their autonomy (Majumder et al., 2017). Other
older people may live with family members or participate in home sharing
(https://www.seniorhomeshares.com/about). They may attend an adult or
memory day care center during the day. Sometimes being able to stay home
or return home includes short-term living arrangements. This could be a
rehabilitation hospital for recovery and physical therapy related to a hip
fracture, or respite care, which gives the usual caregiver a much-needed rest
from 24-hour-a-day caregiving and helps prevent “burnout” (see Box 22-13).

BOX 22-13 Family Caregiving Concerns

Finances Taking time off from work to care and
loss of income; most caregivers are working
women who will not be contributing to their
own retirement accounts for possibly long
periods of time. The Credit for Caring Act is
proposed legislation that would create a $3,000
tax credit for caregivers who work and care for
their parents (AARP, 2019d).
Payment for Caregiving Caregivers are often
not paid. Medicaid eligible and veterans may
get assistance, which varies by state. Long-term
care insurance is often out of the financial reach
of many families.
Hospice and End-of-Life Guidance This
concern centers on how to have the
conversations with family members.
Caregiver Life Balance This concern involves
the daily work of caregiving, especially when it

1949
 falls on one family member, can result in
depression, anxiety, fatigue, guilt, and anger.
Resources These include adult day programs,
support groups, dementia care, and respite
care.
Safety as We Age These concerns include aging
parents driving as well as home safety (AARP,
2020d).
Many nurses do not know the difference between an SNF and a
custodial care nursing home. They often exist within the same building.

SNFs are reimbursed for 30 days by Medicare for rehabilitation for

conditions such as post stroke, spinal cord injury, IV therapy, and PT,
OT, and Speech (CMS, 2020).
When an older adult has a long-term chronic condition that cannot be
managed in the community, a nursing home is an option. There is 24-
hour nursing and nursing assistant care in both SNF and nursing homes,
but the payment model is quite different (see Table 22-2).

Nursing home reform was legislated in the late 1980s, putting increased
demands on facilities to provide competent resident assessment, timely care
plans, quality improvement, and protection of resident rights (Omnibus
Budget Reconciliation Act, 1987). This increased complexity of services has
resulted in increased costs in these facilities. Staffing needs increase as care
becomes more complex and the resident population grows. Licensed
personnel must be knowledgeable decision-makers, managers of unskilled
staff, staff educators, and role models, as well as efficient and effective
administrators in an essentially autonomous practice setting. And, as the
population grows, the need for greater numbers of both licensed and
attendant staff becomes more evident.

1950
END OF LIFE: ADVANCE
DIRECTIVES, HOSPICE, AND
PALLIATIVE CARE
A final need of older adults is preparing for a dignified death. In her classic
work, On Death and Dying, Elisabeth Kübler-Ross (1969) described death as
the final stage of growth and one that deserves the same measure of quality
as other stages of life.

Although death is a natural part of life, many older people fear death as
an experience of pain, humiliation, discomfort, or financial concern for
loved ones. Sometimes, very aggressive and heroic medical treatments
are offered to those near the end of their lives, often at the urging of
family members.
Planning for a dignified death is an important issue for many older
people, and C/PHNs can facilitate conversations among family
members and provide necessary information and resources. Look up
www.theconversationproject.org, a very helpful toolkit to help
individuals and families have the conversation about wishes for end of
life.

The C/PHN will need to be aware of the laws around physician-assisted

suicide and patient self-determination around death. The Death with Dignity
Web site is very helpful: https://www.deathwithdignity.org/learn/access/. In
addition, there are personal and professional decisions around this topic and
nursing practice that a C/PHN might want to think about (Stokes, 2016).

1951
Advance Directives
Living wills and advance health care directives (AHCDs), sometimes
referred to as advance directives, are legal documents that instruct others
about end-of-life choices should an individual be unable to make decisions
independently. The forms for advance directives are available for every state
online through AARP (2020b).
An AHCD only becomes effective under the circumstances specified in
the document. This document allows for appointment of a health care agent
who will have the legal authority to make health care decisions on behalf of
the patient and for specific written instructions for future health care in the
event of any situation in which the patient can no longer speak for himself or
herself. Examples include the following:

The use of dialysis and breathing machines

Use of resuscitation if breathing or heartbeat stops
Tube feeding
Organ or tissue donation

Having such documents prepared and making them known to significant

others can ensure that wishes will be honored. These documents can provide
clear directions for families and health care professionals and are gaining
more recognition and importance as a result of increasing ethical dilemmas
and challenges brought on by advances in technology (American Medical
Association, 2020). Advance directives can be revoked or replaced at any
time, as long as the individual in question is capable of making his or her
own decisions. It is recommended that these documents be reviewed every 2
years or so, or in the event of a change in health status and revised to ensure
that they continue to accurately reflect an individual's wishes.
Projections indicate that by 2030, close to one half of older adults greater
than the 85 years of age will have dementia and may not have a spouse or
family living with them (Meunier et al., 2016). C/PHNs and other health care
professionals will be faced with choices around end-of-life decisions. The
education and decisions need to come far in advance for older adults.

1952
Hospice
Hospice is an option that takes a multidisciplinary approach to end-of-life
care and needs. Hospice is more a concept of care than a specific place,
although some hospice organizations provide individuals with a place to die
with dignity if they have no home or choose not to die at home. Hospice is an
option for people with a “projected” life expectancy of 6 months or less and
often involves palliative care (pain and symptom relief) as opposed to
ongoing curative measures.
Chapter 30 details hospice care. The C/PHN can be a helpful resource in
connecting clients with hospice services before end of life in imminent, and
hospice is most beneficial for all.

1953
Palliative Care
Palliative care consists of comfort and symptom management and does not
provide a cure. For most chronic ongoing health conditions—such as
diabetes, high blood pressure, congestive heart failure, arthritis, and COPD—
there are no cures, only symptom relief. Palliative care should not be viewed
as synonymous with hospice or end-of-life care. Rather, palliative care
should be viewed as any care primarily intended to relieve the burden of
physical and emotional suffering that may accompany illness associated with
aging. Palliative care should be a major focus of illness care throughout the
life span and in any community setting, regardless of whether a client is a
hospice patient or not (National Consensus Project, 2020). There is an
excellent summary of palliative care in Chapter 30.

1954
CARE FOR THE CAREGIVER
The burden of caregiving is receiving more attention in recent years because
it is such a demanding and costly role. An increasing number of older people
are cared for in their home by a spouse or other family member, often
referred to as an informal caregiver, on an unpaid basis.
Almost 75% of persons receiving care at home rely exclusively on
informal caregivers, usually women between the ages of 45 and 64 (Schultz
& Eden, 2016). The demands of caregiving exact a toll on the caregiver, who
not only may miss important screening and health care visits for self but also
often give up a social life. Because of the toll of caregiving on their own
health, caregivers for those with AD and dementia had $7.9 billion in
additional health care costs (AARP, 2020c). Their own decline in health
compromises their ability to be a caregiver unless they get some relief (see
Chapter 32 ; Box 22-13).
Respite care is a service that is receiving increasing attention. Although
there are different approaches to respite care, all have the same basic
objective: to provide caregivers with planned temporary, intermittent,
substitute care, allowing for relief from the daily responsibilities of caring for
the care recipient (AARP, 2020c). Long-term care insurance may cover some
costs of respite care. The 2000 Older Americans Act Amendments provided
funding for states to work through NFCSP to address respite care specifically
on the local level (ACL, 2019a).

1955
THE COMMUNITY HEALTH
NURSE IN AN AGING AMERICA
C/PHNs can make a significant contribution to the health of older adults. The
nurse may function as a collaborator, case manager, advocate, and educator
to assist older adults and their families to maintain or improve health.
Because these nurses are in the community and already have contact with
many seniors, they are in a prime position to carry out a comprehensive
needs assessment, culminating in a nursing diagnosis and holistic plan for the
health care needs of this group. Case management is often a critical aspect of
the nurse's role because the C/PHN must know what resources are available
and when and how to make referrals for these older clients (see Box 22-14).

BOX 22-14 STORIES FROM THE

FIELD
Case Management: Role of the C/PHN
Mr. Jessup is 94 years old and lives with his wife, age 86, in a small
mobile home on some acreage in a rural area of our county. He is hard
of hearing, but he only needs glasses for reading. Mr. Jessup was
diagnosed with prostate cancer 20 years ago and has some bowel
incontinence as a result of radiation treatments; he manages this well
with pull-up protective underwear. They have one son who lives in the
same town; they speak by phone every other day, and he comes by to
visit when he can. Their three grandsons are all away at college and they
rarely see them.
Mrs. Jessup has recently been having memory lapses, and some
difficulty remembering to turn off the stove and close the refrigerator
door. She has trouble with a number of daily tasks. She likes to have
someone bring them fast-food as a treat every week, and they are
beginning to require assistance with errands and housekeeping tasks.
Recently, Mr. Jessup noticed that he was having more difficulty
doing his outside chores. He seems more “weak” and “tired” and he has
recently had quite a bit of “nausea and vomiting.” The Jessup's son took
them for an appointment with his urologist, and it was determined that
his prostate-specific antigen (PSA) was elevated.

1956
 You are a district C/PHN and have recently been assigned to the
Jessup family to assess their functional limitations and provide them
with information on resources they might need over the next few
months.

1. How would you begin your visit?

2. What assessments could be helpful (social, spiritual,
mental/cognitive, etc.)?
3. What resources and services might be helpful to them?

1957
SUMMARY
C/PHNs work with older adults and families in many settings, wherever they
find them, and with whatever health needs are present. While the priority of
community/public health nursing is health promotion and disease prevention,
community nurses work with older adults with chronic health conditions who
are aging in place to help them achieve their maximal health potential.
Because the trend for older adults is to remain in community, C/PHNs need
to assess their living situations and find out as much as possible about the
community's support systems, available resources, and gaps in services.

As the number of older adults in America grows, the need for health
care services and health professionals that serve older people in
communities will escalate.
Healthy longevity is the goal for the aging population and is a focus of
Healthy People. This means being able to function as independently as
possible; maintaining as much physical, mental wellness, and social
engagement as possible while adapting to chronic conditions and
functional impairments.
Through advocacy, education counseling, case management, and
collaboration with clients, families, and health services and providers,
the community health nurse can be effective in improving quality of
care and social conditions for older adults.
Older adults prefer to age in place and live independently in the
community. Public health nurses deliver health care services to a large
and rapidly growing segment of the population.
Alzheimer's dementia is the sixth leading cause of death and the only
disease among America's top 10 that cannot be prevented or cured.
Between 2017 and 2025, every state is expected to see at least a 14%
rise in the AD prevalence (AA, 2020b). The C/PHN will support
families and caregivers who need support caring for older adults with
this devastating disease.
A variety of living arrangements and care options are available from
which to choose and can be tailored to the older person's desires and
needs. These include continuing care communities, villages, day and
memory care centers, PACE programs, assisted living, skilled and SNF
long-term care centers, and hospice.
The community health perspective includes a case management
approach that offers a centralized system for assessing the needs of
older people and then matching those needs with the appropriate
services. The C/PHN should also seek to serve the entire older

1958
population by assessing the needs of the population, examining the
available services, and analyzing their effectiveness. The effectiveness
of programs can be measured according to four important criteria
(targeted to the specific needs of the population): comprehensiveness,
effective coordination, accessibility, and quality.

1959
ACTIVE LEARNING EXERCISES
1. On the Internet, search for and download instructions for filling out
your own advance directive. Complete the form for your state and
discuss your wishes with someone who is likely to be involved in
your health care.
2. Picture an older adult you know well or know a great deal about.
Make a list of characteristics that describe this person. How many of
these characteristics fit your picture of most senior citizens? What are
your biases (ageisms) about them?
3. As part of your regular community health nursing workload, you visit
a senior day care center one afternoon each week. You take the blood
pressures of several people who are taking antihypertensive
medications and do some nutrition counseling. The center
accommodates 60 senior clients, and you would like to serve the
health needs of the aggregate population. List five potential health
needs of this group. What actions might you consider taking at an
aggregate level? With whom would you consult as you plan programs
at the center?
4. Using “Strengthen, Support, and Mobilize Communities and
Partnerships” (1 of the 10 essential public health services; see Box 2-
2 ), discover examples of innovative community programs for elders
at the primary, secondary, and tertiary levels of care. Determine
whether such programs could work in your own community. Discuss
with C/PHNs and local stakeholders or key informants.

thePoint: Everything You Need to Make the

Grade!
Visit http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, study aids for
all learning styles, and more!

1960
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support-program
Administration for Community Living. (2019b). 2018 Profile of older
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events/announcements/now-available-2018-profile-older-americans
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%20ages%20have%20Alzheimer's,10%25)%20has%20Alzheimer's%20dem
entia
Alzheimer's Association. (2020b). How is alzheimer's disease diagnosed?
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communities/network-age-friendly-communities/info-2014/an-
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retirement-communities.html

1961
American Association of Retired People (AARP). (2019c). Financial and
legal: Bill would give some family caregivers financial relief. Retrieved from
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act.html
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 UNIT 6
Vulnerable Populations

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1972
CHAPTER 23
Working With Vulnerable People
“How far you go in life depends on your being tender with the young, compassionate with the
aged, sympathetic with the striving, and tolerant of the weak and the strong—because someday
you will have been all of these.”

—George Washington Carver (1860–1943), Botanist and Scientist

KEY TERMS
Differential vulnerability hypothesis Empowerment strategies
Environmental resources
Health disparities
Human capital
Marginalized populations Racial/ethnic disparities Racism
Relative risk
Social capital
Social determinants of health Socioeconomic gradient
Socioeconomic resources
Vulnerability
Vulnerable populations

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Describe the term “vulnerable populations.”
2. Discuss the effects of vulnerability and relative risk.
3. Differentiate between the concepts of social capital and human capital.
4. List three of the most common factors related to vulnerability.
5. Identify two strategies to solicit and evaluate input from vulnerable
populations when planning health care programs and services.
6. Explain the socioeconomic gradient in health.
7. Describe three types of health disparities.
8. Describe four C/PHN roles or behaviors that help promote client
empowerment.

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INTRODUCTION
The concept of vulnerability is an important one for nurses because of its
implications for health, no matter where they practice. Often, vulnerable
populations are subpopulations, such as ethnic or racial minorities, the
uninsured, those with HIV/AIDS, children, older adults, the poor, and those
who are homeless (American Public Health Association, 2017; Stafford &
Wood, 2017). These subpopulations often have higher morbidity and
mortality rates, less access to health care (and disparities in outcomes of
health care), shorter life expectancy, and an overall diminished quality of life
compared with the population in general (Agency for Healthcare Research
and Quality [AHRQ], 2015; American Public Health Association, 2017).
In this chapter, we examine popular models and theories of vulnerability,
important concepts, and contributing factors. We also briefly discuss health
disparities that are more common among vulnerable members of society and
the role of C/PHNs working with these groups. This chapter provides an
overview of this subject and lays the foundation for other chapters.

1974
THE CONCEPT OF VULNERABLE
POPULATIONS
In this section, we consider several key models and theories related to
vulnerability, the criteria used to determine who is considered vulnerable,
and causative factors linked to vulnerability.

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Models and Theories of Vulnerability
Key models and theories of vulnerability that have been proposed include the
vulnerable populations conceptual model developed by Flaskerud and
Winslow in 1998 (Box 23-1; Fig. 23-1), the Behavioral Model for Vulnerable
Populations (Box 23-2; Fig. 23-2), the differential vulnerability hypothesis
(Kessler, 1979; Box 23-3), the concept of social capital (Fig. 23-3), a general
model of vulnerability, and Maslow's Hierarchy of Needs.

BOX 23-1 Vulnerable Populations

Conceptual Model (Flaskerud &
Winslow, 1998) Flaskerud and Winslow
(1998) developed a popular conceptual
framework of vulnerability (see Fig. 23-
1) that contains three related concepts:
resource availability, relative risk, and
health status. The model provides
evidence of the link between poor health
status and socioeconomic resource
availability through the loss of income,
jobs, and health insurance. The
following concepts are supported by this
model:
Lack of resources (e.g., socioeconomic and environmental)
increases a population's exposure to risk factors and reduces
individuals' ability to avoid illness.
Socioeconomic resources include human capital (e.g., jobs,
income, housing, education), social connectedness or integration
(e.g., social networks or ties; social support or the lack of it,
characterized by marginalization), and social status (e.g., position,
power, role).

1976
 Environmental resources deal mostly with access to health care
and the quality of that care.
Limited access or lack of access to care can arise from many
sources, including crime-ridden neighborhoods, insufficient
transportation systems, lack of adequate numbers and types of
providers, limited choices of health care plans, or no health
insurance.
Relative risk refers to exposure to risk factors identified by a
substantial body of research as lifestyle, behaviors and choices
(e.g., diet, exercise, use of tobacco, alcohol and other drugs, sexual
behaviors), use of health screening services (e.g., mammogram,
colonoscopy), and stressful events (e.g., crime, violence, abuse,
firearm use).
Source: Flaskerud and Winslow (1998).

FIGURE 23-1 Vulnerable populations conceptual model.

(Adapted from Flaskerud, J. H., & Winslow, B. J. (1998).
Conceptualizing vulnerable populations health-related research.
Nursing Research, 47(2), 69–78.)

BOX 23-2 The Behavioral Model for

Vulnerable Populations (Gelberg,
Andersen, & Leake, 2000) Gelberg et al.
(2000) advanced another classic model,
the Behavioral Model for Vulnerable

1977
Populations; this model looks at
population characteristics (predisposing
and enabling factors and needs) as an
explanation for health behaviors and
eventual health outcomes (Burg &
Oyama, 2016). The following concepts
are supported by this model:
Predisposing factors included demographic variables (e.g., gender,
age, marital status), social variables (e.g., education, employment,
ethnicity, social networks), and health beliefs (e.g., values and
attitudes toward health and health care services, knowledge of
disease).
Social structures (e.g., acculturation and immigration), sexual
orientation, and childhood characteristics (e.g., mobility, living
conditions, history of substance abuse, criminal behavior,
victimization, or mental illness) were also considered predisposing
factors.
Enabling factors included personal and family resources, as well as
community resources (e.g., income, insurance, social support,
region, health services resources, public benefits, transportation,
telephone, crime rates, social services resources).
Perceived health needs and population health conditions also were
considered, as were health behaviors including diet, exercise,
tobacco use, self-care, and adherence to care.
The use of health services (e.g., ambulatory and inpatient care,
long-term care, alternative health care) and personal health
practices (e.g., hygiene, unsafe sexual behaviors, food sources)
combined with the other factors to produce outcomes such as
perceived and evaluated health and general satisfaction with health
care services.

The model has been used in research with homeless adults (Doran et
al., 2014) and in examining barriers to interconceptual care (Rhoades et
al., 2014), with mixed results. See Figure 23-2, interrelated pathways
linking education to health.
Source: Burg and Oyama (2016); Doran et al. (2014); Gelberg et al. (2000); Rhoades et al.
(2014).

1978
 FIGURE 23-2 Interrelated pathways linking education to health.
(From Braveman, P., Ergerter, S., & Williams, D. R. (2011). The
social determinants of health: Coming of age. Annual Review of
Public Health, 32, 381–398, used with permission.)

BOX 23-3 The Differential Vulnerability

Hypothesis (Kessler, 1979) Kessler's
(1979) differential vulnerability
hypothesis states that there is a
relationship between social status and
psychological distress; a person's
psychological distress is determined by
the impact of the stressor event as
influenced by social status (this includes
class, sex, marital status, and rural vs.
urban). The formula Pi = Vi (S)i + ai is

1979
 defined as (Kessler, 1979, p. 101): “(P)
Psychological distress is the result of
varying exposure to environmental
stress events or situations (S) acting on
individuals who possess varying
vulnerabilities to stress (V); (a)
represents the residual influence of
constitutional makeup of the mental
health of person (i) independent of any
environmental stresses he/she might
experience” (Kessler, 1979, p. 101).
The hypothesis has been used in research with racial inequity
(Roxburgh & MacArthur, 2014; Wickrama, Bae & Walker, 2016).
Source: Kessler (1979); Roxburgh and MacArthur (2014); Wickrama et al. (2016).

FIGURE 23-3 Social capital is a network of relationships where

one lives and works.

The importance of social capital is sometimes missed, as it can be subtle

and less obvious than the lack of money or jobs (Fig. 23-3). But the presence
of friends and family or someone to rely on in case of an emergency can be
invaluable in assisting individuals through many of life's difficulties. Social

1980
support, or a close confidante, can promote social and psychological health
and help counteract the effects of stressful events. In our mobile society,
many people live great distances from family members and have difficulty
establishing new friendships. Those who live alone or who are socially
isolated are at greatest risk of vulnerability, increased morbidity and
mortality, and decreased overall health (Lubben, Gironda, Sabbath, Kong, &
Johnson, 2015); thus, C/PHNs should be aware of this and strive to provide
additional support and resources.
A general model of vulnerability helps to explain individual and
community risk factors that lead to vulnerability, as well as problems with
access to care and quality of care received that impact health outcomes on
both an individual and community level, as described in a seminal article by
Shi, Stevens, Lebrun, Faed, and Tsai (2008). According to this model,
vulnerable populations often experience clusters of risk factors, and these are
viewed as cumulative. The specific combinations of risks (e.g., low income,
low education) are more detrimental to health outcomes, as is the greater
number of risk factors that accumulate over time.
Most nursing students are familiar with Maslow's Hierarchy of Needs
(Maslow, 1987), with physiological needs (e.g., water, food, air) as the base
of a pyramid, and the needs for safety, belonging, esteem, and self-
actualization building from the basic needs. Chronic poverty, environments
of crime and violence, or disenfranchisement, racism, and discrimination
(vulnerability) can keep people from meeting the higher needs (Bates, 2016).
Racism is largely defined as believing that race is the primary factor of our
capacities and traits as humans and that any racial differences result in
feelings of either superiority or inferiority.

1981
Who Is Considered Vulnerable?
In her classic book, Aday (2001) included the following factors and
populations in the description of who is considered vulnerable:

Income and education

Age and gender
Race and ethnicity
Chronic illness and disability
HIV/AIDS
Mental illness and disability
Alcohol and substance abuse
Familial abuse
Homelessness
Suicide and homicide risk
High-risk mothers and infants
Immigrants and refugees
Military personnel

Other authors considered the uninsured and underinsured as vulnerable

populations because of their difficulties with health care access and the
potential for poor health outcomes, as well as victims of bullying and crime,
children in foster care, those in the gay and lesbian community, veterans and
returning military personnel, and victims/survivors of torture and terrorism
(Hong, Pequero, & Espelage, 2018; Koven, 2018; Mohatt et al., 2018;
Scherrer et al., 2018).

Although many segments of the population may be considered

vulnerable at some point in their lives, some population segments are
more often identified as vulnerable because of their long-term situations
(de Chesnay & Anderson, 2016). The very young and the very old have
particular risk factors that increase their chances of poor health, as well
as unique issues with access to health care.
An extensive body of research substantiates the reality of higher
morbidity and mortality rates for racial and ethnic minorities than for
the White population, thus demonstrating racial/ethnic disparities in
health (Gwede, Quinn, Green, 2016; Institute of Medicine [IOM], 2003;
Neumayer & Plümper, 2015).

1982
Prevalence of Vulnerable Populations and
Causative Factors
Root causes of vulnerability, such as low socioeconomic status (SES), lack of
insurance coverage, racism, and discrimination, have been widely
researched. Which cause or causes are considered most important? The exact
weight of the interaction of these causes has been difficult to ascertain. The
current approach to understanding the complex interrelationships among the
causes and factors related to vulnerability is to examine multiple
determinants of health (Brantley, Kerrigan, German, Lim, & Sherman, 2017;
Gwede et al., 2016); this chapter focuses on the social determinants of health
(Box 23-4).

BOX 23-4 STORIES FROM THE

FIELD
Teen Pregnancy Teen pregnancy is viewed as a
social issue that impacts families for
generations. Although the teen pregnancy rate
has been declining over the past few decades,
the United States still has the highest teen
pregnancy rate among developed nations
(Watson & Vogel, 2017). Teen mothers are less
likely to receive prenatal care and more likely
to live in poverty and have more than one child
before age 20, and their children are more
prone to behavioral issues (Watson & Vogel,
2017).
One teenage mother describes being a teenage mother at school as
follows: “I feel like an ant … traveling the whole world. I have to get
around the world by trying to get a boat to get across the water, trying to
get some food so I don't fall over and die. …. [I]t's the hardest battle
you're ever going to face.” (Watson & Vogel, 2017)
1. Discuss vulnerable populations. What risk factors apply to this
situation?

1983
 2. What primary, secondary, and tertiary interventions can be applied
to this scenario?

Source: Watson and Vogel (2017).

Poverty
If only one indicator is measured—poverty—it is evident that vulnerability
touches a large segment of the global population and the population in the
United States (see Fig. 23-4):

1984
FIGURE 23-4 Infographic: Poverty and Shared Prosperity 2018:
Piecing together the poverty puzzle. (Adapted with permission
from World Bank. (2018). Retrieved from

1985
 https://www.worldbank.org/en/news/infographic/2018/10/17/infogr
aphic-poverty-and-shared-prosperity-2018-piecing-together-the-
poverty-puzzle). See for the complete infographic.

According to the latest figures from the World Bank (2015), an

estimated 767 million people are living in extreme poverty (living on
$1.90 or less a day), and 2.1 billion are living in moderate poverty
(living on between $1.90 and $3.10 a day).
The official poverty rate in the United States is 12.7%, which represents
an estimated 43.1 million people (Center for Poverty Research,
University of California Davis [UCD], 2017).
Poverty thresholds in the United States are $12,486 for a single
individual under age 65, $14,507 for a household of two people with a
householder 65 years or older with no children, and $24,339 for a
family of four with two children under age 18 (Center for Poverty
Research, UCD, 2017).
According to the National Center for Children in Poverty (2017), 36%
of the children in poverty are Black, or African American, 33%
American Indian, 30% Hispanic or Latino, 12% White, and 12% Asian
or Pacific Islander.

How does poverty make one vulnerable to poor health outcomes? The
answer to this question is complex:

One supposition is that having less money means being less able to
afford most aspects of a quality life, including adequate housing in a
safe neighborhood. This living situation may lead to fewer opportunities
for exercise, especially if walking outside puts one at risk of becoming a
victim of violence.
Fewer community resources are usually available, such as grocery
stores, quality schools, recreation facilities, and health care providers.
Lower income level is associated with lower levels of education and
often results in a person having to work at jobs where he or she is
exposed to higher risks (e.g., mining), or the need to work at more than
one job to make ends meet, and often without health insurance coverage
(Centers for Disease Control & Prevention [CDC], 2015a).

Data from the National Health Interview Survey showed that from 2013
to 2015, the percentage of adults aged 18 to 64 years (Martinez & Ward,
2016):

Who were uninsured decreased for poor (40.0% to 26.2%), near-poor

(37.8% to 23.9%), and not-poor (11.7% to 7.7%) adults
Who had a usual place to go for medical care increased for poor (66.9%
to 73.6%) and near-poor (71.1% to 75.9%) adults

1986
 Who had seen or talked to a health professional in the past 12 months
increased for poor (73.2% to 75.8%) and near-poor (71.9% to 75.9%)
adults
Who did not obtain needed medical care due to cost at some time during
the past 12 months decreased for poor (16.8% to 12.4%), near-poor
(14.6% to 11.0%), and not-poor (4.9% to 3.8%) adults

Research has shown that those groups with the lowest income and least
education were consistently less healthy than were those with the most
income and education (World Health Organization, 2020a). Poverty and
race/ethnicity are often intertwined, but SES is considered a consistent and
robust variable related to health and death (Brantley et al., 2017; Montez,
Zajacova, & Hayward, 2017; Montez, Zhang, Zajacova, & Hamilton, 2018;
Neumayer & Plümper, 2015; Williams, Priest, & Anderson, 2016):

Low-income minority neighborhoods with poor access and poor

walkability to fresh fruits, vegetables, and lean proteins are associated
with a significant increase in cardiovascular disease mortality and type 2
diabetes (Gaglioti et al., 2018; Haynes-Maslow, Ammerman & Leone,
2017). Many of these neighborhoods are termed food deserts due to the
lack of available supermarkets (Fig. 23-5).
Research has shown that fast food restaurants are more prevalent in
low-income neighborhoods, and this prevalence has been shown to have
a positive correlation with obesity and type 2 diabetes (Michimi &
Wimberly, 2015; Rummo et al., 2017).

1987
 FIGURE 23-5 Income and race/ethnicity influence access to
healthy food.

Another risk factor for vulnerability that is associated with poverty is

exposure to pollution and smoking:

One finding indicates that the highest amount of pollution is most often
found in neighborhoods where there is more poverty, lower education
levels, and higher rates of unemployment (CDC, 2015a).
Others note an association between SES and poorer respiratory health,
often due to living conditions, such as ambient air pollution and
smoking (Berry, Nickerson, & Odum, 2017), and because of a higher
smoking prevalence among those with lower SES (Lowe et al., 2018).
Also, research has shown that lower SES groups are as likely as higher
ones to attempt smoking cessation but are less likely to be successful
(Perelman et al., 2017). The lower success in the ability to quit smoking
is being examined to find more effective evidence-based treatment for
low-income populations (Evans et al., 2015).

At the population level, increases in total income and reductions in

poverty levels are “strongly associated with subsequent improvements in
population health” (Aday, 2005, p. 190). This is proven out in a systematic
review of maternal mortality outcomes. Financial barriers and lack of

1988
maternal health education for the mother and partner were shown to
negatively impact maternal-child outcomes (Banke-Thomas, Banke-Thomas,
& Ameh, 2017). Income affects health, and poor health can affect the income
of an individual as well as that of a nation (see Chapter 6).

Uninsured and Underinsured

If the uninsured are also classified as a vulnerable population, even more
Americans join the ranks, because the majority of those without health
insurance are working adults who are not eligible for Medicaid or Medicare.

The percentage of uninsured in 2013 was estimated at 16.7%. In 2016,

10.3% of people in the United States were without health insurance
(Kaiser Family Foundation, 2019).
The decline in the percentage of uninsured is attributable in great part to
the Patient Protection and Affordable Care Act (ACA), signed into law
by President Barack Obama on March 23, 2010. This law requires most
U.S. citizens and legal residents to have health insurance coverage,
along with many other provisions (Knickman & Kovner, 2015). See
Chapter 6 & 13 for more on the ACA.
Although the improvement in health insurance coverage is encouraging,
disparities in access to health care continue.
In 2014, 31 million people were underinsured in the United States,
which was unchanged from 2010.
In 2003, only 1% of privately insured adults had a deductible of
$3,000 or more, but that increased to 11% in 2014 (Collins,
Rasmussen, Beutel, & Doty, 2015) and 13% in 2016
(Commonwealth Fund Report, 2017).
Also, most health care experts feel that there will still be disparities in
quality, access, and outcomes for those who are more vulnerable
(Gwede et al., 2016).

How does having inadequate or no health insurance lead to poor health

outcomes? As explained in Chapter 6, those with few or no resources in this
area do not use early screenings and preventive measures, and they delay
getting treatment in an effort to save money. Those without health insurance
receive care only for the problem at hand and not always for underlying
causes. They do not get regular physical examinations and may be
inadequately immunized against common diseases. Thus, they are at risk for
poorer general health. Also, when examination and subsequent treatment are
delayed, diseases, such as cancer or cardiovascular illness, may result in
earlier death.

Race and Ethnicity

1989
The United States is a multiracial, multiethnic country. About one third of the
population belongs to a racial or ethnic minority group, and this proportion
will continue to increase, as minorities are projected to constitute more than
half of all children by 2023 (Frey, 2018; Laun, 2019).

Hispanics represent the largest minority group (16% of the total

population, up from 13% in 2000 census), and they are also the fastest-
growing group, with a lifetime average number of children per woman
of 2.53, compared with 1.71 for White women (Pew Research Center,
2015).
Blacks in the United States account for a higher proportion of new HIV
diagnoses, those living with HIV, and those who have ever received an
AIDS diagnosis, compared with other races and ethnicities (CDC,
2015b). In 2016, Blacks accounted for 44% of HIV diagnoses, though
they comprise only 12% of the U.S. population (CDC, 2015b).
There is a disparity in the prevalence of preterm births in the United
States, with 12.7% of infants born to Black mothers being premature
compared with only 8.0% among White mothers (McKinnon et al.,
2016).
Infant mortality is much higher among African Americans at 10.9%
when compared with 4.9% among White Americans (U.S. Department
of Health and Human Services, 2019).
Hypertension increases the prevalence of cardiovascular disease
outcomes, such as stroke, congestive heart failure, kidney failure, and
cognitive impairment/dementia, and Blacks are disproportionately more
affected by hypertension and its comorbid conditions. In the United
States, the prevalence of hypertension is 40% to 50% in African
Americans compared with 25% to 30% in Whites (Osei & Galliard,
2017).
Blacks have higher prevalence of heart failure, by twofold, stroke, by
twofold to fourfold, and kidney failure, by twofold to fourfold, in the
United States (Osei & Gaillard, 2017).

Why does simply being a member of a racial or ethnic minority group

make someone vulnerable? The reasons are complex and just beginning to be
understood. Williams et al. (2016) found in a review of the scientific
research that racism affects the health of minority racial populations in
multiple ways.

Institutional racism in policies and procedures reduced access to

housing, neighborhood and educational quality, employment
opportunities, and other societal resources.
Cultural racism affects economic status and health by creating a policy
environment adverse to equal policies.

1990
 Experiences of racial discrimination are a type of psychosocial stressor
that can increase health risks.

Recent immigrants have healthier exercise and dietary patterns than do

those born inside the United States.

A systematic review of acculturation, obesity, and health behaviors

among recent migrants showed that there was evidence across multiple
studies for a positive association between acculturation (measured with
standard measures or as duration of stay) and obesity (Alidu &
Grunfeld, 2017).
Others note the generational link between minority group membership
and low educational attainment (e.g., father's education level) and the tie
between education and health (Hahn & Truman, 2015).
A majority of Hispanics and Blacks have spent a lifetime at a lower
level of educational attainment and continue to lag behind in most areas.
One bright spot is that the percentages of Hispanics and African
Americans enrolled in college have increased significantly over the past
two decades. From 1997 to 2016, for instance, the percentage of Black
young adults enrolled in college has increased by 6% and the percentage
of Hispanic young adults has increased by 17% (Digest of Education
Statistics, 2016).

1991
VULNERABILITY AND
INEQUALITY IN HEALTH CARE
Various social factors, known as the social determinants of health, including
SES, affect a person's vulnerability to poor health. Specific areas in which
inequities in health outcomes result from these social factors are known as
health disparities.

1992
Social Determinants of Health
The World Health Organization has defined the social determinants of
health as “…factors such as where we live, the state of our environment,
genetics, our income and education level, and our relationships with friends
and family all have considerable impacts on health…,” including the
available health system (World Health Organization, 2020b, para. 1).
Commonly acknowledged factors, such as social norms or attitudes (e.g.,
discrimination, racism); exposure to crime, violence, and social disorder; and
concentrated poverty, are associated with health outcomes and are recognized
as social determinants of health (CDC, 2015a; USDHHS, n.d.). The
connection between social inequalities and health is illustrated in the Bay
Area Regional Health Inequalities Initiative (BARHII) conceptual
framework: http://barhii.org/framework (BARHII, 2015).
The unequal distribution of these factors among certain groups is thought
to contribute to health disparities that are persistent and pervasive. The IOM
report For the Public's Health: The Role of Measurement in Action and
Accountability called for addressing the underlying factors, not only the data,
related to morbidity and mortality (2010). When we address health
disparities, we must consider these social determinants and work on all levels
—individual, aggregate, community, and population—to reduce them.
Social determinants of health are related to both morbidity and mortality.
Quantified deaths that could be attributed to social factors in the United
States were reported:

The authors found that life expectancy in the United States for the top
and bottom 1% of the income distribution varies by 15 years for men
and 10 years for women (Price, Khubchandani, & Webb, 2018).
Moreover, it is estimated that only 10% to 15% of the increase in length
of life in Western nations can be attributed to improved medical care,
according to Raphael's classic treatise (2003).
Between 2001 and 2014, life expectancy increased by 2.34 years for
men and 2.91 years for women in the top 5% of the income distribution,
but by only 0.32 years for men and 0.04 years for women in the bottom
5% (Chetty et al., 2017).
Life expectancy for low-income individuals varied substantially across
local areas. In the bottom income quartile, life expectancy differed by
approximately 4.5 years between areas with the highest and lowest
longevity (Chetty et al., 2017).
Geographic differences in life expectancy for individuals in the lowest
income quartile were significantly correlated with health behaviors such
as smoking. Life expectancy for low-income individuals was correlated

1993
 with the local area fraction of immigrants, fraction of college graduates,
and government expenditures (Chetty et al., 2017).
Life expectancy can also be linked to where you live as predicted
through zip code (Robert Wood Johnson Foundation, 2018a, 2018b).

To improve the health of disadvantaged groups, early public health

efforts addressed determinants of health such as sanitation and poverty, along
with living conditions and other environmental issues, as noted in Chapters 3
and 9. The present need to address underlying social conditions to improve
health status is borne out by current research on race and socioeconomic
class (Hahn & Truman, 2015). It is now widely acknowledged that to truly
have an impact on the health of the population, there is a need to improve
social conditions (Bharmal, Derose, Felician, & Weden, 2015; CDC, 2018).
Political action and participatory action research are vital tools in reducing
the effects of these conditions, as are methods of community empowerment
(World Health Organization, 2020b; see Chapters 4 and 13). Healthy People
2030 addresses the context to which people's lives influence their health (see
the social determinants of health in Box 23-5).

BOX 23-5 HEALTHY PEOPLE 2030

Social Determinants of Public Health
Economic stability
Education access and quality
Health care access and quality
Neighborhood and built environment
Social and community context
Reprinted from USDHHS (2020). Social determinants of health. Retrieved from
https://health.gov/healthypeople/objectives-and-data/socialdeterminants-health

1994
Socioeconomic Gradient of Health
In a series of large-scale, longitudinal studies in England, the now classic
Whitehall studies, British civil servants were divided into socioeconomic
groups based on their occupational status, from executives to unskilled
workers. What the investigators discovered was an improvement in mortality
and morbidity rates as the level of one's occupation and pay increased. Those
at the lowest levels had the poorest health, but as they moved up the salary
scale and occupational level, their health improved. What makes this so
interesting is that all of the workers had basic health insurance coverage and
free medical care—no real problems with access to health care existed.
Although less pronounced, even when the researchers adjusted for diet,
exercise, and smoking, the gradient persisted (Marmot, Ryff, Bumpass,
Shipley, & Marks, 1997; Marmot & Wilkinson, 2006). The investigators of
one study found higher prevalence of heart disease for all participants at the
lower end of the social stratus. The researchers also found death rates for
diabetic participants to be about 200% higher in the lowest social group
when compared with the highest (Chaturvedi, 1998).
A U.S. study, following up on children of Framingham study subjects,
found an association between lower socioeconomic position and coronary
heart disease. A later study found higher odds of smoking, excess
consumption of alcohol, and obesity, which “may contribute to adult cardio
metabolic disease” by the predisposition of these unhealthy behaviors
(Loucks et al., 2009; Non et al., 2016, para. 5).
This direct relationship between social class or income and health has
been termed the socioeconomic gradient (Hajizadeh, Mitnitski, &
Rockwood, 2016). It has been found in populations around the world,
although not always unfailingly, and has been related to

Poor health outcomes regarding cardiovascular disease in European

countries (Lenhart, Wiemken, Hanlon, Perkett, & Patterson, 2017)
Cancer incidence, mortality, and survival in Western countries (Olver &
Roder, 2017)
Injury rates, such as blunt and penetrating injuries (Chikani et al., 2015)
Increased burden of chronic illness among Kenyan, South African, and
Indian citizens (Mendenhall, Kohrt, Norris, Ndetei, & Prabhakaran,
2017)
Outcomes of adult asthma, chronic obstructive pulmonary disease, and
rhinitis (Torres-Duque, 2017)
Behaviors, such as smoking, that are highest among those who are from
the working class and who have low-income and low educational levels
(Psaltopoulou et al., 2017)

1995
Chronic conditions in older adults, with individuals in the poorest
neighborhoods in Canada being more likely to have more chronic
conditions and die as a result of those conditions (Lane, Maxwell,
Grunier, Bronskill, & Wodchis, 2015)
Higher rates of in-hospital mortality in U.S. pediatric patients and
Iranian acute coronary syndrome patients (Abbasi et al., 2015)
Lower levels of education and income being associated with higher
rates of low birth weight, whereas higher levels of occupation and
income being associated with lower rates of infant mortality (Elder,
Goddeeris, & Haider, 2016)

1996
Health Disparities
Health disparities are differences in the quantity of disease, burden of
disease, and other adverse health conditions present in different groups
(Zhang et al., 2017).

Health disparities may be unavoidable, such as health-damaging

behaviors that are chosen by an individual despite health education and
counseling efforts, but most are thought to be due to inequities that can
be corrected (Mueller, Purnell, Mensah, & Cooper, 2015).
A long-held belief about health inequities, adopted by the World Health
Organization (2017), is that they are unnecessary and avoidable as well
as unjust and unfair, so that the resulting health inequalities also lead to
inequity in health.
Health disparities can be objectively viewed as a disproportionate
burden of morbidity, disability, and mortality found in a specific portion
of the population in contrast to another.
The topic of social determinants of health was added to Healthy People
2020 (Office of Disease Prevention and Health Promotion, 2020a). The
National Healthcare Quality and Disparities Report revealed that
disparities persist, but several racial disparities in rates of childhood
immunizations and adverse events associated with procedures have been
eliminated (AHRQ, 2015).
Reported disparities exist in the areas of quality of health care, access to
care, levels and types of care, and care settings; they exist within
subpopulations (e.g., elderly, women, children, rural residents, disabled)
and across clinical conditions.
Promoting healthy choices does not eliminate health disparities; action
must be taken to improve the conditions within people's environments.
That is why Health People 2030 has increased its focus on SDOH
(USDHHS, n.d.). In fact, one of Healthy People's 2030 goals focuses on
SDOH: “Create social, physical, and economic environments that
promote attaining the full potential for health and well-being for all”
(USDHHS, n.d., para 4).

Poor access to quality care and overt discrimination are examples of

disparities. Discrimination can occur during service delivery if health care
providers are biased against a specific group or hold stereotypical beliefs
about that group. Providers may also not be confident about providing care
for a racial or ethnic group with whom they are unfamiliar. Language may be
a problem, as can cultural values and norms that are unfamiliar to providers.
Patients can also react to providers in a way that promotes disparities;

1997
patients may not trust the information given to them and may not follow it as
explained, leading to inadequate care (Mueller et al., 2015).

Access to Care
The landmark IOM (2003) report Unequal Treatment: Confronting Racial
and Ethnic Disparities in Health Care noted a large body of research
highlighting the higher morbidity and mortality rates among all racial and
ethnic minority groups when compared with Whites. This report drew
attention to an issue that continues today and remains relevant. Differences in
health care access were also explained, whether due to inadequate or no
health insurance, problems getting health care, poorer quality of care, fewer
choices in where to go for care, or the lack of a regular health care provider.
For instance, because there are fewer numbers of health care providers in
minority neighborhoods, finding a primary care provider is more difficult for
those living in these areas. Providing low-cost or free clinics within low-
income neighborhoods has been shown to improve the management of
chronic conditions and decrease rates of hospitalization (Hutchinson et al.,
2018).
Progress in this area has remained slow. The Institutes of Medicine's
Progress Report highlights the following mechanisms to address 21st century
health care needs: better coordination of care, nurses to practice to the full
extent of their license, increased educational levels of nurses (including more
doctorate and bachelor's prepared nurses), increased workforce diversity, and
nurse engagement in leadership roles (National Academy of Sciences, 2019).
Residential segregation, although illegal, still exists and can play a role
in health disparities. Many vulnerable populations, especially racial and
ethnic minority groups and low-income populations, find health care at
safety-net hospitals and community clinics where they are at the mercy of
balanced budgets and vast bureaucratic systems (AHRQ, 2015). However,
more recent data showed that the ACA is improving access for uninsured
individuals to safety-net clinics in states with expanded Medicaid coverage
(Angier et al., 2015).
Other geographic factors can affect access to health care services. For
example, a classic study by O'Mahony et al. (2008) found that only 25% of
pharmacies in non-White neighborhoods, compared with 72% in
predominately White neighborhoods, stocked sufficient opioid drugs to meet
the needs of palliative care patients in different New York neighborhoods.
Health care access is also problematic for other vulnerable groups. For
example, services and resources for the mentally ill and substance abusers
are often fragmented and inadequate, as are those for abusing families and
homeless persons. Refugees and immigrants may have difficulty finding
affordable and easily accessible health care, largely because of their lack of

1998
health insurance and the need to find care at free clinics or emergency rooms
(Richard et al., 2016). When vulnerable individuals cannot get appropriate
health care or treatment for illness or disease, for whatever reason, they are
more likely to have health deficits.

Quality of Care
Quality of care is another area in which health disparities persist. One aspect
of quality care is the comfort level patients have with their providers.
Research indicates that racial and ethnic minority clients feel more
comfortable and satisfied with care from a health care provider who comes
from the same racial and/or ethnic group (Fig. 23-6; AHRQ, 2015).
However, a shortage of ethnically diverse health care providers exists.
Despite racial and ethnic minorities constituting 37% of the U.S. population,
only 19% of registered nurses are from minority racial and ethnic groups
(American Association of Colleges of Nursing, 2015).

FIGURE 23-6 Racial and ethnic minority clients often prefer

health care providers from the same racial and ethnic background.

Lack of quality health care services is common among racial and ethnic
minority groups. A recent study on Black and White older adult Medicare
general surgical patients showed that Blacks had higher 30-day mortality, in-
hospital mortality, in-hospital complications, and failure-to-rescue rates,
longer length of stay, and more 30-day readmissions (Silber et al., 2015). The
researchers suggested that poorer health of Blacks on surgical presentation
was a major contributing cause for the disparities (Silber et al., 2015).
Communication can also be a factor in poor quality of care. Marginalized
vulnerable populations, such as substance abusers, at-risk mothers and
infants, abusing families, suicide-and homicide-prone individuals, and the

1999
mentally ill or disabled, may feel they are treated as “second-class citizens,”
and cultural barriers and misunderstandings can lead to a discontinuation of
recommended regimens. Poor health outcomes may result as effectiveness of
health care for vulnerable populations is not often considered or even well
defined (Hutchinson et al., 2018).

2000
WORKING WITH VULNERABLE
POPULATIONS
Through the day-to-day provision of care and participation in larger efforts in
the community, the nurse can help improve health outcomes for vulnerable
populations (see Box 23-6).

BOX 23-6 QSEN: Focus On Quality

Patient-Centered Care for Working With Vulnerable
Populations 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's 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.) C/PHNs work with many vulnerable groups, including the
homeless population. Vulnerable groups within the community may be
marginalized and lack access to quality health care services. To build rapport
and trust, nurses must provide respectful understanding and care while
focusing on the needs of the client. How do the QSEN competencies assist
nurses in demonstrating patient-centered care to the homeless?
Students in a community health clinic spent time working with homeless
clients and their families in a homeless center. Some students had limited
previous exposure to diverse populations and were aware only of stereotypes
and misconceptions regarding this population. Homeless women heads-of-
household and their children made up 60% of the population using this
facility. Students were unaware of the variance of demographics and
backgrounds regarding this vulnerable group.
In conjunction with the homeless center, student identified clients' needs
and provided an educational health fair. Local agencies supplied free needed
items; education stations were then created to support heath issues
surrounding the donated items (e.g., an oral health education station provided
free travel-size toothbrushes).
While offering health education, students engaged with clients and their
families, which gave them the opportunity to learn about vulnerability. One

2001
student had a conversation with a mother about how she became homeless.
The woman shared that after her husband died, she had no family or support
systems for herself or her child with severe asthma. The woman lost her
home and insurance, so she was unable to pay for her child's medical bills.
Another student talked with a man about how long he had been homeless.
This man was a veteran and suffered from PTSD and drug misuse; alienated
from his family and friends, he had been homeless for several years.
In speaking with clients, students identified issues that prevented use of
shelters by some clients, such as lack of privacy or rules prohibiting pet dogs.
Students learned valuable skills related to working with a vulnerable group
and breaking through fears related to stereotypes and biases.
Source: Cronenwett et al. (2007).

2002
The Role of Public Health Nurses
C/PHNs can work to improve the health of vulnerable populations by
empowerment, facilitating external support from patient's family and friends,
and engaging in evidence-based practice.

Empowerment
Because vulnerability often equates with feelings of powerlessness, the
actions of C/PHNs can either promote engagement or destroy chances for
rapport. C/PHNs can use empowerment strategies in their work with clients
once trust and rapport have been established (Box 23-7). The personal
values, experiences, characteristics, and actions of both nurses and clients
influence the speed at which this process takes place and the eventual level
of connection. Helping clients identify their fears and clearly defining the
C/PHN role with the client and family are also important.

BOX 23-7 Community/Public Health

Nurse Actions to Promote Client
Empowerment Which
community/public health nursing
activities/actions are most effective in
promoting empowerment among nurses'
vulnerable clients? In Falk-Raphael's
(2001) well-known qualitative study of
public health nurses (C/PHNs) and their
clients, several themes were noted as
components of the C/PHN role:
Empowerment is “an active, internal process of growth” that is
reached by actualizing the full potential inherent within each client,
and this occurs “within the context of a nurturing nurse–client
relationship” (p. 4). C/PHNs describe the process of empowerment
as a two-way street with clients not only gaining knowledge and
skills and “acting on informed choices” but also further

2003
 empowering the nurse to continue the work of the empowerment
(p. 6).
Having a client-centered approach, denoted by flexibility in
dealing with clients, for example, “meeting them where they are,”
“communicating at their level,” and “backing off and following
client's agenda” (p. 6)
Developing a trusting relationship based on mutual respect and
dignity, for example, clients as active partners with the C/PHN
assuming more or less responsibility as needed; being empathetic,
nonjudgmental, and “creating a safe environment” (p. 7)
Employing advocacy, both at an individual level as well as political
advocacy, for example, using their role and power as a professional
to cut through bureaucratic red tape, connecting clients with
available community resources, supporting clients in reaching their
health goals, making their expertise available, and being a client
resource as someone who is open and “available” (p. 8)
Being a teacher and role model, using a variety of strategies and
providing opportunities for clients to safely practice new skills. For
example, using strategies such as teaching classes, providing
individual coaching, providing positive reinforcement and support,
demonstrating skills such as assertiveness, and encouraging
community action/participation are helpful
Capacity building through encouraging and supporting of clients'
work toward attaining health goals, for example, “reflective
listening and an empathetic approach” focusing on strengths, not
limitations; facilitating client “self-exploration” and providing
encouragement for them to “act on their choices” while being
“realistic about barriers to success”; or having expectations for
client accountability regarding their decisions and actions (p. 9)
Source: Falk-Raphael (2001).

Building and preserving relationships with clients is a central focus of

C/PHN home visits. It requires building trust and rapport and helping them to
feel accepted, engaged, and ready. The building phase involves working with
individual clients to improve their social connections, build their strengths,
and work toward their goals. Building self-efficacy, motivation, and health
literacy are essential in this stage, as are helping them with coping skills and
giving encouragement as they build resilience.
Extending strategies include helping clients to use new strategies and
apply them in other situations. Phone calls and other methods of checking in
with clients are used to help them change behaviors and access services.
Negotiation and teamwork approaches are helpful in this stage. Keeping a
focus on solutions rather than problems helps build client strengths. Six

2004
principles of solution-focused nursing, built on mental health nursing
concepts, are helpful (McAllister, 2010):

Focus on the person, not the problem.

Do not focus solely on problems. Begin with an emphasis on strengths,
as this can build client hope and self-confidence.
Resilience is just as important as vulnerability.
Work to change unjust societal and cultural forces.
Nurses should assist clients as they adapt and grow and not focus solely
on care and illness.
Encourage a proactive approach that uses the three stages of client
involvement: joining, building, and extending.

These solution-focused nursing principles of client empowerment are

exemplified in a study directed by the American Academy of Nursing. In
examining the commonalities of nurse-designed models of health care, the
authors of this study found four common elements (Mason, Jones, Roy,
Sullivan, & Wood, 2015, p. 548):

Health holistically defined

Individual-, family-, and community-centric approaches to care
Relationship-based care
Group and public health interventions (Box 23-8)

BOX 23-8 PERSPECTIVES

A C/PHN's Viewpoint on Community/Public

Health Nursing I have been a C/PHN for many
years and been fortunate enough to work with
various populations. I remember a case when I
learned that although experience is a valuable
asset, sometimes this contributes to assessment
miscues. I had an established relationship with a
socioeconomically disadvantaged postpartum
client, who was experiencing anxiety, feelings of

2005
being overwhelmed, and insomnia. The
interventions that I had successfully used for so
many other moms in similar situations with
postpartum depression had failed with this client.
It was not until I inquired about a picture of my
client, Nancy, in her military uniform that she
shared with me that she had served for a few
years in the Middle East. She further stated that
she did not like to discuss her past, she regretted
not being physically able to continue her military
career, and she just wanted to “get some sleep.”
Long story short, we were able to get Nancy into a
Veteran's Administration (VA) residential
treatment program for substance abuse and
medical treatment for traumatic brain injury
(TBI). I learned through this encounter that
experience coupled with a patient-centered
assessment, minus my internal preconceptions,
results in the best outcomes for patients. Nancy
had more than the usual stressors affecting her,
and I was glad that I was finally able to pick up on
those clues and address her needs more
completely.
—Tessa, C/PHN

While empowering clients, nurses should also remember to empower

themselves through collaboration with others and self-care. Working with
disadvantaged populations can be challenging and exhausting. Often, novice
community health nurses feel overwhelmed and suffer “compassion fatigue”
when confronted with the crushing realities that their vulnerable,
disenfranchised clients face on a daily basis. Feelings of guilt sometimes
surface when nurses contrast their own life experiences with those of their

2006
clients. To be effective in working with vulnerable populations, it is often
more helpful to donate money and items on a group level rather than an
individual level and to work for substantial changes in community attitudes
and policies. Also, it is vital to remain grounded to continue to have the
necessary energy and compassion (Box 23-9).

BOX 23-9 Evidence-Based Practice

Caring and Compassion Dmytryshyn, Jack,
Ballantyne, Wahoush, and MacMillan (2015),
studying public health nurses (C/PHNs)
working with a Nurse–Family Partnership
program, found that compassion fatigue could
be problematic for nurses working with
vulnerable young mothers in this long-term
home visiting program (described in more
detail in Chapter 4). C/PHNs generally found
the nurse–client relationship rewarding but
needed to adapt their philosophy and definition
of client success to see clients as the experts of
their own individual lives. In this qualitative
study, C/PHNs expressed personal costs of
worrying about clients and doubting their own
effectiveness in their ability to address concerns
of clients. When they were able to shift the
focus to the client, they reported greater
satisfaction in the nurse–client relationship and
in watching the successes of their clients over
time.
Source: Dmytryshyn et al. (2015).

In one study, outcomes of empowerment for clients included increased

self-esteem and confidence, improved self-efficacy, and the ability to
“reframe situations in a positive way” (Falk-Raphael, 2001, p. 10). Clients

2007
also subsequently made better choices regarding their health and used
resources more appropriately. They were better able to seek information and
services and became more politically active. Clients' focus became more
proactive than reactive, and they felt that they could communicate more
effectively to define boundaries or express feelings. Consequently, clients
were also better able to collaborate with their health care providers,
becoming more trusting partners in care by demonstrating ownership for
their actions and their health. Some clients noted a newfound ability to see
their communities in a more holistic way and looked for ways to change
things for the better. A large part of C/PHN practice is to work with the
vulnerable and encourage them to become more self-reliant and responsible
for their health.

Facilitating External Support

The degree of external support clients have, along with their temperament
and other individual factors, affects their ability to cope with stress and
adverse situations. The support can be from family members, neighbors,
friends, teachers, or others. C/PHNs can help clients establish external
support at both the individual and population levels (Boxes 23-10 and 23-
11). (For an interactive map that provides information on the degree to which
specific U.S. communities are affected by external stresses on human health,
see the CDC's Social Vulnerability Index at https://svi.cdc.gov/.)

BOX 23-10 STORIES FROM THE FIELD

A View of Disasters When disaster strikes the
communities of those who are struggling to
survive, the effects are devastating, and the
recovery is long and challenging. Communities
with poorly built homes, without strong
foundations or storm windows, are less safe during
tornadoes and hurricanes. Floods impact low-lying,
low-income neighborhoods the hardest (Lowrey,
2019). The high cost of living in California has
encouraged low-income individuals to migrate to
less expensive and remote fire-prone areas
(Lowrey, 2019).

2008
 In 2018, the most destructive fire in California history incinerated the
town of Paradise within a matter of hours. The poor were the hardest hit, and
2 months after the disaster, because of inadequate housing for the poor, there
were still hundreds living in shelters. Many of those impacted were elderly
and disabled, living in trailer homes. Local hospitals and other health care
facilities were also incinerated, impacting access to health care. A nurse who
was interviewed after the disaster, referring to the struggling poor impacted
by the devastating fire, likened the incident to a house of cards; when
removing a card, the whole house collapses (Lowrey, 2019).
In 2017, Hurricane Harvey caused catastrophic flooding and many deaths
in Houston, Texas. The New York Times interviewed a survivor of this
disaster 1 year later. She spoke about the experience of losing her home and
living in a trailer. The survivor had no savings to use for recovery, and the
support she received from the government, nonprofit groups, and volunteers
was not enough for her and her family to return to a sense of normalcy. The
survivor and her family were left feeling sad, broken, and confused
(Fernandez, 2018).
In 2005, Hurricane Katrina broke through the levee system in New
Orleans, Louisiana, causing massive flooding. Many of the poor residents did
could not flee because they did not have a car, and they didn't have money to
pay for a hotel and other necessities. Health issues related to the aftermath of
the hurricane included concerns about contamination of local waters with
solid waste, pesticide use for vector control from an abundance of
mosquitoes, and reduction in air quality from mold and dust. The poor bore
the brunt of the disaster, and the few facilities that existed to quickly help the
victims became miserable and dangerous places (Schake, Sommers,
Subramanian, Waters, & Arcava, 2019). Moving from large shelters to trailer
homes negatively affected the mental health of some survivors and caused a
great strain on family relationships. A Hurricane Katrina survivor who was
born and raised in a housing project in New Orleans was relocated, as many
were, to Houston, where she had no family, social support, nor means of
transportation (Voice of a Witness, 2019).
Source: Fernandez (2018); Lowrey (2019); Schake et al. (2019); Voice of a Witness (2019).

BOX 23-11 Foundational Public Health

Services (FPHS) Model The FPHS
model is a conceptual framework
describing the capacities and programs
that state and local health departments

2009
 should be able to provide to all
communities and for which costs can be
estimated.
Foundational Public Health Service
Foundational Areas
Environmental Healtha
Chronic Disease
Injury Prevention
Maternal, Child Health
Access Linkage
Communicable Disease

Foundational Capabilities
All Hazards
Communications
Policy Development
Assessment
Community Partnership
Organizational Competencies

Other Health/Services
Critical Care
Environmental Protectiona
Behavioral Health
Disability Related
Other Services
a“Environmental Health” refers to prevention (permitting,
education, regulation) activities. “Environmental Protection” refers to
remediation and environmental quality.
Adapted with permission from Resnick, B. A., Fisher, J. S., Colrick, I. P., and Leider, J. P.
(2017). The foundational public health services as a framework for estimating spending.
American Journal of Preventive Medicine, 53(5), 646–651.

Using Evidence to Reduce Vulnerability

2010
Community health nurses can help vulnerable populations, communities,
individuals, and families reduce their vulnerability by using evidence from
research, expert opinion, and best practices (see Chapter 4 on evidence-based
practice). Often, evidence is embedded in policies, procedures, and clinical
guidelines. Thus, the first place to locate evidence for practice is in the
specific agency documentation for nursing practice. Sometimes, a
community need is discovered that requires creative thinking and evidence-
based interventions (Box 23-12).

BOX 23-12 Population Focus

Improving Health Care Professionals' Caring
for LGBTQ Persons Karen and Lisa had been
together for 17 years. They lived in a state
where same sex marriage is not legal but they
were registered domestic partners. Together
they had three children ages 9, 11, and 15. Their
children were conceived through artificial
insemination. Two of the children were
conceived by Lisa and one by Karen.
For their summer vacation, they decided to visit a well-known
amusement complex for a week. Three days into their vacation, Karen
suddenly complained of a severe headache and within minutes, was
unresponsive. She was taken by ambulance to a local hospital.
When Lisa arrived at the hospital with their children, she was
stopped by the emergency room admissions clerk, who said she needed
her insurance information. After providing the information, she asked to
see her partner. The admissions clerk found the charge nurse who asked
Lisa what her relationship was to Karen. When Lisa told her they were
partners, the charge nurse told her that only immediate family would be
allowed in to see her and she was not considered family. Lisa tried to
explain that she was Karen's only immediate family, that both her
parents were dead and that they had been together for 17 years. Again,
the charge nurse refused to allow her in. Lisa spent the next couple
hours on the phone with friends back home, sending one of them to their
home to find their official domestic partnership paperwork.
After the paperwork had been faxed to the admissions clerk, Lisa
approached the charge nurse again asking to see Karen. In a
condescending tone, the charge nurse told Lisa that her paperwork is not

2011
 recognized in this state and she again refused to allow her to see Karen.
She did, however, agree to allow the 9-year-old daughter (the only one
of the children Karen gave birth to) to come into the emergency room,
but Lisa was concerned that this would be too traumatic for her since
she could not go with her nor could her older siblings.
Karen had been intubated immediately upon arrival to the
emergency room and underwent CT imaging, which revealed a massive
intracranial hemorrhage, likely from an AV malformation. Four hours
after her arrival at the hospital, Karen died. Alone.

1. How do you define family?

2. How would you react to this policy?
3. What would you do to meet the needs of the patient and the
patient's family?
Source: National LGBT Health Education Center (2015, 2016, n.d.); The Fenway Institute
(2015).

—Marla Seacrist, PhD, RN

Many areas for improvement of the lives of vulnerable populations lie in

areas related to prevention and health promotion, as described above.
Primary prevention is readily available in the form of immunizations for
children, adolescents, and adults. Nursing activities to promote increasing
immunization levels among vulnerable people will result in greater economic
and social returns for the whole community. Similar is the involvement of
nurses in smoking prevention and smoking cessation activities. Also, some
vulnerable subpopulations require additional insight and experience, such as
veterans (Box 23-13) and victims of human trafficking (Box 23-14).

BOX 23-13 Population Focus

Veterans Health Veterans are a unique and
diverse population in the community. There are
approximately 20 million veterans living in the
United States, with almost 2 million of those
being women (VetPop, 2016). Veterans are older
in comparison to non-Veterans (NCVAS, 2018),
have shorter life expectancy, lower amounts of
education, and household income when

2012
compared to the general U.S. population
(NCVAS, 2017). The military culture
(deployments, service commitments, training,
and battlefield exposure) and the subsequent
impact on the health of veterans and their
families can only be experienced by this
population. The current veteran population is
diverse, with representation from varying
gender and sexual orientations, ethnicities and
races, ages, and geographies (Veterans Health
Administration, 2018). These characteristics
have historically resulted in greater health
disparities and therefore constitute veterans as
a vulnerable population. Veterans can
experience long-lasting negative effects because
of their time in the military. These negative
effects are often the result of traumatic stress
and can create vulnerabilities that result in
mental health disorders, alcoholism, substance
abuse, dysfunctional relationships,
homelessness, depression, and unemployment
(Koven, 2018).
Traumatic exposures can lead to posttraumatic stress disorder
(PTSD). PTSD has been associated with an increased risk for
depression, anxiety, attachment avoidance, obesity, type 2 diabetes, and
substance abuse (Scherrer et al., 2018). PTSD has been associated with
a nearly 200% increase in hospitalizations among active duty service
members between 2006 and 2012, and it is a leading diagnosis in the
U.S. Department of Veterans Affairs medical settings (Armenta et al.,
2018). These statistics may underestimate the impact of PTSD because
many service members in need of treatment might not seek care.

Symptoms of PTSD and depression overlap significantly (Sher,

Braqualais, & Casas, 2012).

2013
 Common features of depression include diminished interest or
participation in significant activities, irritability, sleep disturbance,
difficulty concentrating, restricted range of affect, and social
detachment (Sher et al., 2012).
Veterans who live in rural communities are more socially isolated
and are 20% more likely to commit suicide than veterans who live
in urban areas (Mohatt et al., 2018).
Obesity is twice as common in patients with PTSD compared to
those without PTSD and those with PTSD were 30% more likely to
report being diagnosed with type 2 diabetes than those without
traumatic exposure (Scherrer et al., 2018).
Traumatic brain injuries have resulted in frontal lobe deficits that
are linked to impulsive behaviors such as aggression and violence
(Kois, et al., 2018; Mohatt et al., 2018).
Source: Armenta et al. (2018); Kois et al. (2018); Koven (2018); Mohatt et al. (2018); NCVAS
(2017, 2018); Scherrer et al. (2018); Sher et al. (2012); Veterans Health Administration (2018);
VetPop (2016).

Cory Church, PhD, RN-BC

BOX 23-14 Human Trafficking Each

year, approximately 14,500 to 17,500
women, men, and children are trafficked
into the United States for the purposes
of forced labor or sexual exploitation
(American Civil Liberties Union, 2018).
The Global Slavery index (2018)
estimates that on any given day in 2016,
there were 403,000 people living in
conditions of modern slavery in the
United States, a prevalence of 1.3 victims
of modern slavery for every thousand.
Human trafficking has significant effects on both physical and
mental health. Victims of human trafficking rarely come forward to seek
help because of language barriers, fear of the traffickers, and/or fear of

2014
 law enforcement. Traffickers use force, fraud, or coercion to lure their
victims and force them into labor or commercial sexual exploitation.
Traffickers look for people who are susceptible for a variety of reasons,
including psychological or emotional vulnerability, economic hardship,
lack of social safety net, natural disasters, or political instability.
Victims of human trafficking often have untreated medical
problems, including physical injuries associated with abuse and torture
(e.g., burns, lacerations, missing or broken teeth), malnutrition,
dehydration, substance use disorders, depression, anxiety, and PTSD
(Nursing for Women's Health, 2016; Richards, 2014). It is estimated
that 80% human trafficking victims are women and girls (Nursing for
Women's Health, 2016). Female victims are at increased risk for
gynecologic and obstetric problems, including persistent or untreated
sexually transmitted infections, unintended pregnancies, repetitive
abortions or miscarriages, trauma to the rectum or vagina, and infertility
(Nursing for Women's Health, 2016; Richards, 2014).
Nurses are ideally positioned to screen, identify, care for, provide
referral services for, and support victims of human trafficking. It is
imperative for nurses who provide care to human trafficking victims to
have knowledge of local organizations specializing in working with
trafficked women; free health services (general practice, reproductive
health, hospital, and mental health); sources of advice on housing and
other social services; legal aid/immigration advice services; local
churches/community support organizations; language training centers;
and nongovernmental organizations in the victim's home country (U.S.
Department of the State, 2018). Screening patients for human
trafficking in private, safe, health care settings and, if needed, utilizing
professional interpreter services are imperative in providing care to this
vulnerable group of people. During interviews and care encounters with
these victims, it is key for nurses to be respectful and nonjudgmental.
Source: American Civil Liberties Union (2018); Nursing for Women's Health (2016); Richards
(2014); U.S. Department of the State (2018).

Veterans who have experienced trauma may not recognize dysfunctional

coping styles such as social isolation and mistrust of others as symptoms of
mental health disorders but as functional coping strategies. Increase in
alcohol and substance use has been shown to parallel and increase in PTSD
symptoms (Koven, 2018). Military sexual trauma (MST) increases PTSD
symptoms and attachment anxiety, causing issues with intimacy and trust
(Holiday, et al., 2018). MST is defined by the Veterans Health
Administration as sexual assault and repeated, threatening sexual harassment
occurring during military service (Veterans Health Administration, 2018).

2015
The prevalence of MST among veterans is estimated to be 21.5% among
women and 1.1% among men (Kimmerling et al., 2007).
Along with physical and psychological injuries, war has the capacity to
affect veterans spiritually and morally. Veterans exposed to combat can
experience moral injury. Moral injury has been defined as “perpetrating,
failing to prevent, bearing witness to, or learning about acts that transgress
deeply held moral beliefs and expectations” (Drescher et al., 2011, p. 10).
Some of the symptoms reported among combat veterans with PTSD in the
literature that arguably might be related to moral injury include (Drescher et
al., 2011)

Negative changes in ethical attitudes and behavior

Change in or loss of spirituality, including negative attributions about
God
Guilt, shame, and forgiveness problems
Anhedonia and dysphoria
Reduced trust in others and in social/cultural contracts
Aggressive behaviors
Poor self-care or self-harm

A greater understanding of the emotional scars experienced by veterans

and their greater risk for comorbidities will help improve and direct care,
resulting in better outcomes.
Women veterans are also increasing in the community and are the fastest-
growing population within the veteran community (U.S. Department of
Veterans Affairs [USDVA], 2015). In the last 10 years, women enrolled in
health care service through the Veterans Health Administration have doubled.
Women veterans are younger and more racially and ethnically diverse in
comparison with male veterans (Northern Center for Veteran's Analysis and
Statistics [NCVAS], 2016). Higher numbers of female veterans have
experienced MST (USDVA, 2010). The Veterans Health Administration is
working to address strategic priorities in the areas of primary care, health
education, and reproductive health. Each Veterans Health Administration
health care system contains an MST coordinator and a Women Veterans
Program manager to advise and advocate for female veterans' health care
services. Nurses in both acute and primary care areas can seek out these
services for their patients.
It is evident that Veterans have multiple determinants that affect health
and access to care. The Veterans Health Administration health care system is
working to improve disparities among vulnerable populations and increase
access to care (USDVA, 2016). Nurses in all care settings can call the
Veterans Health Administration to determine access and benefits for

2016
veterans. It is equally important for nurses to assess military service in
patients and the impact of service on one's health.
The Military Health History Pocket Card for Clinicians (USDVA, 2017)
provides an easy guide for clinicians to understand veterans' unique medical
problems and concerns associated with military service. Nurses can ask,
“Would it be ok if I talked with you about your military experience? Did you
have any illnesses or injuries while in the service?” The pocket card can help
nurses understand if veterans are seeking compensation and benefits for their
care, or the current living situation of a veteran. These questions help a nurse
determine the level of care needed for veterans in the community. Finally, the
pocket card can help establish rapport and collaborative relationships with
veterans (Box 23-15).

BOX 23-15 PERSPECTIVES

An Emergency Room Nurse's Viewpoint on

Community/Public Health Nursing I have been an
emergency room nurse for several years and been
fortunate enough to work with various
populations. As a beginning emergency nurse, I
did not understand that I would advocate for
services and resources of patients that sought care
in the emergency department. I remember a
patient who was experiencing depression, anxiety,
and having suicidal ideation came to the local
county hospital. Fortunately, I read through the
patient's social and medical history only to find
that the patient had prior military experience and
posttraumatic stress disorder. I brought up the
patients' military experience, and this was a way
for us to establish a nurse–patient relationship.

2017
After speaking with the veteran, I was able to
determine that he wanted to seek mental health
care through the Veterans Health Administration
(VHA), but the nearest hospital was several hours
away. Through collaboration with the nursing
case manager, we were able to establish
transportation to the VHA hospital for inpatient
mental health treatment. I learned through this
encounter that assessing military history in
patients is key, especially in individuals in the
community with mental health concerns. I was
finally able to understand my role in advocating
for resources and help for individuals in the
community.
—Cory Church, PhD, RN-BC

2018
Improving Health Literacy
In addition to immunizations, smoking cessation, and other preventive
interventions, the following topics are highlighted as evidence-based
concepts shown to improve the health status of vulnerable populations:
health literacy, access to nursing services, and policy.
People living in low-income communities often have low educational
levels that are related to low literacy and low health literacy levels. An
estimated 80 million Americans have limited health literacy. Because clients
have difficulty obtaining, processing, and understanding health information,
it is not surprising that low health literacy is associated with poorer health
outcomes and poorer use of health care services. A systematic review found
that low health literacy was associated with more emergency care use, higher
hospitalization rates, fewer instances of influenza vaccine and
mammography, poorer ability to read labels and interpret health messages,
and greater inability to demonstrate appropriate medication administration,
as well as higher mortality and poorer overall health status among senior
citizens (AHRQ, 2015).
Assisting vulnerable groups and communities to improve health literacy
is one approach for reducing vulnerability and improving health outcomes.
Many cities have literacy programs that use volunteers to provide tutoring.
This is an excellent way for nurses to give back to the community. Literacy
training contributes to health literacy by improving reading, writing, and
comprehension skills. A crucial aspect of improving health literacy is
improvements in public schools so that more students graduate with adequate
skills for higher education and employment. See Chapters 10 and 11 for more
on health literacy.

2019
Improving Access to Nursing Services
The benefits of home health are well known (Olds et al., 1997). Home
visiting can be provided from almost any setting that provides services to
communities. The usual settings are local health departments, home health
care agencies, community-based hospice agencies, and visiting nurse
associations. In addition, school nurses, ambulatory nurses, parish or faith-
based nurses, and other nurses have recently provided limited home visiting
services to clients or families seen in a variety of settings, including
outpatient clinics, Head Start programs, places of worship, and health
centers. Expanding home visiting to all vulnerable groups holds promise for
improving the health of many individuals and communities (Fig. 23-7).

FIGURE 23-7 Home visiting has been shown to have positive

outcomes for a variety of vulnerable populations. Results from
over three decades of research have demonstrated that home
visiting by registered nurses is effective in improving outcomes for
low-income women and children.

2020
 School-based health centers (SBHCs) are considered one of the most
effective strategies for delivering preventive care, especially for difficult-to-
reach populations such as adolescents. Numerous evaluations have shown
that SBHCs achieve marked improvements in adolescent health care access
when compared with that in other settings (Shackleton et al., 2016). These
clinics are included in health care reform funding, largely because of their
proven track record for accessibility and quality.
Nurse-led clinics (NLCs) have also increased access to care for
communities and provided care that is more affordable, convenient, and with
reduced patient waiting times. The nursing role in such clinics involves
patient assessment, admission, health-related education, treatment and
monitoring, discharge, and referral to other health care professionals.
Findings indicate that NLCs were well received by patients, with positive
experiences reported by patients (Randall, Crawford, Currie, River, &
Betihavas, 2017). See Chapters 28 and 29. Improving access to nursing care
in the community has been shown to have benefits for population and
individual health.

2021
Improving Health and Public Policy
Policies to reduce vulnerability for individuals, families, and communities
have been shown to be effective at all levels: local, state, and national. Policy
based on evidence is an important component of reducing vulnerability for
communities and individuals. This section addresses health and public
policy, including policy in schools, cities, counties, and health care settings.
Policy includes social, economic, environmental, and health aspects. See
Chapter 13 for an expansive discussion of policy.
Small changes in policy can make a big difference in outcomes for
vulnerable communities. For example, policies to provide healthy foods in
school vending machines provide healthier choices for all students, not just
those considered vulnerable. Mandatory physical activity time for school
children contributes to preventing obesity and enhancing learning in all
children and it is essential that future research and policy makers continue to
recognize the school environment as a way to improve health for all (Cisse-
Egbuonye et al., 2016; Owen, Kerner, Newson, & Fairclough, 2017).
Communities that lack safe places for physical activities need to have
attention directed to the appropriate governing bodies, such as the city
council or the department of recreation. Community residents can be
effective in bringing about change that improves a total community (Hood,
Gennuso, Swain, & Catlin, 2016). One model that addresses both individual
and social determinants of health is the County Health Rankings Model (Fig.
1-3 ; Robert Wood Johnson Foundation, 2018a).

2022
SOCIAL JUSTICE AND PUBLIC
HEALTH NURSING
Social justice occurs when a society provides for the overall health and well-
being of all people by treating people fairly. It involves an equal societal
bearing of burdens and reaping of benefits, and it is a widely held view that
social justice is the foundation of public health nursing (Box 23-16; Matwick
and Woodgate, 2017).

Community health nurses who practice social justice have broad and
holistic views of health; they have strong convictions that health care is
a basic human right and that improving the health of communities is an
example of social justice.
Social justice ensures the distribution of resources that benefits
marginalized populations and holds in check the self-interest of more
privileged populations. Impartiality is the goal.
For instance, C/PHNs concerned with social justice include socially
marginalized and vulnerable populations (e.g., criminal justice involved,
undocumented residents) in their influenza pandemic planning
processes. Not to do so would constitute discrimination and would be
morally indefensible.

BOX 23-16 Population Focus

Challenges for Community/Public Health
Nursing Related to Refugee Resettlement
“A refugee is a person who has had to flee his or her country of origin
due to a well-founded fear of persecution due to war, race, religion,
ethnicity, nationality, political opinion, or association with a particular
group.” (UNHCR, 1951 Refugee Convention)

Currently, there are large numbers of displaced people worldwide. The

United Nations High Commission for Refugees (UNHCR) registered 70.8
million displaced persons, 25.9 million refugees, and 3.5 million asylum
seekers in its database for the year 2019 (UNHCR, 2020). Refugees granted
resettlement in the United States are among the most vulnerable refugee
cases, including single mothers, children, the elderly, survivors of violence
and torture, and people with acute medical needs.

2023
 Refugee women, in particular, have been exposed to extreme levels of
poverty, deprivation, violence, and trauma, which often remain unaddressed
after resettlement (COE, 2020). Displacement from one's home and country
of origin, loss of family through civil unrest or other traumatic events, as
well as loss of familiar cultural norms are enormous challenges for this
population (UNHCR, 2020). Further stressors include concerns about poor
job opportunities and a fear of poverty. Low literacy skills, language barriers,
differences in cultural practices, and lack of knowledge about health care
limit access to physical and mental health care services (Riggs, Yelland,
Duell-Piening, & Brown, 2016). A lack of culturally appropriate mental
health services, providers, and psychosocial programs to address these issues
further complicate provision of care for this population.
When assessing the needs of a local population, nurses need to take into
consideration both the traumatic events that individuals have experienced as
well as the resiliency that they demonstrate in adapting to their new homes.
Innovation and creativity are key in developing appropriate interventions for
delivery of care to the resettled refugee population. To be effective,
community interventions and quality improvement programs must be
designed in collaboration with local refugee resettlement organizations that
have expertise in working with this population. Appropriate nurse-led
interventions might include psychosocial support groups (Felsman, 2016),
health literacy programming for English as a Second Language (ESL)
classes, individual health coaching for persons with chronic illness, and
doula services for pregnant refugee women.

The Story of Ester (name changed for

privacy) Rebels kidnapped Ester's
husband in the Democratic Republic of
Congo during the civil war one
evening. Soon after, rebel forces came
back, took her and her children to the
forest, and attempted to rape her and
her daughter. When she resisted, the
rebels shot her in the hip, crippling her.
The rebel leader kidnapped her

2024
daughter and took her as his wife. Her
son, niece, and nephew ran into the
forest. She was rescued and taken to a
hospital by a kind person on a bicycle.
She eventually made her way to a
UNHCR refugee encampment, where
she registered as an official refugee and
lived for many years.
Ester now lives in the United States in a small city, learning how to
negotiate a new language, culture, foods, and health care system. She did
eventually find her son and speaks to him by phone when she can.
Wheelchair bound, she struggles to make a living; her goal is to reunite her
family in America, but it will take a lot of money.

What is the best plan of care for Ester as a new refugee?

Source: COE (2020); Felsman (2016); Riggs et al. (2016); UNHCR (2020).

Irene Felsman, DNP, MPH, RN

2025
SUMMARY
Vulnerable populations are at risk for poor health outcomes, including
increased risk for morbidity and mortality.
Various models or theoretical frameworks examine personal and
environmental resources and risks relative to vulnerability.
Leading factors that make aggregates vulnerable are poverty, age,
gender, race or ethnicity, being uninsured or underinsured, being a
single parent, and having little or no education.
Social determinants of health are factors strongly associated with health
outcomes and include social norms or attitudes, such as discrimination
and racism; exposure to crime, violence, and social disorder; and
concentrated poverty.
The socioeconomic gradient, a direct relationship between social
class/income and health, has been repeatedly demonstrated in research
conducted around the world.
Health disparities are defined as differences in access to quality health
care and in health outcomes, particularly along income/class and
racial/ethnic lines, and are usually characterized as avoidable and unfair.
To be effective, C/HNs must establish a sense of trust and rapport with
their clients by finding common ground.
Empowerment strategies with individual clients can help them to meet
their full potential while also providing empowerment to the nurses
working with them.
Community health nurses can provide individual support as well as
support and leadership for vulnerable communities.
Nurses can use evidence-based practice when addressing health
disparities among vulnerable populations.
C/PHNs should be concerned with improving the health literacy, access
to health care, and health outcomes through political action.
C/PHNs must be aware of the value of cultural, racial, and
socioeconomic differences and that these differences are often turned
into discrimination in health care services and policies. With a focus on
social justice, they must be determined to ensure equitable access to
care for all.

2026
ACTIVE LEARNING EXERCISES
1. Identify at least four vulnerable groups within your community. Using
one of the models of vulnerability depicted in this chapter, determine
the health status for each of these groups. Describe the relative risk
for each group.
2. Using “Communicate Effectively to Inform and Educate” (1 of the 10
essential public health services; see Box 2-2 ), find available
community resources for each of the groups you identified in exercise
1. Where are the resources located? How easily accessible are they?
What outreach services do they provide for the vulnerable population
they serve? Describe some socioeconomic resources. What areas are
most deficient?
3. Talk to two expert C/PHNs and discuss the concept of empowerment
with them. What strategies have they used with clients? Ask them to
share examples of when they felt that they made a real difference in
the lives of their clients. Note any similarities between these nurses'
responses and the roles and behaviors of C/PHNs and client
empowerment strategies described in this chapter.
4. Check with the health department about any interagency groups or
committees that may be addressing the needs of vulnerable
populations in your community. What issues are most important to
this group? Who are the members? Note the agencies represented.
Are there any community members present? If possible, attend a
meeting or access minutes of a recent meeting and determine the
types of issues being discussed. Is there a sense of community
involvement and participation?
5. Search for a current evidence-based article on vulnerable populations
based on ideas from this chapter. Discuss the main points of each
article and how they may relate to vulnerable populations (e.g., health
disparities, socioeconomic gradient), as well as individual clients you
may be seeing in your clinical rotations (e.g., empowerment, health
literacy). Based on the research findings, what interventions might be
most helpful? Are they feasible in your area? With your specific
populations?

thePoint: Everything You Need to Make the

Grade!

2027
 Visit http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, study aids for
all learning styles, and more!

2028
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CHAPTER 24
Clients With Disabilities
“I choose not to place ‘DIS,’ in my ability.”

—Robert M. Hensel (1969–, Disability Advocate)

KEY TERMS

Activity limitations American Sign Language Americans with

Disabilities Act (ADA) Assistive devices and technology Disability
Environmental factors Family and Medical Leave Act Impairments
Individuals with Disabilities Education Act (IDEA) International
Classification of Functioning, Disability, and Health (ICF) National
Council on Disability Participation restrictions Respite care
Secondary conditions Social Security's Supplemental Security Income
(SSI) Temporary Assistance for Needy Families (TANF) Universal
design

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Discuss the national and global implications of disabilities.
2. Describe the economic, social, and political factors affecting the
well-being of individuals with disabilities and their families.
3. Provide an example of primary, secondary, and tertiary prevention
practices for individuals with disabilities.
4. Describe the laws that protect individuals with disabilities, such as
the Americans with Disabilities Act.
5. Discuss the benefits of universal design for all persons.
6. Explain the role of the community health nurse when working with
clients with disabilities.

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INTRODUCTION
Currently, an estimated 61.4 million (25.7%; Fig. 24-1) of
noninstitutionalized American adults live with disabilities, consisting of
vision, hearing, mobility, self-care, cognitive, and independent living
deficits (Centers for Disease Control and Prevention [CDC], 2018;
Okoro, Hollis, Cyrus, & Griffin-Blake, 2018). Disability is an
overarching term to describe limitations in activities, impairments, and
restrictions in one's ability to participate; “Disability refers to the
negative aspects of the interaction between individuals with a health
condition (such as cerebral palsy and depression) and personal and
environmental factors (such as negative attitudes, inaccessible
transportation and public buildings, and limited social supports)” (WHO,
2011, p.7). Conditions such as an aging population and a higher risk for
disabilities in older people, as well as a global increase in chronic health
conditions, have led to a greater prevalence in disabilities.

2043
2044
 FIGURE 24-1 Disability impacts ALL of us. (Reprinted from
Centers for Disease Control and Prevention. (n.d.). Disability
Impacts All of US. Retrieved from
https://www.cdc.gov/ncbddd/disabilityandhealth/documents/di
sabilities_impacts_all_of_us.pdf.)

Across the world, people with disabilities have poorer health outcomes, lower education
achievements, less economic participation and higher rates of poverty … partly because
people with disabilities experience barriers in accessing services…, including health,
education, employment, and transport as well as information. These difficulties are
exacerbated in less advantaged communities (WHO, 2011, p. 5).

According to the Census Bureau, disability status is determined by

difficulties in these six areas: hearing, vision, cognitive, ambulatory, self-
care, and independent living; children 5 to 14 can have difficulty in
hearing, vision, ambulatory, and self-care; and children <5 can have
difficulties in hearing and vision (American Community Survey, 2015).
Among young adults, cognitive disabilities were the most common,
whereas mobility disabilities were more prevalent in those over the age
of 45 (Okoro et al., 2018). Overall, disabilities related to mobility were
the most prevailing (Kraus, Lauer, Coleman, & Houtenville, 2018;
Okoro et al., 2018). The primary physical causes for limitations included
back and neck pain and arthritis, whereas depression and anxiety were
the leading psychiatric causes (Kennedy, Wood, & Frieden, 2017). In
2015, one of every five adults in the United States had been diagnosed
by a health care provider with arthritis, most commonly osteoarthritis.
More than one third of those over the age of 65 have a disability
(Kraus et al., 2018). As our populations age, these numbers will increase.
There is little difference in gender in the likelihood of a disability, yet by
race, American Indian/Alaskan Natives (17.7%) and Whites (14.1%)
were more likely to report a disability (Pew Research Center, 2019).
Some states are more likely to have people with disabilities than other
states. Among the 50 states, Utah had the lowest percent of the
population with disabilities at 9.9%, whereas West Virginia had the
highest percent at 20.1% (Kraus et al., 2018). With population growth
and an aging population, by 2030, the number of adults with arthritis is
expected to increase to 67 million (CDC, 2019b).
Globally, 15% of the world's population has a disability (World
Health Organization [WHO], 2019a). Worldwide, nonfatal injuries result
in temporary or permanent disabilities in likely thousands of people
yearly. In the adolescence age group, depression is the number one cause

2045
of disability and anemia is the number three cause of disability. Twenty
percent of years lost to disability are due to mental illness (WHO, 2015).
Disabilities in children and adults over 60 years were more common in
low-to middle-income countries (Banks, Kuper, & Polack, 2018). Adult
hearing loss and vision problems were the highest cause of disabilities
worldwide. Mental illnesses, such as depression, bipolar disorder,
schizophrenia, and alcohol use disorders, were in the top 20 causes of
disabilities worldwide (GBD 2015 Disease and Injury Incidence and
Prevalence Collaborators, 2016).
In addition to the human burden of disability, the related financial
costs of direct medical care and associated indirect costs had significant
impact on public and private payers of health and social insurance. Those
living with disabilities are at a greater risk of poverty due to the high cost
of medical care directly related to the disability, as well as the costs
associated with secondary conditions, lower educational attainment, and
a higher rate of unemployment or low-paying employment (American
Psychological Association, 2019). Costs related to disabilities vary
depending on the severity of the disability, the individual's age, and
household composition (Mitra, Palmer, Kim, Mont, & Groce, 2017).
Employment status varies depending on the type of disability.
Individuals with hearing disabilities have the highest percent of
employment, and those with self-care disabilities have the lowest rate of
employment (Kraus et al., 2018). In 2016, 35.9% of those with
disabilities were employed compared with 76.6% of persons without
disabilities. Individuals with disabilities make a median income of
$10,000 less than persons without disabilities (Kraus et al., 2018).
This chapter begins with an overview of disabilities, followed by a
discussion of current national and global trends in addressing these
issues. The various organizations that focus on improving the well-being
of those affected by disabling conditions, the impact of these disabilities
on families, and the role of the C/PHN in addressing the related needs of
individuals, families, and aggregates are discussed. The benefits of
universal design and issues of easy access for all ages and abilities are
introduced.

2046
PERSPECTIVES ON DISABILITY
AND HEALTH
People with disabilities daily face negative societal views and
stereotypes of disability, and many, along with their families, allies, and
advocates, have challenged these views. New and more positive
approaches continue to emerge that view individuals and their needs
from a more person-centered, holistic standpoint. The diverse personal
narratives of those living with disabilities emphasize the individual
circumstances and unique responses to disability, and social support and
potential inclusive care for the individual have a positive impact on
engaging those with disabilities in settings such as work (Cook, Foley, &
Semeah, 2016).
Individuals living with a disability must be included in clinical and
population health strategies to prevent acquisition of additional chronic
diseases or threats to their health (Mahmoudi & Meade, 2015; Reichard,
Gulley, Rasch, & Chan, 2015). A literature review conducted on the
benefits of park-based physical activities found improvement in the three
domains of health: physical, social, and psycho-emotional and spiritual
(Saitta, Devan, Boland, & Perry, 2019). In the landmark U.S. Surgeon
General's Call to Action to Improve the Health and Wellness of Persons
with Disabilities placed the health of persons living with disabilities
equal in importance to the health of the nation, and today, disability
remains a priority for the nation, as reflected in Healthy People 2030
(Box 24-1; U.S. Department of Health and Human Services, 2020).

BOX 24-1 HEALTHY PEOPLE 2030

Disability and Health—Objectives

2047
Reprinted from U.S. Department of Health & Human Services (USDHHS). (2020). Healthy
People 2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

One area in which further development is needed to better meet the

needs of people with disabilities is that of health and wellness apps, such

2048
as medical text messaging or mHealth. Although mHealth apps are
helpful for those with chronic conditions such as hypertension or
diabetes, they are limited in usefulness for persons with disabilities
(Jones, Morros, & Deruter, 2018). Accessibility necessitates redesign of
these apps for use by those with vision or hearing impairment, poor fine
motor skills, or cognitive disabilities (Jones et al., 2018).
Another potential area of development is the use of technology to
enhance the integration of persons with disabilities into society. Manzoor
& Vimarlund (2018) completed a literature review on the use of digital
technology to improve social inclusion. Results revealed that none of the
articles discussed the level of user knowledge needed to use the
technology or the cost associated with the technology. Only a few
articles discussed technology that could assist in the job market,
participation in social events, and accessing educational opportunities
(Manzoor & Vimarlund, 2018). As technology advances, hopefully new
and innovative solutions addressing these needs will emerge.

2049
Healthy People 2030
In the United States, Healthy People is the most influential series of
planning documents that seek to address health promotion and disease
prevention as a basis for improving the health of all Americans (U.S.
Department of Health and Human Services, 2020). Healthy People
strives toward a vision of a society in which all people live long, healthy
lives. Through its clearly delineated, science-based, and measurable
objectives, the decennial Healthy People has had far-reaching influences
on national and state health initiatives, health care policy, research
priorities, and funding since its first efforts in 1979. The evolving
American perspectives on disability and on chronic illness have been
reflected in the changing focus of the Healthy People series. A
comparison among Healthy People plans since its inception underscores
the emergence of new approaches to both identifying priority areas and
planning to improve the health of individuals with disabilities and
chronic illness. In Healthy People 2000, only one priority area was
devoted to disability and chronic illness: “Diabetes and Chronic
Disabling Conditions” (USDHHS, 2016). One of the most influential
aspects of the decade of Healthy People 2010 was to promote a change
in thinking within the health care community about the health promotion
and disease prevention needs of people with disabilities. This shift was
essential to remedy the lack of existing health promotion and disease
prevention activities for this population. Misconceptions of those with
disabilities include the following: (1) all people with disabilities have
poor health or may have chronic pain; (2) those with disabilities should
be treated as different and special; (3) public health activities need to
focus only on preventing disability; (4) people with disabilities are
similar; (5) there is no need for a clear definition of “disability” or
“people with disabilities” in public health practice; and (6) environment
does not play a significant role in the disability process (Together We
Rock, n.d.).
In Healthy People 2020, the section “Disability and Health” further
strengthens Healthy People's approach to disability to emphasize the
principles of health promotion and disease prevention for those currently
experiencing disabilities and/or chronic illnesses. Rather than narrowly
defining individuals with disabilities and/or chronic illnesses through
their limiting conditions, Healthy People 2020 developers understand
that individuals with disabilities and/or chronic illnesses have the
potential to meet and exceed health promotion and disease prevention
goals set for the nation's population as a whole. This approach is

2050
consistent with the multifaceted national goal of improving parity across
all groups and among all individuals. For example, the goal of
“Disability and Health” in Healthy People 2020 is to engage those with
disabilities of all ages to maintain the optimal state of health and prevent
chronic conditions so that the highest quality of life can be maintained
(ODPHP, 2016). For Healthy People 2030, 62 main objectives are
identified across the following five broad categories:

health conditions
health behaviors
populations
settings and systems
social determinants of health (U.S. Department of Health & Human
Services, 2020)

These objectives reflect a growing emphasis on holistic approaches

that recognize that life satisfaction is just as important to human health
and well-being as are preventive services. In addition, Healthy People
2030 indicates a growing realization that healthy life-years for persons
with disabilities equate to decreased health costs at local, state, and
national levels, just as they do for persons without disabilities (ODPHP,
2016; Box 24-2).

BOX 24-2 PERSPECTIVES

Focus on Persons With Disabilities Recent

events from the COVID-19 pandemic and
rolling electrical outages in California to
prevent wildfires highlight the isolating effect
events can have on the health and well-being of
those with a disability, specifically those with
limited mobility. Living independently can be
difficult for those using wheelchairs and

2051
walkers and for those relying on care providers.
The recent pandemic provided other aspects of
care to consider such as good hygiene, cleaning
and disinfecting, and preventing the spread of
infection, as well as having plans for if the
direct support provider gets sick, ways to
ensure enough prescription medication is on
hand, and how to obtain assistance with
purchasing household items and groceries.
Electrical outages required patients in the
community to have backup medical equipment,
generators, batteries, nonperishable food, and
flashlights or lanterns.It is imperative that
clients with mobility limitations have a plan in
place to support their care and well-being
during these isolating events. A C/PHN's
disaster preparedness plans must address such
crises and provide resources for clients and
their families so they are not forgotten.
Mark, a C/PHN case manager in the field

Halfway between Healthy People 2010 and Healthy People 2020,

the 2005 Midcourse Review analyzed changes since implementation of
Healthy People 2010. It recognized the issue with accommodations for
those with disabilities in disaster management and disaster settings
(USDHHS, 2016). The United States experienced a great deal of natural
disasters in 2018 with the fires and mudslides in California, flooding in
Maryland, and hurricane Florence in the Carolinas. Man-made disasters
included mass shooting devastated the country in Thousand Oaks
California in which 12 people were killed, mainly young adults, and in
Pittsburgh Pennsylvania where a gunman killed 11 people in a
synagogue. Smith and Notaro (2015) found individuals with disabilities

2052
are significantly less likely to be prepared for disasters than persons not
disabled, and those with activity limitations or severe mental health
illness are especially at risk of unpreparedness. The U.S. Department of
Home Land Security (2018) met with individuals with disabilities and
local agencies and advocacy groups for feedback on ways to improve
disaster relief to the population with disabilities. Issues addressed
included improved communication, involve persons with disabilities in
the emergency planning, ensure shelters are accessible to all, and
improve FEMA resources. Universities provide training to staff, faculty,
and students on actions to take if an active shooter comes on campuses.
This training meant to assist the population on what to do should an
event occur may have unexpected outcomes for individuals with
disabilities (Box 24-3).

BOX 24-3 PERSPECTIVES

A Community Member Viewpoint on Active

Shooter Response by Persons With Disabilities
I went to the “Active Shooter Response”
workshop at work to stir things up. As a
wheelchair user, I knew the currently popular
“Run. Hide. Fight.” model didn't take people
like me into consideration. I was prepared to
draw attention to every point that didn't apply
to people with various disabilities and put the
facilitator on the spot for alternative solutions.
I wanted to make people think, but I quickly
realized I had a lot of thinking to do myself.
The facilitator shared some interesting tactics that seemed useful, like
creating obstacles between yourself and the shooter, finding a hiding

2053
place, and the difference between cover and concealment. Then it was
time to test our new skills. I felt surprisingly good about adapting what
I'd learned.
The first drill began with a police officer rushing in, screaming for
everyone to “get down.” I stood out like a spire when everyone else
collapsed to the ground. My glaring vulnerability felt like a gut punch. I
could drop out of my chair, but then I'd be stranded. My only hope to
save myself is to stay in my chair, but where does that leave me with
the officer? I'm at the mercy of his training and ability to quickly
evaluate the situation.
We reset and drilled again. The “shooter” stormed in, and my
colleagues ran from the room slinging furniture behind them, slowing
down the faux assailant…and me! Their impromptu barricades
effectively trapped me with an armed aggressor.
In that moment, my cautious optimism melted into terror. The well-
intentioned light I meant to shed on the need for inclusive emergency
preparedness seemed so petty when people were running for their lives.
The A.D.A, accessibility, inclusion, even the kindness of strangers, all
the social strategies I had come to rely on for helping me navigate life
were suddenly off the table, and I can't even be upset.
My friends and neighbors have families they desperately want to go
home to and lives they want to go on living just like I do. You can't
really know how a person will react in a crisis, and I have no right to
expect anyone to put themselves in danger for me. I don't even want
that. In a world where active shooter drills have become necessary, and
weather events are becoming more and more extreme, have I finally
met my match?
My fellow disabled citizens and I will continue to keep an eye out
for ways to disappear in a wheelchair and fight off attackers with
crutches and canes, but we all must learn how to be aware of the people
around us and create protocols that give everyone at least a chance to
survive.

Amanda Timpson, who was diagnosed with bilateral spastic diplegia

cerebral palsy as a toddler and became a wheelchair user at the age of
22 due to a car accident

The health of people with disabilities is influenced by many social

and physical factors. Using the ICF and the WHO principles of action for

2054
addressing health determinants, Healthy People 2020 identified three
areas for public health action. These areas are listed below (ODPHP,
2020):
1. Promote full potential of health and well-being.
2. Eliminate health disparities among people with disabilities and those
without disabilities.
3. Address determinants of health and address health equity for people
with disabilities.

2055
International Classification of Functioning,
Disability, and Health
The International Classification of Functioning, Disability, and
Health (ICF) supports the more positive, emerging approaches to
understanding disabling conditions (WHO, 2019b). The ICF (WHO,
2019b) is a universal classification system using standardized language
that views the domains of health from a holistic viewpoint. It takes into
account body functions and structures, activities and participation,
environmental factors, and personal factors. This multidimensional
approach supports a complex evaluation of an individual's circumstances
in terms of functioning, disability, and health. By combining the
“medical model” with the “social model,” the ICF provides a
biopsychosocial approach for assessing people with disabilities. Its
approach emphasizes that no two people with the same disease or
disability have the same level of functioning. The aims of the ICF are to
provide a scientific basis for understanding and research, improve
communication among providers and those with disabilities, allow for
data comparisons, and provide a coding system for health information
systems (WHO, 2019b).
The following concepts and related definitions further clarify the ICF
view of health:

Body functions: physiologic functions of body

Body structure: anatomic parts of the body
Impairments: problems in body function or structure
Activity: task or action
Participation: to be involved in a life situation
Activity limitations: difficulty an individual may have with an
activity
Participation restrictions: limitations in involvement
Environmental factors: the physical and social environments
where people live and conduct their lives (WHO, 2019a)

For public health nursing practice, application of the ICF reinforces

that disability and disease are additional factors to be considered in
planning and implementing a care plan for individual clients and for
population groups in the community. For individual clients, the ICF
guides and facilitates assessment across a wide range of variables.
Although two individuals may have the same apparent disability, such as

2056
a below-the-knee amputation, their health status and personal well-being
can be quite different. One may have a more positive outlook, more
social supports, or fewer additional health issues that complicate
rehabilitation than another. The C/PHN must always consider the totality
of the situation, including the biologic, psychological, sociocultural, and
environmental realms of the whole person.

2057
The World Health Report
World Report on Disability (WHO, 2011) addresses the barriers for those
with disabilities and the role of the environment in facilitating or
restricting participation for those with disabilities. The barriers include
inadequate policies and standards, negative attitudes, lack of provision of
services, problems with service delivery, inadequate funding, lack of
accessibility, lack of consultation and involvement, and lack of data and
evidence (WHO, 2011, pp. 9–10). According to the report, when those
with disabilities encounter barriers, results may include poorer health
outcomes, lower educational achievements, less economic participation,
higher rates of poverty, and increased dependency and restricted
participation. The WHO challenged the global community to address
barriers and inequalities for those with disabilities in regard to health,
rehabilitation, support and assistance, environments, education, and
employment (WHO, 2011). In addressing the barriers to health care, the
following provide for a more patient-centered care approach for the
disabled: use of equipment with universal design, communication of
information in appropriate formats, and using alternative models of
service delivery provides. In addition, health service providers must have
education and training to know how to provide care to those with
disabilities. Services for care should focus on efficiency and
effectiveness; increasing access to assistive technology increases
independence and participation and may reduce costs. Those that are
disabled must be empowered to manage their health and advocate on
their own behalf. Additionally, policy responses must emphasize early
intervention, the benefits of rehabilitation, and provision of services
close to where people live (WHO, 2011).
In the seminal report by the, World Health Report (WHR) (WHO,
2002b) emphasized that health care providers worldwide should broaden
their clinical and population health practices, rather than continue to
focus narrowly on acute illness. Changes in lifestyles and behaviors that
have key impacts on increasing healthy years of life should be
emphasized. The 10 leading health risks identified by the WHO are as
follows:

air pollution and climate change;

noncommunicable diseases;
global influenza pandemic;
fragile and vulnerable settings;
antimicrobial resistance;

2058
 ebola and other high-threat pathogens;
weak primary health care;
vaccine hesitancy;
dengue; and
HIV (WHO, 2019c).

Across the globe, these 10 health risks affect low-and middle-income

countries; low levels of socioeconomic status are correlated to poor
health and lower quality of life (WHO, 2019c). For those with
disabilities, individuals and their families “…are at increased risk for
poor health and quality-of-life outcomes when their disability status
affects their socioeconomic standing” (American Psychological
Association, 2019, para 6).
Environment now plays a role in the health of individuals, with
drought, famine, conflict, and population displacement creating
protracted crisis situations and contributing to lack of care, chronic
illness, disability, and premature death (WHO, 2019c). Of the leading 10
health risks (above), six are directly related to pathogens:

ebola
global influenza pandemic

Vaccine hesitancy and increase in vaccine preventable diseases,

dengue, HIV, and antimicrobial resistance (WHO, 2019a). Diabetes,
cancer, and heart disease are responsible for over 41 million deaths each
year and can be attributed to the use of tobacco, alcohol, unhealthy diets,
and air pollution. Children are most at risk when unable to access basic
health care. In addition, children in vulnerable settings may face famine,
drought, and lack access to vaccinations. Malnutrition and deficits of
important nutrients can lead to a wide array of preventable disabilities.
For example, the leading cause of acquired blindness in children is
vitamin A deficiency (Vijayaraghavan, 2018), and the leading cause of
intellectual disability and brain damage is iodine deficiency (Georgieff,
2017).

2059
The United Nations Convention on the Rights of
Persons With Disabilities
An estimated 1 billion people across the globe live with disabilities, with
110 to 190 million (2.2% to 3.8%) people 15 years and older having
significant difficulties in functioning (WHO, 2016). Factoring in the over
2 billion family members affected by disability, the WHO stressed that
almost one third of the world population is directly impacted by
disabilities. The sheer magnitude of this issue and the recognition that
people with disabilities are significantly overlooked across the world led
to the 2006 United Nations (UN) Convention on the Rights of Persons
with Disabilities (CRPD). To date, 160 countries have signed the
Convention or its Optional Protocol (UN, 2016). This document remains
the standard for considering the rights of those with disabilities,
regardless of age, race, gender, or other demographic considerations.
Some of the key principles include respect for dignity and autonomy,
nondiscrimination, inclusion into society, acceptance and

respect for differences, equality of opportunity, accessibility, gender

equality, and respect for children's capacities and preserving their
identity (UN, 2016).

More information is located on their website:

https://www.un.org/development/desa/disabilities/convention-on-the-
rights-of-persons-with-disabilities.html.
Although the U.S. Congress passed legislation in support of the U.N.
CRPD in 2009, this positive effort proved symbolic, because the effort
fell short of the needed step to ratify the Convention. This happened
because only Congress can ratify treaties. Despite a wide variety of
successful legislation and program development at the national level (see
Civil Rights Legislation, below), the United States has been unable to
ratify the UN CRPD. As of January 2019, the CRPD is still pending in
the U.S. Senate (U. S. Department of State, 2019).

2060
The World Report on Disability
In 2011, the WHO and the World Bank reassessed global progress on
disability since the 2006 CRPD (UN, 2016). The Convention provided
guidance to governments globally and communicated that it was their
responsibility to improve the lives of individuals and families living with
disability. Citizens of every country must and need to participate in their
country's development. People living with disabilities must advocate for
the removal of barriers that prevent their full participation in their
communities, including access to health, education, employment,
transportation, and information services. To assure full participation of
people with disabilities in their communities, stakeholders in each
country—and globally—must establish an inclusive world characterized
by enabling environments, rehabilitation and support services, adequate
social protection, and relevant policies, programs, standards, and
legislation (WHO, 2019a).
Specific recommendations include:

Address unmet health care needs.

Assess health risks for those with disabilities (such as comorbidities
or engagement in health-risk behaviors).
Advocate for those who have barriers to care (WHO, 2019a).

Citizens of every country, including Americans at every level, can

become engaged in translating the World Health Organization into
action. Even though government at every level must play a significant
part, operationalizing the recommendations affords important roles for
service providers, academic institutions, the private sector, communities,
and especially people with disabilities and their families (WHO, 2019a).

2061
HEALTH PROMOTION AND
PREVENTION NEEDS OF
PERSONS WITH DISABILITIES
Two ways that CHNs and other health care providers can better address
the health care needs of people with disabilities are to take advantage of
every opportunity to promote their quality of life and to work to
eliminate disparities between their level of health care access and quality
and that of people without disabilities.

2062
Missed Opportunities by Health Care Providers
to Affect Quality of Life
All of us, whether with or without disabilities, require basic elements to
maintain health, including clean air and water, a safe place to live,
sunshine, exercise, nutritious food, socialization, and the opportunity to
be successful in life's pursuits. As self-evident as these health-promoting
elements may seem, for the millions of persons who deal with disability,
such basic needs too often take second place to other issues. It is equally
problematic that health promotion and disease prevention measures,
most notably at the primary and secondary levels, are often nonexistent
or lacking (Fig. 24-2). Individuals with disabilities are more likely to
experience difficulties accessing health care, dental services,
mammograms, Pap tests, and fitness activities and are more likely to use
tobacco, be overweight or obese, have hypertension, and have lower
employment rates (ODPHP, 2016). Key to addressing these barriers is for
people with disabilities to have an opportunity to participate in public
health activities, receive appropriately timed health interventions, engage
with the environment without restrictions, and be able to participate in
life without limitations (Fig. 24-3; ODPHP, 2020).

FIGURE 24-2 Preventive services, such as immunizations, are

sometimes forgotten among the disabled population.

2063
 FIGURE 24-3 A disabled rugby player.

The CDC is making an effort to reduce health disparities among

persons with disabilities. Surveillance, or use of surveys, helps to
determine the needs and problems that people with disabilities
experience, and research programs help to prevent the development of
secondary conditions. Secondary conditions include mental, emotional,
social, medical, or family/community issues that may be experienced as
a result of having a disabling condition. For instance, inadequate
transportation was reported by 31% of adults with disabilities compared
with only 13% of adults without disabilities; poverty is also a concern, as
26% of adults with disabilities report an annual income of under $15,000
compared with 9% of those without disabilities (CDC, 2020). The focus
of the health care delivery system is increasingly skewed toward
secondary and tertiary prevention efforts, and limited emphasis is placed
on the primary prevention needs of this population. Health care providers
often fail to address many issues related to health promotion and
prevention with people with disabilities that they do cover with those
without disabilities, which is a grave concern (CDC, 2020). For example,
issues such as sexuality are often not explored with individuals with
disabilities. Holland-Hall and Quint (2017) discovered that sexual health
education was frequently ignored in the adolescent population with mild-
to-moderate disabilities even though their sexual activity is equal to that
of their peers.
Disability often serves as the presenting reason for an individual's
encounter with the health care community, including the C/PHN. As a
result, the disability often drives the selection of prevention efforts, to the
possible exclusion of other, equally important health issues. Box 24-4

2064
offers several examples of missed opportunities in the areas of primary
and secondary prevention. It is of particular concern to the practice of
community/public health nursing that the broad range of health
promotion and prevention needs of all clients be addressed.

BOX 24-4 Missed Opportunities

Example 1
A 60-year-old woman, blind since birth, self-sufficient, and active
all of her life, has developed severe arthritis. She encounters a
health care system that far too often focuses on her “disabilities”
and not her “abilities.” The focus is placed squarely on her tertiary
health promotion needs, often at the expense of health-promoting or
lifestyle-enhancing needs. The result is a failure to recognize that
the “disability” of arthritis is likely no less and no more an issue for
her than for a sighted person. She receives the same medication
therapy as does a sighted person but may not be offered a physical
therapy program because of her disability. Her need for physical
therapy is no less important, but locating an appropriate, safe, and
easily accessible program requires some additional work on the part
of her provider. At issue is that options potentially discussed with a
sighted person are more apt to be omitted completely, which may
negatively affect the client's overall health and well-being.

Example 2
A 20-year-old man with learning disabilities, who is employed at a
local factory, receives a regularly scheduled physical examination
with a new provider. He lives in a congregate care facility, which is
an out-of-home facility that provides housing for people with
disabilities in which rotating staff members provide care for 16 or
more adults or any number of children/youth younger than 21 years
of age. It excludes foster care, adoptive homes, residential schools,
correctional facilities, and nursing facilities (U.S. Department of
Health and Human Services [USDHHS], 2016). The major finding
of the examination is that he is due for a tetanus booster and should
also begin the series for hepatitis A, because he lives in a high-risk
area of the western United States. He takes the referral slip and
leaves the office. One year later, at his regularly scheduled visit, it
becomes clear that he never received his immunizations.
Apparently, he didn't know what he was supposed to do with the

2065
 paper, because he has difficulty reading, and he had no idea where
to go to get his “shots.” The primary prevention elements were
provided, but clearly not in a manner appropriate for this individual.
With additional explanation and follow-up, perhaps the outcome
would have been quite different.

Example 3
A 34-year-old woman, who has been severely obese since the birth
of her last child (4 years ago), has not had a gynecologic
examination since that birth. She is aware of the need to have
regular examinations, yet she cannot bring herself to make an
appointment. The reason is that she knows she will have to be
weighed, and this terrifies her, especially because it is done in an
open area where others can see. She finally gets the courage to call
for an appointment and tells the clerk that she does not want to be
weighed. The clerk's response is less than helpful, and she is
essentially told that it is “policy.” She makes the appointment but
does not keep it. This situation could have been handled in a
compassionate manner, recognizing the painful experience that
weighing is for many individuals and suggesting alternatives, one of
which could have been simply to bypass the scales until after the
interview and examination. At that point, the woman may have been
more amenable to the measurement and a more discrete area could
have been offered. In this case, the opportunities to provide primary,
secondary, and tertiary prevention were lost.

Gofine, Mielenz, Vasan, and Lebwohl (2018) documented the risk of

missed opportunities for clinical preventive services among people with
mobility disability. Americans 50 to 75 years old with a mobility
disability were less likely to receive routine colorectal cancer screening.
The researchers also discovered that age, comorbidities, and the severity
of the disability played a role. Additionally, Na et al. (2017) determined
that the care for chronic diseases and preventive care such as annual
visits to the primary care provider, vision exams, and mammograms for
women decreased as activity limitation increased for older adults
receiving Medicare. Furthermore, women with intellectual and
development disabilities were less likely to receive routine cervical
cancer screenings, even if they had been sexually active, as evident by
previous pregnancies (Brown, Plourde, Ouellette-Kuntz, Vigod, &
Cobigo, 2016). In light of the Healthy People 2030 guidelines, these
studies indicate a need to focus concerted efforts on improving

2066
preventive health screenings and services for those with disabilities (U.S.
Department of Health and Human Services, 2019).

2067
Health Care Disparities
Individuals living with disabilities, along with their families and
advocates, have embraced concerns about the type and quality of the
health-related services to which they have access and the referral process
they face. They also have concerns about the care they receive being
appropriate to their individual circumstances. Lack of access to
individualize, quality health care can result in increased illness and
disability, as well as potentially decreased quality or length of life. It is
important to consider the impact that access to care can have in the
continuum of health and the health care disparities between those with
disabilities and those without disabilities, such as the risk for unmet care
needs. For example, the inability to access medical, dental, and
prescription drug care is 57% to 85% higher in those with disabilities
than in those without disabilities (Mahmoudi & Meade, 2015). The
recent opioid epidemic also touches those with disabilities. When
compared with adults without disabilities, adults with disabilities were
prescribed opioids more frequently, misused opioids at a higher rate,
misused the drug for pain, and received less treatment for opioid misuse
(Lauer, Henly, & Brucker, 2019). This study highlights the need for
health care providers to improve services and referrals for this
population. Additional disparities may exist in services received by those
with disabilities.
A medical home should provide care that is family centered and
coordinated with a permanent health care provider, have any easy
referral process, and be the usual source of care (Rosen-Reynoso et al.,
2016). Ideally, services provided should be prompt and easy to navigate.
However, only 43% of children with special health care needs and
emotional, behavioral, or developmental disabilities had a medical home
(Rosen-Reynoso et al., 2016). Several factors were found to negatively
impact needed services: non-English speakers, male child with disability,
severity of disability, at or below 200% of poverty level, uninsured,
Black or Hispanic race, and single-parent households (Rosen-Reynoso et
al., 2016). Reducing health disparities between those with disabilities
and those without disabilities provides an opportunity for maximal health
of those with disabilities, as well as for the general U.S. population.
Primary, secondary, and tertiary prevention activities are essential
aspects of quality care for all persons. According to a recent literature
review, researchers found that individuals with disabilities face four
obstacles in accessing preventive care:

2068
 the physical environment of the provider's office not being large
enough for a wheelchair;
transportation challenges, including expense, poor access, and late
pick-ups;
health care providers having a negative demeanor; and
financial concerns (Marrocco & Krouse, 2017).

Those with disabilities require specialized attention to needs

resulting from or related to their disabilities, yet they also require
preventive care to attain healthier outcomes (Marrocco & Krouse, 2017).
C/PHNs are in a prime position to advocate for needed changes for those
with disabilities. Such changes include increased attention to health
promotion and disease prevention needs, accessible and appropriate
delivery of those services, and specialized treatment plans that
incorporate the latest knowledge of a specific illness or disability (Box
24-5).

BOX 24-5 PERSPECTIVES

A Nurse's Viewpoint on Community Health

Nursing I have worked supporting people with
disabilities, different roles, such as home health,
C/PHN home visitor, and public health nursing
manager. As C/PHN, assessment and screening
are essential interventions when interacting
with disabling individuals and their families.
Listening to parents and caregivers could make
a difference to assess for early services. For
example, I received a referral to check a
toddler's development. Mom was concerned
that something was wrong with her child. The

2069
initial biopsycho-social assessment of the
toddler and family did not show any red flags,
but the mother needed health teaching,
parenting, and connection with resources
available for children zero to five.
Further developmental screenings identified caution in gross and fine
motor skills that required a referral to the regional center, early
intervention program. Through on-going case management, consulting
with the medical providers, and advocating for specialty services due to
lack of improvement, this toddler was finally connected with specialty
services and diagnosed with a degenerative muscle disorder. The family
applied to social security disability program to meet their child and
family needs, find transportation, and modify the environment to
accommodate a wheelchair, hospital bed, homeschooling, therapies, and
medical services among others. The C/PHN interventions for this child
and family, as a home visitor case manager, included collaboration with
staff from multiple agencies, advocacy, and coordination with the
children services' C/PHN care manager. Parents learned to voice their
concerns, got involved with the community, and advocated for their
child until the end of her life, several years later.
As C/PHN, we need to assess the needs of people with disabilities
at the individual, family, community, and system level. C/PHN needs to
keep in mind the developmental stages of people with disabilities and
aspects of sexual health to prevent sexual, physical, and emotional
abuse. Across the life span, people with disabilities have sexual health
needs finding partners and forming their own family, which could be
challenging and requires C/PHN interventions and referrals to agencies,
including child and adult protective services. When working with
people with disabilities, advocacy is one C/PHN intervention that is a
common denominator. People with disabilities and their families need a
voice, support, information, guidance, encouragement to get services
from basic human needs of food and shelter to complex health care to
maintain health and wellness, be active, surrounded, and supported by
the community.

—Claudia Pineda Benton, Supervising Public Health Nurse for

Community Health Nursing Field and Maternal Child Adolescent
Health Programs

2070
CIVIL RIGHTS LEGISLATION
Legislation is vital to ensure that every individual's rights are protected
and that there is legal recourse to secure needs that have been denied. As
is often true for other issues of equality, legislation is only one of many
steps that must be taken. The movement to achieve civil rights for
persons with disabilities in this country has gained momentum and
continues to seek the influence and public attention that will improve the
health and lives of those with disabilities and handicaps. The
Americans with Disabilities Act (ADA) was signed into law in 1990 to
protect the civil liberties of Americans living with disabilities and
continues to updated, as recently as 2017, when movie theaters were
required to provide captioning and audio description for movies that are
produced with those features (United States Department of Justice
[USDOJ], n.d.). This legislation and others, such as Section 504 of the
Rehabilitation Act of 1973 and Individuals with Disabilities Education
Act in 1990, resulted from a long and difficult struggle (Landmark,
Zhang, Ju, McVey, & Ji, 2017). Individuals with disabilities and their
advocates made their voices heard by repeatedly demanding an end to
inferior treatment and lack of equal protection under the law, which have
impeded their daily lives. The ADA has set the standard for a number of
subsequent laws that, together with pre-ADA legislation, have become a
broad spectrum of protections for people with disabilities. These laws,
which are listed in Table 24-1, cover a variety of issues, including
telecommunications, architectural barriers, and voter registration.

2071
TABLE 24-1 Disability Rights Laws

Source: U.S. Department of Justice Civil Rights Division, Disability Rights Section (2020).

This federal law protects those with a disability, which is defined as

“…a person who has a physical or mental impairment that substantially
limits one or more major life activities, a person who has a history or
record of such an impairment, or a person who is perceived by others as
having such an impairment. The ADA does not specifically name all of
the impairments that are covered” (USDOJ, 2009, page 2). The ADA
does not list specific diagnoses but focuses on the impact the disability
has on daily living, such as on the ability to care for self, perform manual
tasks, see, hear, eat, sleep, walk, stand, lift, bend, speak, breathe, learn,
read, concentrate, think, communicate, and work. Despite this specificity,
there remains a broad range of interpretations and legal challenges with
respect to who is actually covered by the ADA.
In addition to the uncertainty about who is actually protected by the
ADA, there can also be confusion about who is required to comply with
the provisions of the Act and what specific remedial actions are
necessary. The ADA currently applies to all employers with 15 or more
employees (including religious organizations), and all activities of state
and local governments irrespective of their size. Public transportation,
businesses that provide public accommodation, and telecommunication
entities are also required to provide access for individuals with

2072
disabilities. It is important to note that the ADA does not override federal
and state health and safety laws (U.S. Department of Labor [USDOL],
n.d.a).
Individuals who believe that their legal rights under the ADA have
been violated may seek remedy by filing a lawsuit or submitting a
complaint to one of four federal offices, depending on the specific type
of alleged violation: (1) the USDOJ, Civil Rights Division; (2) any U.S.
Equal Employment Opportunity Commission field office; (3) the Office
of Civil Rights, Federal Transit Administration; or (4) the Federal
Communications Commission. The process for filing a complaint is not a
simple task, and many seek the assistance of attorneys, legal aid
societies, or various private organizations, some of which are discussed
later in this chapter (Box 24-6).

BOX 24-6 Office of Civil Rights:

Compliance With the Americans With
Disabilities Act The responsibility of
the U.S. Department of Justice, Office
of Civil Rights (OCR), is to investigate
complaints of alleged violations of the
Americans with Disabilities Act
(ADA). An example of one of those
complaints involved a 22-year-old
Connecticut woman with cerebral
palsy. She had been placed in a
nursing home because of changes in
her living situation and health care
status, but wanted to move back into
the community. The OCR intervened
to ensure that the woman secured

2073
appropriate housing and that
counseling and intensive case
management services were in place
when she moved back into the
community. Another example
involved a man with traumatic brain
injury (TBI) who was told he must
remain in a hospital when he
requested home health care services.
OCR intervened and secured physical,
occupational, and speech therapy for
the client, as well as physical
modifications needed for his home. A
32-year-old quadriplegic man had
lived independently in his own
apartment with a health aide's
assistance, but suddenly lost his
apartment and was transferred
against his will to a facility. He was
able to get a wheelchair accessible
apartment but could not get health
aide services. OCR intervened on his
behalf and secured a personal care
assistant so that he could live in his

2074
 new apartment. Without the
protection afforded under the ADA,
the outcome could have been much
different.
Source: USDHHS, Office for Civil Rights (September 2006).

The USDOJ published A Guide to Disability Rights Laws (2009).

The guide provides information on federal civil rights laws for those
with disabilities and is available in large print, CD, and Braille. The laws
included are

Americans with Disabilities Act (ADA)

Telecommunications Act
Fair Housing Act
Air Carrier Access Act
Voting Accessibility for the Elderly and Handicapped Act
National Voter Registration Act
Civil Rights of Institutional Persons Act
Individuals with Disabilities Education Act (IDEA)
Rehabilitation Act
Architectural Barriers Act

The most challenging aspect of providing services for persons with

disabilities is to alter the perceptions and misunderstandings of others
about people with disabilities (Yee, 2016). The perspective of one
community member offers one such example (Box 24-7).

BOX 24-7 PERSPECTIVES

A Community Member Viewpoint on Hearing

Loss I lost my hearing as a young adult. By the
time I was 28 years old, I had no natural

2075
hearing left. I received a cochlear implant when
I was 32. Around the time I decided to have the
implant, I was struggling so much to survive in
the hearing world (phone usage, conversations
with hearing people, etc.). The decision to
receive a cochlear implant changed my life. I
could now communicate with the hearing world
again. While the cochlear implant has some
amazing benefits, there are some negatives still.
For one, I still do not have perfect hearing. I
have enough hearing, though, for people to not
realize I am deaf. This “hidden disability” can
be problematic. Many people assume I am just
stupid. It happens all the time. What they don't
know is that I am actually well educated and
very intelligent. Often, I hear my friends,
family, and fellow students talk about how
smart I am, but when I don't hear something I
sound stupid. I might mishear the beginning of
a conversation and respond with something
totally off topic. This particular trait should be
a red flag that the person may have a hearing
loss. It is very demoralizing for people to treat
you like you are stupid, when the reality is you
just can't hear well. Another very difficult
thing about having a cochlear implant is that
when you can't wear it for some reason (dead
battery, loss, medical procedure, etc.) you feel
absolutely powerless, and often fearful, in the

2076
hearing world. I've most often experienced this
in the health care environment. When I had to
have surgical procedures that required
removing my implant, I could not hear the
instructions provided to me in preop. I could
not hear the words that were intended to calm
or comfort me. Instead, I was in a constant
state of panic wondering if I was missing
important information related to my health and
safety. Hearing people should also realize that
deaf people are extremely tuned to the visual
world. We see your frustrated eye rolls, side
glances, and facial expressions very acutely. It
is very hurtful and frustrating to see this and
not be able to do anything about it. Like many
“hidden disabilities,” imagining yourself in
someone else's shoes would probably facilitate a
more beneficial and pleasant interaction.
Veronica Russell

The National Council on Disability (n.d) is an independent federal

agency charged with advising the President, Congress, and other federal
agencies regarding policies, programs, practices, and procedures that
affect people with disabilities. Its policy areas include civil rights,
cultural diversity, education, emergency management, employment,
financial assistance and incentives, health care, housing, international
issues, long-term services and support, technology, transportation, and
youth issues. NCD's Web site has publications dating back to 1986 on
civil rights. Information can be found at
https://www.ncd.gov/policy/civil-rights.

2077
FAMILIES OF PERSONS WITH
DISABILITIES
Families that include a member with a disability face many challenges.
Below we consider factors affecting families' ability to cope with the
disability and the impact of caregiving on families.

2078
Factors Affecting the Family's Ability to Cope
The parents of a child with disabilities must come to grips with many
unknowns. Shenaar-Golan (2017) studied subjective well-being in
parents of children with disabilities. Often times their financial stability
is depleted and parents express concern for the future well-being of their
child, especially as the parents age. The study found that the parents'
level of hope and perception of the disability and the parental
relationship affected their subjective well-being (Shenaar-Golan, 2017).
The child's transition from a minor to an adult and the child's leaving the
school setting, which provides a routine for the child, may cause anxiety
for parents and the child. Parents may not have the necessary knowledge
to ensure a smooth transition. Researchers found that a structured
training period for parents of soon-to-be-adult children with autism
increased their knowledge of services such as SSDI, housing, and
Medicaid and made them feel more comfortable in advocating for their
children and more empowered (Taylor, Hodapp, Burke, Waitz-Kudla, &
Radideau, 2017). Families may also have little understanding of what
services they are entitled to because of language barriers, difficult agency
policies, or disjointed service delivery. These challenges may be
magnified when a family member is newly diagnosed with a disability.
The C/PHN is usually not the first health care professional that the
family encounters. They may already have been through a lengthy
struggle to receive assistance. In these circumstances, the nurse may be
confronted with a frustrated family, reluctant to trust yet another health
care provider. Nurses must earn the trust and confidence of the family by
practicing consistency, following through with promised actions, and
always being truthful. Not all problems that the family faces can be
remedied, and even for problems that do have solutions, time and effort
may be needed to obtain the desired result. Nageswaran and Golden
(2018) uncovered four themes in the relationship between the caregivers
(parents) and the home health nurse:

the relationship developed over time;

trust and communication were crucial;
boundaries were difficult to maintain; and
a good working relationship between the nurse and the caregiver
decreased caregiver stress, lowered stress for the health care
provider, and improved care of the child.

2079
 Additionally, when working with an older child and the family, the
CHN needs to remain respectful to both parties. The child is a separate
entity, and the child's wishes need to be considered as much as possible
(Cureton & Silver, 2017).

2080
The Impact of Caregiving on Families
Caring for a family member who is disabled, whether a child or an adult,
is stressful. High levels of anxiety, stress, depression, and illness are
often reported in these families (Dykens, 2015). Caregiver strain is
common in families caring for a member with disabilities. These
caregivers have multiple roles, associated with employment, caring for
other children in the family, the parents' relationship, and providing care
for the child with needs (Pilapil, Coletti, Rabey, & DeLaet, 2017).
Caregiving affects the parents' physical and/or psychological health,
financial status, and family function (Pilapil et al., 2017).
Hamilton, Mazzucchelli, and Sanders (2015) also examined parental
support for children with disabilities. In the adolescent years, the needs
of the child dramatically shift, as parenting styles that worked at a
younger age are no longer effective. Parents report struggling to
understand these needs and making accommodations for the transitions
of their adolescent children, and this frustration leads to increased stress
and feelings of grief. The study suggested that a targeted, evidence-based
parenting program should be tailored for this special population. Nurses
should be prepared to provide parenting support and referrals to parental
support groups and educational programs that can assist the parents in
providing the best care possible to their children with disabilities.
Nurses should also be aware of the physical needs of parents caring
for children with disabilities. In a study by Garip et al. (2017), the
researchers noted that mothers of children with cerebral palsy reported
depression and lower quality of life associated with a high level of
fatigue. Nurses should assess the mother's fatigue level and be watchful
for signs and symptoms of depression to assure that the parent is able to
provide the care needed for the child.
Caregivers of older adults tend to be spouses or adult children. One
study found an average of 30 hours per week of care was provided
(Wolff et al., 2018). Although caregivers reported less emotional,
financial, and physical difficulties between 1999 and 2015 (Wolff, 2018),
many suffer from poor physical health, depression, and anxiety (Riffin,
Van Ness, Wolff, & Fried, 2019). Over half of caregivers reported
caregiver burden related to the recipient's dementia (Riffin et al., 2019).
Fewer than 10% of caregivers use supportive services or attend training
on best practices in providing care (Riffin et al., 2019). C/PHNs working
with this population should provide caregivers with community resource

2081
referrals such as in respite care, support services, and local classes for
training.
Children and adults with disabilities are at risk of abuse due to many
factors. The exact number of children with disabilities who are abused
remains unknown. The abuse could be triggered by the parents being
stressed with the obligations of caring for a disabled child or frustrated
with the child's difficult behavior (CDC, 2018). Other risk factors for
abuse include inadequate social support for the parents, financial
burdens, and time constraints in caring for a child with disabilities
(Prevent Child Abuse America, 2019).
Categories of elder abuse or dependent adult abuse include physical
abuse, psychological abuse, neglect, and financial abuse. Platt et al.
(2017) discovered that over 63% of men and 68% of women with
developmental disabilities had been abused as adults. More women than
men had been sexually abused, but for other types of abuse, there was no
difference between genders (Platt et al., 2017). Health care providers
may find it difficult to detect intimate partner violence (IPV) in women
with disabilities. Health care staff need to be educated on communication
skills with women who have experienced IPV to detect and treat these
women (Ruiz-Pérez, Pastor-Moreno, Escribà-Agüir, & Maroto-Navarro,
2018). In a study conducted by Ballan, Freyer, and Powledge (2017),
researchers discovered that men with disabilities experienced IPV at a
higher rate than men or women without disabilities. More than 71% of
the men described physical abuse as the most severe type of abuse and
nearly half had seen a medical provider. Yet, fewer than 16% of these
men had been referred to IPV assistance (Ballan et al., 2017). Clearly
more needs to be done to protect this population from abuse.
Geographic differences were noted in a national survey of therapy
services provided to infants and toddlers with developmental disabilities.
Magnusson and McManus (2017) found that states differ in their ability
to meet the needs of these children for physical, occupational, and
speech therapy. IDEA requires states to provide early intervention
services but allows the individual states to set their own criteria. Children
living in states with narrow early intervention eligibility had a significant
level of unmet therapy needs. Furthermore, children of racial/ethnic
minorities had higher levels of unmet needs (Magnusson & McManus,
2017). Paying for needed resources places a financial burden on many
families. Parents of children with special needs are more likely to be
single, unemployed, or underemployed and to have incomes of <$50,000
per year (McRee, Maslow, & Reiter, 2017). The cost of care of a child
with special needs is high and a financial burden to families even when

2082
considering only the obvious costs, such as health care provider and
hospital bills, diagnostic testing, medical treatments, and prescription
medicines (Price & Oliverio, 2016). However, the care often includes
many less obvious costs, such as 24-hour supervision for activities of
daily living, and these costs often do not end when these children reach
the age of 18, but last for their lifetimes. Therapy, health care
professionals, financial planners, support group facilitators, educational
advocates, special education attorneys, and other professionals may be
required for care.
Although Healthy People 2030 directly addresses delays in receiving
primary and preventative care, obstacles to obtaining assistive devices
and technologies may still be encountered (U.S. Department of Health
and Human Services, 2019). Temporary Assistance for Needy
Families (TANF), Social Security's Supplemental Security Income
(SSI), and Medicaid are three government assistance programs nurses
should familiarize themselves with. TANF is a time-limited federal
program that provides assistance to families that cannot meet basic
needs. Each state determines how to use the funds (U.S. DHHS, n.d.).
SSI is a federal program that provides income to persons with disabilities
who have little or no income to meet their basic needs (Social Security
Administration, 2018). Lastly, Medicaid provides affordable coverage as
well as services not normally covered by provider insurance (Musumeci,
2018). Those with disabilities and their families often are unaware of
eligible programs and confused about the rules and regulations of each
program. CHNs working with this population need to educate themselves
on government resources and nonprofit agencies that assist the family in
attaining equipment and supplies. Advocating for our clients and
providing case management provide a welcome relief to families.
Respite care is another resource of great importance for families.
Due to the constant demands of providing care 24 hours per day, 7 days
per week and the stress associated with numerous demands, respite offers
relief and hope in regaining normalcy, not only for the primary caregiver,
but for the siblings, as well (Whitmore & Snethen, 2017). When focus is
placed on the needs of one family member, other children may feel that
their own needs are not as important, which can lead to behavioral and
health-related problems (Box 24-8). Although more spouses and adult
children who care for older adults with disabilities are using respite care,
only 15% of caregivers currently use it (Wolf et al., 2018). Respite care
is vital to the family's health and should be considered a priority in the
overall treatment plan. ARCH National Respite Network and Resource
Center provides a list of respite services nationwide.

2083
BOX 24-8 C/PHN Use of the Nursing
Process
Supporting a Family With a Child With
Autism
ASSESSMENT
The local public health department received a referral from the
school nurse requesting a home visit on the Smith family. The
family recently moved to the area with three small children. The
school nurse expressed concern because the children are late to
school every morning, their clothes are dirty, and they arrive to
school hungry. The C/PHN arrives to the home unannounced in
order to assess the home life. Both parents are home but the father
retreats into the bedroom when the nurse arrives. The mother of the
children, Joanne, is 25 years old and has recently lost her job at a
small boutique. The father, Richard, is 26 and has started working
two jobs to pay the bills. The family recently moved to a new town
100 miles away from the wife's family who provided emotional
support and help with childcare. The one-bedroom apartment is
cluttered and dirty. The apartment is void toys and family photos.
James the 5-year-old was diagnosed with autism at the age of two.
He is seen hitting his head against wall and throwing clothes.
Joanne is attempting to calm her son and is yelling to Richard to
help without success. The other children are playing videos ignoring
their mother's request for help. Joanne expresses being
overwhelmed since the family moved away from her family and
friends. The family has not connected with a medical home yet,
finances are insufficient to pay bills, and they have no social
support in the new neighborhood. The two older children ages 7 and
10 are sick with colds and have productive coughs. They have
missed 4 days of school and are falling behind in their studies. The
mother appears unconcerned about her children's health issues. The
family does not have a medical home and the mother expresses
being overwhelmed with the children's health issues, especially
James. The C/PHN notices the lack of affection between members.

PROBLEM STATEMENTS
1. Ineffective parenting skills

2084
 2. Support for a healthy family management plan

PLAN/IMPLEMENTATION
Problem Statement 1
The C/PHN will:

Assess the family support systems and refer the parents to

support groups of children with disabilities.
Provide resources for sliding scale family counseling and other
governmental or private organizations.
Provide information regarding respite care for parents to have
time for themselves and the other children.
Encourage parenting classes and role model communication
techniques with children.
Continue to assess parents stress level and assess for possible
abuse.
Schedule monthly follow-up visits to provide a resource and
support to the parents.

Problem Statement 2
The C/PHN will:

Assist the family in finding a medical home.

Educate the parents in healthy behaviors such as exercise and
proper nutrition.
Assess health literacy of parents and provide information that
best meets their needs and understanding.
Acknowledge each family member's health concerns.

EVALUATION
The C/PHN conducted follow-up visits every 2 weeks to check on
family progress. After 1 month, the C/PHN reported the family had
a medical home that provided antibiotics for the older children's
sinus infection. The two older children and the parents had gone to
the park twice using a free respite service provided through a local
church. The children are attending school and are doing well. The
parents have joined support group for parents with children with
disabilities and have made friends with group members. The mother

2085
 is observed playing with children. The home while still cluttered is
clean. The C/PHN informs the parents they are doing wonderful and
will decrease her visits to monthly. She encourages the parents to
contact her if they have any questions or concerns.

The issue of employment is generally of great significance to

families, as employment options may be quite limited when a family
member has special needs. The family may have to remain in a particular
location to access needed health and social services, reducing the
possibility of increased earning potential at a different location or in
another field of employment. Although some legal protections are
provided under the Family and Medical Leave Act of 1993, it does not
apply in all situations. For instance, it is only available in companies
with more than 50 employees and is most often used for birth and care of
a newborn or newly adopted child or for temporary care of a family
member with a serious health problem (spouse, parent, or child). More
importantly, it allows only for time off; it does not mandate that
employers continue a salary during those periods (USDOL, n.d.b).
Family members may have to choose between taking unpaid time off and
continuing to work while dealing with the needs of the family member as
best they can. Some individuals choose to work part-time or not to work
at all so that they can care for family members (Baillargeon, Bernier, &
Normand, 2011). At a time when many families have two wage earners
to help meet financial commitments, families engaged in caregiving may
have to rely on only one income. Limitations in income are particularly
challenging considering the myriad needs of those who are disabled,
needs that may not be covered by any insurance.
Falk (2016) explored the relationship between welfare status and
health. The researcher noted that families receiving TANF often were
eligible for many programs and that the different policies and
requirements are difficult for families to navigate.
Caregiver health needs and mental health status are another area of
concern for families. The mental health of the mother as caregiver is
documented to be an area of concern, and the expression of depression in
this population is concerning (In Sook & Hyun Sook, 2015; Yamaoka et
al., 2015). Although research often focuses on the mental health of the
mother as caregiver, a line of research exploring paternal mental health
when caring for a child with an intellectual disability is growing. This
research suggests that the child's behavior problems, father's daily stress,
low parenting satisfaction, and childcare needs are the biggest predictors
for the father's mental health difficulties (Giallo et al., 2015). A study

2086
exploring family health of parents caring for a child with disabilities
indicated that parent caregivers who experienced activity restriction and
low social support and those families in the lowest quartile of monthly
expenditure were more likely to experience psychological distress
(Yamaoka et al., 2015). It is important for nurses to provide detailed
information about the child's health needs, disease, disability, medical
services available, and social support available to meet the needs of the
child to decrease parental mental health stress and disorders.
Recognizing that caregivers within a family are at increased risk for poor
health outcomes, it is important that the C/PHN select appropriate
interventions to address the health needs of all family members.
Families may experience financial difficulties, poor physical or
mental health, and a variety of other challenges. For instance, a classic
study on loss of family income related to having a child with autism
spectrum disorder found an average decrease in annual income of 14%
for these families (Montes & Halterman, 2008). Families are often ill
prepared to deal with the complicated systems that must be accessed to
obtain needed care. The C/PHN is in an optimal position to interpret
those systems to the families and to advocate for the needed care,
services, and equipment (Fig. 24-4). The nurse must view the family
holistically, recognizing additional needs that may develop as a result of
the situation currently faced, and include an assessment of caregiver and
family work patterns when caring for families with a family member
who is disabled.

FIGURE 24-4 Public health nursing support for families with

children with disabilities can be critical in helping them access
resources and services.

2087
Organizations Serving the Needs of Individuals
With Disabilities and Their Families
Many governmental and privately funded organizations are dedicated to
serving individuals with disabilities and their families as well as
educating the public on disabilities. These organizations provide nurses
with a starting point for exploring specific topics pertinent to practice. As
clients and families may also be accessing online content through
personal or public internet access, it is important for nurses to prescreen
and make recommendations to clients and families about reliable and
accurate sites. Numerous organizations provide Web sites to assist
individuals with disabilities and their families; a few key Web sites are
listed in Table 24-2.

TABLE 24-2 Web sites to Assist Those With Disabilities

and Their Families

The C/PHN student is encouraged to explore these resources and to

learn more about specific disabilities that can impact clients and their

2088
families. For example, parents may not realize their child has a hearing
loss. It may take an outside family member, a neighbor, a teacher, or a
nurse to notice a child who is not talking at an age-appropriate level or
who does turn to the source of a sound. Children born prematurely and
the elderly are at risk for hearing loss. Genetic syndromes and accidents
can also cause unexpected loss of hearing. In fact, one out of every eight
people in the United States has a hearing loss (CDC, 2019a). Luckily,
there are screening tools, treatments, and interventions for those that are
deaf or hard of hearing. In addition to technology such as hearing aids
and cochlear implants, many people learn alternate ways to communicate
such as sign language. Box 24-9 offers a brief summary of the purpose
and use of American Sign Language and other signed languages, and
Box 24-10 discusses Braille.

BOX 24-9 Sign Language in Brief

Sign language is the use of “handshapes” and gestures to

communicate ideas or concepts.
American Sign Language is a unique language with its own rules of
grammar and syntax.
American Sign Language is primarily used in America and Canada
and is the natural language of the deaf community; in Britain,
British Sign Language (BSL) is used.
Sign languages are not universal.
International Sign Language (Gestuno) is composed of vocabulary
signs from various sign languages for use at international events or
meetings to aid communication.
Systems of Manually Coded English (i.e., Signed English, Signing
Exact English) are not natural languages but systems designed to

2089
 represent the translation of spoken language word for word.
Source: ASL University (n.d.); CDC (2014); National Institute on Deafness and Other
Communication Disorders (2015).

BOX 24-10 What Is Braille?

Braille takes its name from Louis Braille, an 18-year-old blind
Frenchman who created a system of raised dots on paper for reading
and writing by modifying a system used on board sailing ships for
night reading. The six raised dots of each Braille “cell” vary to form
palpable letters and punctuation. Persons experienced in Braille can
read at speeds of 200 to 400 words per minute, comparable to print
readers. Braille text can be written (1) by hand with a slate and
stylus; (2) with a Braille writing machine; or (3) with specialized
computer software and a Braille-embossing device attached to the
printer.
Source: National Federation of the Blind (n.d.)Note: More information about Braille is
available at: http://nfb.org/search/node/braille.

2090
UNIVERSAL DESIGN
For those living with a disability or chronic disease and their family
members, the issue of access is of utmost importance. Universal design
is the concept of purposely creating environments in a way that they are
accessible to all without the need for modifications. The term universal
design has been attributed to Ron Mace, founder of the Center for
Universal Design, based out of North Carolina State University. Mace,
who had polio as a child, died suddenly in 1998, leaving behind a long
legacy of advocacy on behalf of accessibility in design (Center for
Universal Design, 2016). Universal design is at the core of the ADA, and
it is important to note the relationship between inclusiveness and
reduction of barriers to access (Hums, Schmidt, Bocak, & Wolff, 2016).
Universal design is for everyone, not solely for those with disabilities.
The issue of accessibility is not new. The ADA, as discussed earlier,
addresses issues of access in employment, governmental building, and
public accommodations. The Fair Housing Accessibility Guidelines,
effective beginning in 1991, provide for design and construction of
multifamily dwellings (four or more units) in accordance with
accessibility requirements (United States Department of Housing and
Urban Development, n.d.). Provisions mandate that doorways be wide
enough to accommodate wheelchairs, dwellings be readily accessible to
and usable by persons with handicaps, and accessible routes be
throughout buildings (Figs. 24-5, 24-6, 24-7; Fair Housing Accessibility
First, n.d.). The specific provisions may be found at
https://www.fairhousingfirst.org.

2091
FIGURE 24-5 Ramps are needed for those using wheelchairs
to gain access to buildings.

FIGURE 24-6 Recommended height of electrical outlet for

ease of access for wheelchair-seated person. (From CDC
Image Library. Retrieved from
http://phil.cdc.gov/Phil/quicksearch.asp.)

2092
 FIGURE 24-7 Handicap access shower. (CDC Image Library.
Retrieved from http://phil.cdc.gov/Phil/quicksearch.asp.)

For those with existing disabilities and as the population ages,

ensuring easy accessibility to all in businesses, housing, and places of
recreation is of paramount importance. Having the opportunities for
healthy participation in physical activity may forestall or prevent the
development of illness. For the community, having an environment that
promotes rather than restricts a healthy lifestyle can be economically
advantageous (Fig. 24-8). A healthier population may be achieved with
attention to the environmental barriers that impede healthy lifestyles for
all persons, including those with disabling conditions.

2093
FIGURE 24-8 Planned, mixed-use development with curb
cuts, well-marked crossings, sidewalks, and accessible
commercial and public spaces. (Source: Center for Universal
Design. CDC Image Library.)

2094
THE ROLE OF THE
COMMUNITY/PUBLIC HEALTH
NURSE
This section considers the various roles of the C/PHN working with this
population. It is important to review these roles in the context of
multilevel practice: the individual, the family, and the community.
Chapter 2 first examined the broad spectrum of roles that the C/PHN
assumes within the community (i.e., clinician, educator, advocate,
manager, collaborator, leader, researcher), as well as the 10 essential
services of public health. Consider an example of the variety of roles
with respect to a 55-year-old female client who uses a wheelchair. The
client has difficulty obtaining a gynecologic examination because of the
lack of accessible examination tables at the local clinic; as a result, she
has not had an examination for more than 20 years. Recognizing the
need for a complete examination, the C/PHN arranges with the clinic to
find appropriate alternatives that will aid the client in receiving the
needed examination, possibly by ensuring that additional personnel are
provided. The C/PHN is an advocate at the individual level providing the
essential services of monitoring health. Because this solution is
temporary and less than optimal, the nurse contacts a number of clinics
in neighboring communities and finds one that has appropriate
equipment for people who have difficulty transferring to a standard
examination table. Unfortunately, this clinic is 1 hour away. The nurse
then contacts a number of other C/PHNs and discovers that they also
have a significant number of women clients with this problem who have
not received a gynecologic examination in many years. The C/PHN
discovers a need at the community level through research. Essential
services provided include monitoring health and diagnosis and
investigation at the community level.
Through a coordinated effort, the nurse is able to develop
partnerships with a local transportation company and the clinic to
arrange a twice-yearly gynecologic screening program for women in the
community who require special accommodations. Acting as an advocate
and coordinator at the community level, the C/PHN mobilizes
community partnerships, develops policy, and links the population to
needed services. Information sheets that discuss the need for annual

2095
gynecologic examinations and advertise the program are distributed to
area C/PHNs, employers, and health clinics. Functioning in the educator
role at the community level, the C/PHN is providing the essential
services of informing, educating, and empowering others. Data
collection on examinations provided over the next few years shows a
65% increase in the number of women with special needs who have
received a gynecologic examination within the past year. Continuing in
the role of researcher at the community level, the C/PHN practices the
essential services of evaluating the services and reaching new solutions.
This is not an uncommon scenario in the practice of
community/public health nursing. Often, the needs of an individual may
open the door to areas of concern for many in a community and provide
a basis for intervention that can benefit a larger population. The
complexity of issues surrounding these conditions requires creativity,
tenacity, honesty, and, most of all, knowledge. C/PHNs who are
informed about the issues that affect those with disabilities at local, state,
and national levels are prepared to offer assistance to their clients and to
their communities.
Although successes at the individual level are laudable, the extent to
which the health and well-being of those affected are improved must be
the ultimate goal. Forming partnerships within the community places the
C/PHN in a prime position to initiate and support efforts to improve the
health status of those populations.
It is important for C/PHNs to consider population health among
those with disabilities. As Grady (2011) reminds us, our U.S. population
is living longer, is suffering multiple chronic illness and disabilities, and
needs nurses trained to meet the requirements of this aging population.
Population health promotion and prevention of secondary disabilities are
also public health concerns across age groups and conditions (Ouellette-
Kuntz, Cobigo, Balogh, Wilton, & Lunsky, 2015). Community-based
interventions that help support all populations with self-management
skills, improve health behaviors, and prevent secondary disabilities have
been shown to be popular and can result in cost savings as well as
improved health outcomes (Ravesloot et al., 2016).

2096
SUMMARY
The issues of disability are of growing importance in public health
and to community/public health nursing, both nationally and
internationally.
Through the efforts of the WHO, the international community has
been challenged to provide increased attention to health promotion
and disease prevention.
The aging of the U.S. population and the rise in lifestyle-related
illnesses such as diabetes and obesity are often linked with
increasing rates of disability. Health disparities and differing access
to services are a focus of Healthy People 2030.
Healthy People has placed increasing focus on individuals' well-
being, helping those with disabilities to get support and services
within the health care system, at work, home, and school. To
improve quality of life, accessibility in our homes, schools and
workplaces is essential.
Legislation is but one step toward equality for those affected by
disabilities and chronic illnesses. The IDEA and ADA secured
many improvements in accessibility and specific legal protections
for the disabled, but it is only the beginning.
C/PHNs are in a prime position to advocate for the health needs of
the disabled and chronically ill. With a long history of serving those
who are most vulnerable, C/PHNs can help make needed changes at
the individual, family, and community levels.

2097
ACTIVE LEARNING EXERCISES
1. Interview an individual with a disability (e.g., hearing, vision,
mobility) about the challenges that he or she has faced in
interactions with nondisabled persons and in everyday activities.
2. Using “Utilize Legal and Regulatory Actions” (1 of the 10
essential health services), how does legislation effect the health
and well-being of a disabled client and their family? Looking at
disability rights, how would you address the essential services
specific to Developing Policies and Enforcing Laws?
3. Take an inventory of your house or apartment and make a list of
modifications you would need to make if you had a disability.
Would you even be able to stay in your current residence (e.g.,
are you living in a second-floor apartment in a building that does
not have an elevator)?
4. What resources are available in your community to assist disabled
individuals and families?
5. Address health promotion activities for clients and their families
in your community health clinical course who are either disabled
or have a chronic illness. Examples of health promotion activities
could include healthy eating, physical activity, and leisure-time
activities. Does the public health department have any outreach
services for disabled clients to encourage them to obtain routine
preventable services? Ask some of your clients with disabilities
and chronic illnesses about their experiences and feelings about
preventive services.

thePoint: Everything You Need to Make the

Grade!
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style review questions, journal articles, supplemental materials,
study aids for all learning styles, and more!

2098
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2110
CHAPTER 25
Behavioral Health in the Community
“Mental health and mental disorders are not opposites, and mental health is not just the absence
of mental disorder.”

—World Health Organization

KEY TERMS
At-risk alcohol use Behavioral health Integrated behavioral health Mental
disorders Mental health Substance-related disorders

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Identify key mental disorders and describe their effect on individuals and
the community.
2. Identify commonly used substances and their effect on health.
3. Follow the steps of the nursing process in detection of at-risk alcohol use
and management of that risk.
4. Use prevalence data to inform the development of individual-and
community-level interventions to address mental health and substance
use disorders.
5. Use the Strategic Prevention Framework to guide the implementation of
sustainable prevention activities to promote the behavioral health of the
community.

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INTRODUCTION
This chapter provides an overview of behavioral health, a term used to refer
to both mental health and substance use. A comprehensive approach to
behavioral health recognizes a continuum of care, from promotion to
prevention, treatment, and recovery. Community/public health nursing
practice is discussed, with a focus on individual-, community-, and policy-
level interventions. The community/public health nurse has a key role in
working with individuals, families, and communities to promote optimal
behavioral health and thereby decrease the prevalence and incidence of
mental and substance-related disorders (Box 25-1).

BOX 25-1 Behavioral Health

Terminology
At-risk alcohol use: Thresholds for alcohol use are based on
healthy individuals and those adults 21 years or older. Alcohol
assumption that causes risk to a person's health or increases risk to
others is unsafe. Health conditions and activities may indicate a
lower level of alcohol consumption (Mahmoud, Finnell, Savage,
Puskar, & Mitchell, 2017).
Behavioral health: This term, which is used to refer to both
mental health and substance use, looks at a comprehensive
approach, recognizing a continuum of care, from promotion to
prevention, treatment, and recovery.
Integrated behavioral health: Integrated care blends medical and
behavioral health factors in one setting. The advantage of an
integrated system is coordination of care, and team communication
of all health care providers as they work toward person-centered
health goals (Agency for Healthcare Research and Quality, 2012a,
2012b).
Mental health: Healthy People 2030 addresses increased
treatment for those with mental health. In addition, screening and
early identification is essential for all including youth and the
homeless (U.S. Department of Health and Human Services
[USDHHS], 2020).
Mental disorders: “Health conditions that are characterized by
alterations in thinking, mood, and/or behavior that are associated
with distress and/or impaired functioning. Mental disorders
contribute to a host of problems that may include disability, pain,

2112
 or death” (Office of Disease Prevention and Health Promotion,
2020)
Substance-related disorders: Use of 10 separate classes of drugs
that, when taken in excess, activate the brain reward system,
resulting in neglect of normal everyday activities. This system
influences the reinforcement of behaviors and the production of
memories (American Psychiatric Association, 2013).
Source: Agency for Healthcare Research and Quality (2012a, 2012b); American Psychiatric
Association (2013); Mahmoud et al. (2017); U.S. Department of Health and Human Services
(USDHHS) (2018, 2020).

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CONTEMPORARY ISSUES
From concerns over the opioid crisis and alcohol use and controversies over
supervised injection sites and the legalization of marijuana to the integration
of behavioral health services and the emergence of antistigma strategies,
behavioral health issues have undeniably preoccupied the United States in
recent years.

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Opioid Crisis
A total of 63,632 Americans died of drug overdoses in 2016, and two thirds
of these deaths involved a prescription or illicit opioid (Centers for Disease
Control and Prevention [CDC], 2018a). As the supply of prescription opioids
has been reduced, rates of deaths from heroin and fentanyl have rapidly
increased (Hall & Farrell, 2018). Community and public health nurses
(C/PHNs) have crucial roles to play in addressing this public health problem,
including identifying persons at risk because of opioid use and providing
education, support, and resources for this population (Fig. 25-1).

FIGURE 25-1 CDC's efforts to prevent opioid overdoses and other

opioid-related harms. (Reprinted from Centers for Disease Control
and Prevention. (2019). Retrieved from
https://www.cdc.gov/opioids/pdf/Strategic-Framework-
Factsheet_Jan2019_508.pdf)

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Supervised Injection Sites
Supervised injection sites, also known as safe consumption sites, have been
found to mitigate overdose-related harms and unsafe drug use as well as
facilitate the acceptance of treatment and other health services (Kennedy,
Karamouzian, & Kerr, 2017). These services are available in Europe,
Australia, and Canada and are beginning to emerge in the United States. The
first supervised injection sites in North America were established in
Vancouver, Canada, and the experience gained from them has informed the
expansion of this harm reduction approach elsewhere. Proponents of these
services view them as beneficial to public health and the community.
Opponents believe these sites do nothing to deter drug use or help individuals
stop opioid use. Contentious legislative battles are ensuing as federal law
prohibits these services, and if such sites are opened, they will face action by
the United States Department of Justice to close them. Box 25-2 identifies
some of the tensions between harm reduction and public safety. Informed by
the evidence related to health outcomes for persons who use these services
and areas in which they are situated, C/PHNs will be able to advocate for
best practices to promote the health of this population and society.

BOX 25-2 Safe Consumption Sites:

Tensions Between Harm Reduction and
Public Safety
Harm Reduction
Do safe consumption sites reduce drug overdose deaths?
Do safe consumption sites encourage people who use opioids to
seek help/treatment?

Safety Concerns
Do safe consumption sites create social problems in
neighborhoods?
Do safe consumption sites encourage more people to use drugs?
Source: European Monitoring Centre for Drugs and Drug Addiction (2018).

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Legalization of Marijuana/Cannabis
Paralleling the opioid epidemic, there has been a rapid expansion of the
legalization of cannabis in the United States, for both medical and
recreational use. In 2012, Colorado and Washington became the first two
states to legalize marijuana for recreational use. Since then, 33 states and
Washington, DC have passed laws allowing use of marijuana for medical
purposes and eleven states (Washington, Oregon, California, Nevada,
Colorado, Alaska, Maine, Vermont, Massachusetts, Illinois, and Michigan)
and Washington, DC have legalized recreational, or nonmedical, use by
adults (Fig. 25-2; National Council of State Legislatures, 2020).

FIGURE 25-2 State cannabis programs. (Reprinted with

permission from National Conference of State Legislatures. (2019).
State medical marijuana laws. Retrieved from
http://www.ncsl.org/research/health/state-medical-marijuana-
laws.aspx)

Marijuana helplines have been established to assist persons seeking

information and help in several of these states. In their assessment of such
helplines in four states, Carlini and Garrett (2018) reported that helpline staff
had no knowledge about the effects and interactions of marijuana's two main
components (tetrahydrocannabinol and cannabidiol), nor could they explain
the differences in risk between smoking, eating, or vaporizing marijuana. It is
essential for C/PHNs to have basic knowledge about marijuana components

2117
and methods of use. Educating individuals or the public with this information
does not imply endorsement of marijuana use, but rather is an essential role
that C/PHNs should assume.
Some also suggest that there may be a therapeutic role of cannabis in
opioid use treatment.

A study by Socías and colleagues (2018) concluded that at least daily

cannabis use was associated with higher retention in opioid treatment
when compared with less than daily consumption.
Yet, this emerging area of research calls for further exploration because
previous studies reported mixed results on this association (Timko &
Cucciare, 2018).
C/PHNs need to stay abreast with the trends in the care of persons with
opioid use disorder and critically evaluate novel approaches to improve
engagement in care for this population.

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Alcohol Use
The emphasis on the opioid crisis has in some ways overshadowed concerns
over alcohol use, which, according to the World Health Organization
(WHO), contributes to 3 million deaths annually (WHO, 2018a). C/PHNs
can provide evidence-based strategies to address this significant problem and
help achieve the WHO goal of 10% reduction in the harmful use of alcohol
globally by 2025 (WHO, 2018b) and the alcohol-related Healthy People goal
of reducing alcohol use in the United States (Fig. 25-3).

2119
FIGURE 25-3 Alcohol and health. (Reprinted with permission
from World Health Organization. (2018). Global status report on
alcohol and health. Geneva, Switzerland: Author. Retrieved from
http://www.who.int/substance_abuse/infographic_alcohol_2018.pd
f?ua=1)

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Integration of Behavioral Health Services
For decades, primary care, mental health, and substance use services have
been separated, requiring patients to seek services among multiple sites and
providers to obtain comprehensive care. Recognizing that the needs of
persons with mental health problems, substance use, and physical conditions
were not being adequately met, provider organizations began to design and
implement integrated services in their practice and communities. These
model services provided primary care in behavioral health clinics or
behavioral health services in primary care. Integrated behavioral health
models of clinical integration guide the providers in addressing the need for
populations based on the behavioral risk/complexity and the physical health
risk/complexity. The Four Quadrant Clinical Integration Model by the
National Council for Behavioral Healthcare (2009) serves as a guide for
C/PHNs to determine broad approaches to meet the needs of individuals and
populations. Figure 25-4 depicts the relative balance between the complexity
of behavioral health needs and the complexity of physical health needs.

2121
FIGURE 25-4 Four Quadrant clinical integration model. (Adapted
with permission from National Council for Behavioral Health.
(2009). Behavioral health/primary care integration and the
person-centered healthcare home. Washington, DC: Author.
Retrieved from
https://www.samhsa.gov/sites/default/files/programs_campaigns/sa
mhsa_hrsa/four-quadrant-model.pdf)

2122
Antistigma Strategies, Peer-Based Support, and
Naloxone
Stigma is a key barrier to seeking treatment for behavioral health conditions
for many who could benefit from it (Knaak, Mantler, & Szeto, 2017), yet
there is a lack of research on this topic. Corrigan and Nieweglowski (2018)
proposed antistigma strategies that could be incorporated into public health
programs targeting opioid stigma. Such strategies may be relevant for
C/PHNs to help resolve stigma that has persisted for decades. Stereotypes,
prejudice, and discrimination underlie stigma, factors that, in part, can be
confronted through education that dispels myths with facts.

A study by Mahmoud and colleagues (2019) reported that after

receiving education on how to detect and manage alcohol and opioid
use, nursing students' stigma-related perceptions were favorably
changed.
Further, as these nursing students engaged with this patient population
in the clinical setting, their attitudes toward working with these patients
exhibited positive changes (Mahmoud et al., 2019).
Contact with persons who are in treatment or in recovery may be a good
addition to education programs that are meant to reduce stigma
(Corrigan & Nieweglowski, 2018).
C/PHNs are in key positions to apply these antistigma strategies when
providing education to the public and engaging people in recovery.

Peer-based recovery support services provided by persons who have a

lived experience and experiential knowledge of substance use disorders have
proliferated over the past decade. These peer roles are garnering increased
support in the face of the opioid epidemic.
Another trend is the increasing public availability of naloxone, an opioid-
reversing drug (USDHHS, 2018). Given their presence in community
settings, The C/PHN has a key role in the fight against the opioid epidemic
(see Box 25-3). C/PHNs can and should carry and use naloxone as a key part
of the public health response to the opioid crisis.

BOX 25-3 The C/PHN's Role in the

Fight Against the Opioid Epidemic
Prescription of opioid pain medications
has increased since the 1990s, with

2123
assurance from pharmaceutical
companies that risk of addiction was low
(Gale, 2016). Subsequently, overuse of
both prescription and nonprescription
opioids occurred with associated
increase in overdose events of 30% to
70% from 2016 to 2017 (Vivolo-Kantor
et al., 2018).
The Department of Health and Human Services (HHS) declared a
public health emergency and proposed strategies to combat this opioid
epidemic (Hargan, 2017). The accompanying community burdens
associated with the loss of life, productivity, and health care treatment
dollars as well as increased demands on criminal justice systems were
deemed unsustainable. In response, the American Nurses Association
(ANA) emphasized the nurse's role in assessment and formulation of
plans to decrease the impact of this epidemic while still advocating for
appropriate treatment for painful conditions (ANA, 2018).
As frontline caregivers to the opioid-using population, Cleveland
Clinic nurses have taken lead roles in the opioid task force established
in early 2017. The task force has multiple focus areas designed to
change harmful behaviors (Consult QD, 2017).
First, nurses are studying the clinical settings, and describing
patterns of those addicted to opioid medications. Integral to
improvement of clinical care is incorporating alternative treatments to
chronic pain as well as the provision of rescue medications in cases of
overdose (Consult QD, 2017).
Next, health policy and laws that impact the availability of naloxone
to first responders and pharmacists are addressed. In addition, policy is
needed to facilitate treatment of addicted pregnant women and address
associated child custody matters (Consult QD, 2017).
Finally, nurses provide prevention education in the community with
nurse-led information sessions within public gathering facilities. In
addition, nurses develop curricula and educate peers how to avoid
“compassion fatigue,” which frequently develops when providing care
for those with substance abuse and addiction (Consult QD, 2017).
Source: American Nurses Association (ANA) (2018); Consult QD (October 16, 2017); Hargan
(2017); Vivolo-Kantor et al. (2018).

2124
PREVENTION OF SUBSTANCE USE
AND MENTAL DISORDERS
Relevant to behavioral health, the Healthy People 2030 leading health
indicators focus on mental health and mental disorders, substance abuse, and
tobacco (U.S. Department of Health and Human Services, 2020). The
overarching goals are to:

Improve mental health through prevention and by ensuring access to

appropriate quality mental health services
Reduce substance abuse to protect the health, safety, and quality of life
for all, especially children
Reduce illness, disability, and death related to tobacco use and
secondhand smoke exposure

Across these three major priority areas, C/PHNs can use evidence-based
interventions to address the targeted outcomes. Interventions can be
categorized according to the three levels of preventive behaviors, as shown in
Box 25-4.

BOX 25-4 Levels of Prevention Pyramid

The C/PHN Works With High-Risk Populations
for Mental Disorders and Substance Abuse
SITUATION: Community and public health
nurses play a key role in affecting the social
determinants of health in vulnerable populations.
The main goal of the C/PHN is to improve the
population's health through highlighting
prevention and addressing the determinants of
health within that population.
GOAL: To provide examples of the three levels of prevention when
working with high-risk populations for mental disorders and substance
use. These examples are meant to provide a starting point for the C/PHN

2125
 practice and will vary based on the population served. The first step in
working with any aggregate is the development of trust.

Charlene Niemi PhD, RN, PHN, CNE.

A comprehensive approach to behavioral health means seeing prevention

as part of an overall continuum of care. The Behavioral Health Continuum of
Care Model (Wisconsin Behavioral Health Association, n.d.), depicted in
Figure 25-5, recognizes multiple opportunities for addressing behavioral
health problems and disorders. The components of the model include
promotion, prevention, treatment, and recovery.

2126
FIGURE 25-5 Behavioral health continuum of care model.
(Reprinted with permission from Louis, L. Oppor of parents lead.
Retrieved from
http://www.parentslead.org/sites/default/files/ContinuumofCareMo
del.pdf)

Promotion strategies reinforce the entire continuum of behavioral health

services. These strategies are designed to create the environments and
conditions that support behavioral health and help individuals overcome
challenges.
Prevention strategies, as characterized by Gordon (1983) in a classic
article on prevention, may be grouped into three different categories,
according to the level of risk that each addresses: universal, selective,
and indicated.
Universal prevention includes those strategies delivered to broad
populations wherein the benefits outweigh the costs and risks for
everyone. Examples of this include public health campaigns related
to suicide prevention, legislation related to impaired driving, and a
minimum age for purchase of alcohol.
Selective strategies are indicated when a person's risk of becoming
ill is elevated. Through detection of risk, vulnerable subgroups of
individuals can be identified. As a result, programs and practices
can be provided to reduce the risk.
Indicated strategies address specific risk conditions, focusing
efforts on individual risk factors or behaviors that put individuals at
high risk for developing a behavioral disorder.
Treatment begins with case identification, which entails the ability to
correctly identify those individuals who have a behavioral disorder with
minimal false positives. Once identified, individuals who are at risk
need to be referred for evidence-based treatments.
Recovery focuses on promoting a high-quality and satisfying life in the
community for all people. By engaging with individuals in recovery,
C/PHNs can provide support and help them achieve their recovery

2127
goals, monitor progress toward and recognize when they are moving
away from goals, and support their transitions throughout the recovery
process. C/PHNs can foster activities that contribute to wellness and a
meaningful life, enhancing ways that persons in recovery can connect
with others in their communities.

2128
MENTAL HEALTH
Improving mental health is a key goal of Healthy People 2030 (Box 25-5).
Mental health is essential to personal well-being, family and interpersonal
relationships, and the ability to contribute to community or society (U.S.
Department of Health and Human Services, 2020). C/PHNs should
understand the risk factors that challenge and undermine the health of
individuals across the lifespan, such as adverse childhood experiences
(Merrick et al., 2018) and social determinants of health (Walker & Druss,
2018). Early and regular mental health screenings are important for detecting
emerging mental health problems. C/PHNs can engage the community in
health-promoting activities and help establish community conditions to
support health behaviors. These strategies are important for the prevention of
mental disorders, which are associated with significant distress or disability
in social, occupational, or other activities (American Psychiatric Association
[APA], 2013).

BOX 25-5 HEALTHY PEOPLE 2030

Selected Mental Health and Mental Disorders
Objectives

Reprinted from U.S. Department of Health & Human Services (USDHHS). (2020). Healthy People
2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

2129
Suicide
Two Healthy People 2030 objectives related to mental health improvement
are to (1) reduce the suicide rate and (2) reduce suicide attempts by
adolescents (U.S. Department of Health and Human Services, 2020). Suicide
is a leading cause of death in the United States. According to the CDC
WISQARS data (CDC, 2020a), in 2018, suicide was the tenth leading cause
of death overall, claiming the lives of 48,344 people, and by age groups,
suicide was ranked as the

Second leading cause of death for persons aged 10 to 34 years

Fourth leading cause of death for persons aged 35 to 54 years
Eighth leading cause of death for persons aged 55 to 64 years

The National Violent Death Reporting System collects data regarding

violent deaths, including those resulting from suicide. Recognizing at-risk
groups is an important first step in reducing suicide rates. C/PHNs can use
report summaries to develop, implement, and evaluate programs and policies
to prevent suicides and other violent deaths. For example, the report by Ertl
and colleagues (2019) provides information related to the circumstances
preceding suicides reported in 32 states in 2016. The most common
precipitating circumstances included substance use and current depressed
mood in the individual. More than one fourth of these individuals were
receiving mental health treatment at the time of their death (Ertl et al., 2019).
Demographic characteristics are also important considerations for suicide
prevention. Based on deaths occurring in 2016, the overall suicide rate for
males was nearly 3.5 times the rate for females, and non-Hispanic American
Indian/Alaska Natives had the highest rates of suicide (Ertl et al., 2019).
The method of suicide and location of the injury can also be important
data for C/PHNs developing prevention strategies. Firearms have been
reported to be used in nearly half (49.4%) of suicides, followed by
hanging/strangulation/suffocation (27.8%) and poisoning (14.4%) (Ertl et al.,
2019). Houtsma, Butterworth, and Anestis (2018) discussed strategies to
mitigate the risks related to firearms, including decreasing their availability
through removal and safe storage and educating professionals and
individuals within the firearm community so that they can, in turn,
disseminate knowledge about safe handling and storage of firearms. C/PHNs
can reach out to at-risk individuals in the community and increase safety for
those who may be capable of firearm suicide, as well as assess the rates of
such suicides to determine the impact of their efforts.
Results from the 2017 Youth Risk Behavior Surveillance System
highlight the need for reducing suicide attempts by adolescents. Kann and
colleagues (2018) reported that 17.2% of high school students in the United

2130
States had seriously considered attempting suicide in the previous 12 months
and that 13.6% of students surveyed had made a plan about how they would
attempt suicide. The CDC has developed a technical package that provides
evidence-based strategies for preventing suicide (Stone et al., 2017). C/PHNs
can lead programs to provide children, youth, and adults with skills to
resolve problems and negative influences that are associated with suicide.
Evidence-based strategies discussed by Stone et al. (2017) include the
following:

Strengthen economic supports.

Strengthen access and delivery of suicide care.
Create protective environments.
Promote connectedness.
Teach coping and problem-solving skills.
Identify and support people at risk.
Lessen harms and prevent future risk.

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Major Depressive Episode
In 2018, about 17.7 million U.S. adults (those aged 18 years or older)
reported experiencing at least one major depressive episode; of those, 37%
reported that they received no treatment (SAMHSA, 2019a). As seen in
Figure 25-6, the prevalence was higher among adult females than males, in
individuals aged 18 to 25 years, and among adults reporting two or more
races.

FIGURE 25-6 Past year prevalence of major depressive episode

among US adults (2017). (Reprinted from NIMH. (2017). Major
depression. Past year prevalence of major depression episode
among US adults (2017). Retrieved from
https://www.nimh.nih.gov/health/statistics/major-depression.shtml)

Among adolescents, 14.4% of the U.S. population aged 12 to 17 years

reported at least one major depressive episode (SAMHSA, 2019a). As seen
in Figure 25-7, the prevalence was higher among adolescent females than
males, with increasing prevalence from age 12 to 16 years and highest
among White adolescents and those reporting two or more races. Of
adolescents with major depressive episode, nearly 60% reported that they
received no treatment (SAMHSA, 2019a).

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 FIGURE 25-7 Past year prevalence of major depressive episode
among US adolescents (2017). (Reprinted from NIMH. (2017).
Major depression. Past year prevalence of major depression
episode among US adolescents (2017). Retrieved from
https://www.nimh.nih.gov/health/statistics/major-depression.shtml)

What can C/PHNs do to help reduce the proportion of persons who

experience major depressive episodes and increase the proportion who
receive treatment?

A systematic review and meta-analysis by Deady and colleagues (2017)

reported that a range of eHealth cognitive behavioral programs have
small, but positive effects on symptoms reduction for depression at both
indicated/selective and universal prevention levels. The authors suggest
that eHealth has potential for more reach with fewer resources than
more traditional approaches because it is better able to overcome a
range of financial, geographic, and time barriers (Deady et al., 2017).
Technology-supported interventions for depression, such as Step-by-
Step, developed by the WHO, are feasible to deliver to communities,
adaptable, evidence based, and scalable in multiple settings (Carswell et
al., 2018). This online psychological intervention is directed toward
people with depression, includes informational and interactive
exercises, and is designed to be a minimally guided self-help
intervention (Carswell et al., 2018).
C/PHNs could have a valuable role in providing support to end users to
help them overcome any barriers to using or navigating through the
content of such applications and encouraging their engagement by
sending personalized messages and feedback (Fuller-Tyszkiewicz et al.,
2018).

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 National Depression Screening Day is held annually during Mental
Illness Awareness Week in October
(http://screening.mhanational.org/screening-tools). C/PHNs can be actively
involved by hosting an event in the community, conducting screenings, and
providing information to help youth and adults identify the signs and
symptoms of depression in themselves, their family members, and their
peers. The Patient Health Questionnaire is the most commonly used
depression screening instrument in the United States (O'Connor et al., 2016).
Because the U.S. Preventive Services Task Force recommends there be
adequate systems in place to ensure accurate diagnosis, effective treatment,
and appropriate follow-up (Siu et al., 2016), C/PHNs should document a list
of resources in the community where adults and adolescents can be evaluated
and treated for major depression.

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SUBSTANCE USE
The Diagnostic and Statistical Manual of Mental Disorders 5th Edition
(DSM; APA, 2013) provides diagnostic criteria for substance-related
disorders encompassing 10 classes of drugs: alcohol; caffeine; cannabis;
hallucinogens; inhalants; opioids; sedatives, hypnotics, and anxiolytics;
stimulants; tobacco; and other or unknown substances. A departure from the
previous edition of the DSM, the fifth edition shifted from categorizing the
severity as “abuse” or “dependence” to recognizing substance use along a
continuum from “mild” to “moderate” to “severe” based on the
corresponding symptoms that are reported (APA, 2013). For some, substance
use may increase the risk of harm to their health or well-being and/or
increase the risk of harm to others (Mahmoud et al., 2017), and as such, they
may not meet the criteria for a substance use disorder diagnosis. Healthy
People 2030, as shown in Box 25-6, focuses on substance use. C/PHNs
should know how to detect the level of risk associated with alcohol and other
drug use and the skills to intervene accordingly. The sections below address
the scope of the problem associated with each substance, how to screen for
risk, and how to intervene accordingly. For commonly used substances, signs
of use, and associated health risks, see
https://www.drugabuse.gov/sites/default/files/Commonly-Used-Drugs-
Charts_final_June_2020_optimized.pdf and
https://www.drugabuse.gov/drug-topics/commonly-used-drugs-charts

BOX 25-6 HEALTHY PEOPLE 2030

Selected Substance Use Objectives

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U.S. Department of Health & Human Services (USDHHS). (2020). Healthy People 2030: Browse
objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

2136
Alcohol Use
Although the opioid crisis continues to loom and rightfully command
attention, alcohol contributes to the death of more than 3 million people each
year (WHO, 2018). The 2018 National Survey on Drug Use and Health
(NSDUH) collected information from persons in the United States aged 12
years or older on past month alcohol use, binge alcohol use, and heavy
alcohol use (SAMHSA, 2019a). Figure 25-8 displays the prevalence for each
category and its definition.

FIGURE 25-8 Past month binge and heavy alcohol use:

percentages (2015 through 2018) for people aged 12 years or older,
by age group. (Reprinted from Substance Abuse and Mental Health
Services Administration. (2019). Key substance use and mental
health indicators in the United States: Results from the 2018
National Survey on Drug Use and Health (HHS Publication No.
PEP19-5068, NSDUH Series H-54). Rockville, MD: Center for
Behavioral Health Statistics and Quality, Substance Abuse and
Mental Health Services Administration. Retrieved from
https://www.samhsa.gov/data/sites/default/files/cbhsq-
reports/NSDUHNationalFindingsReport2018/NSDUHNationalFin
dingsReport2018.pdf)

The percent of alcohol varies by beverage. In screening for alcohol use, it

is important to explain the definition of a standard drink. A graphic depiction
of a standard drink available from the National Institute on Alcohol Abuse
and Alcoholism (n.d.a) is useful for providing this information (Fig. 25-9).

2137
 FIGURE 25-9 What is a standard drink? (Reprinted from National
Institute on Alcohol Abuse & Alcoholism (NIAAA). (n.d.a). What
is a standard drink? Retrieved from
https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-
consumption/what-standard-drink)

The National Institute on Alcohol Abuse and Alcoholism (n.d.b) has

established low-risk alcohol consumption limits for healthy adults based on
sex (Fig. 25-10). There are no safe limits for youth, and various health
conditions and activities may warrant lower limits or no alcohol consumption
at all. For example, alcohol consumption is contraindicated at any time
during pregnancy (CDC, 2018b).

FIGURE 25-10 Low-risk alcohol consumption limits. (Reprinted

from National Institutes of Health (NIH). (2016). Rethinking
drinking: Alcohol and your health. Retrieved from
https://pubs.niaaa.nih.gov/publications/RethinkingDrinking/Rethin
king_Drinking.pdf)

2138
 Grounded in an understanding of the nursing process, the definition of a
standard drink, and recognition of the alcohol consumption limits for healthy
adults, C/PHNs can promote the reduction of alcohol use by delivering
evidence-based interventions. Box 25-7 illustrates the application of the
nursing process to care of a patient with alcohol use disorder, including the
standard steps of screening, brief intervention, and referral to treatment
(SBIRT). This example illustrates how SBIRT can be used in public health
nursing to help meet the Healthy People 2030 goal of reducing substance
use. The National Institute on Alcohol Abuse and Alcoholism (NIAAA)
publications, Planning Alcohol Interventions Using NIAAA's CollegeAIM
(NIAAA, n.d.c) and Alcohol Screening and Brief Intervention for Youth: A
Practitioner's Guide (NIAAA, 2020), provide step-by-step guidance and
tools for the delivery of this set of clinical strategies.

BOX 25-7 C/PHN Use of the Nursing

Process
Detection and Management of At-Risk Alcohol
Use

2139
Source: Babor et al. (2001); Pringle et al. (2017).

At the community level, C/PHNs can organize and actively engage in the
National Alcohol Screening Day. This annual event, an initiative of the
National Institutes of Health, is conducted to provide information about
alcohol and health as well as free anonymous screening
(https://nationaldaycalendar.com/national-alcohol-screening-day-thursday-
of-first-full-week-in-april/). C/PHNs can help identify and address gaps in
the treatment system by surveilling the types of specialty treatment that are
provided in the community and assessing the time to access treatment as well
as other factors affecting one's ability to receive timely and affordable
treatment.

2140
Drug Use
The annual NSDUH for persons in the United States aged 12 years or older
obtains information on drugs including marijuana, cocaine, heroin,
hallucinogens, inhalants, and methamphetamine (SAMHSA, 2019a).
C/PHNs should remain up to date on the prevalence of drug use in the
community. The SBIRT clinical strategies can be used to identify and address
drug use, including the use of a psychotherapeutic drug that is not as
directed, including without a prescription of one's own. A single screening
question begins the process (Smith, Schmidt, Allensworth-Davies, & Saitz,
2010); a positive response to that question triggers the administration of the
Drug Abuse Screening Test (DAST; Skinner, 1982; Yudko, Lozhkina, &
Fouts, 2007). To view the DAST, go to
https://cde.drugabuse.gov/instrument/e9053390-ee9c-9140-e040-
bb89ad433d69. The intervention is provided based on the level of risk per
the DAST score.

Marijuana
The drug that survey respondents most commonly reported as having used in
the past month is marijuana, used by 43.5 million people aged 12 years or
older (SAMHSA, 2019a). Marijuana use was reported by 43.5 million, or
15.9%, of Americans aged 12 years or older reported in 2018; this percentage
of use was higher than any of the percentages of use from 2002 to 2017
(SAMHSA, 2019a). With the emerging context of legalization of marijuana,
it will be important for C/PHNs to continue to monitor the prevalence of
marijuana use in their communities. Given the adverse health effects and
harms associated with marijuana use (Memedovich, Dowsett, Spackman,
Noseworthy, & Clement, 2018), C/PHNs need to educate the public on its
impact on health. (See Boxes 25-8 and 25-9.)

BOX 25-8 QSEN: Focus on Quality

Patient-Centered Care for Behavioral Health: Adolescent Access
to and Use of Marijuana
Evidence-Based Practice: Integrate best current evidence with clinical
expertise and patient/family preferences and values for delivery of optimal
health care (Cronenwett et al., 2007, p. 123).
(See http://qsen.org/competencies/pre-licensure-ksas#quality_improvement
for the knowledge, skills, and attitudes associated with this QSEN
competency) More states are permitting commercial production and sales of
recreational, or retail, marijuana. A public health concern is a potential

2141
increase in adolescents' access to and use of marijuana given the evidence of
negative health effects on this population. The National Survey on Drug Use
and Health (NSDUH; https://nsduhweb.rti.org/respweb/homepage.cfm),
conducted annually, asks questions about marijuana use for Americans ages
12 and older. Information from the NSDUH is used to support prevention
and treatment programs, monitor substance use trends, estimate the need for
treatment, and inform public health policy. In Colorado, the
commercialization of medical marijuana allowed the proliferation of
consumable marijuana products including candies, lozenges, baked goods,
and beverages, with little attention paid to standardized dosing levels,
guidance for novice users, food safety, and contamination issues. The
legalization of marijuana cultivation for dispensaries has impacted growing
conditions and horticultural practices with the goal of increasing the supply
and the potency of the psychoactive ingredient tetrahydrocannabinol (THC).

1. What are the harms associated with marijuana use among

adolescents? How would you incorporate that evidence in educating
the public?
2. Are strategies used to prevent unintentional poisoning transferrable to
children and youth related to edible products and access to
marijuana? If so, how would those be used in public health
messages?
3. What data are needed to monitor impaired driving and risks of
fatalities associated with marijuana use? Are limits for drivers' THC
levels warranted?
4. What areas of the health care system should be under surveillance to
monitor the impact of increased access to marijuana? How would
data collected from those systems be used to inform public awareness
campaigns or support policies and regulations to protect children,
youth, and the community at large?
Source: Cronenwett et al. (2007).

BOX 25-9 Marijuana Use in the United

States According to a 2018 Gallup poll,
66% of Americans favor legalizing the
recreational use of marijuana
(McCarthy, 2018). It is estimated that
43.5 million Americans between the ages
of 12 and older used marijuana in 2018

2142
(SAMHSA, 2019). Delta-9-
tetrahydrocannabinol (THC) is the main
psychoactive chemical found in the
Cannabis sativa plant. Although usually
smoked, it can be brewed in tea or
mixed in foods called edibles. The THC
content has steadily increased since
1976, when marijuana had an average of
THC content of 0.72% (Marijuana
Break, 2018). In 2014, this rose to 50%
to 80% in some samples (NIDA, 2018).
Marijuana use disorders (MUD) account for about 30% of all users.
Frequent users prior to age 18 are at a four to seven times greater risk of
developing MUD. Roughly 4 million people in the United States have
MUD (NIDA, 2018). Academic difficulties occur with use, including
increased risk of skipping college classes, poorer grades, and poorer
graduation rates (Arria, Caldeira, Bugbee, Vincent, & O'Grady, 2015),
and cognitive difficulties were significantly related to the minutes of
marijuana use (Conroy, Kurth, Brower, Strong, & Stein, 2015).
Judgment and attention are impaired (NIDA, 2018).
Frequent use is associated with mental health problems including
depression, increased anxiety with use (Keith, Hart, McNeil, Silver, &
Goodwin, 2015), panic, fear, and paranoia (NIDA, 2018). When used in
large doses, acute psychosis may occur.
THC affects several parts of the brain, including the hippocampus
and the orbitofrontal cortex, causing impaired thinking and difficulty in
absorbing new information. A 25-year study found that those with a
lifetime exposure to marijuana had lower scores in verbal memory. The
effects on the cerebellum and basal ganglia result in poor balance and
coordination as well as slowed reaction time (NIDA, 2018).
THC stimulates the mesolimbic system to release a high level of the
neurotransmitter dopamine producing the “high.” When compared to
nonusers, in marijuana users there was a higher incidence of other drug
use such as alcohol (use including binge drinking), almost half used
cocaine, and 30% used amphetamines (Keith et al., 2015).

2143
 Currently, 14 states and the District of Columbia have legalized
recreational use of marijuana (National Conference of State
Legislatures, 2020). Teens and young adults' perception of the risks of
the drug have decreased partially due to the legalization of the drug for
medical and recreational use in some states (NIDA, 2018). Research
continues to shed light on the benefits and dangers of marijuana use.
C/PHNs need to stay up-to-date on the community trends and research
in order serve their communities.
Source: Arria et al. (2015); Conroy et al. (2015); Keith et al. (2015); Marijuana Break (2018);
McCarthy (2018); National Institute on Drug Abuse (NIDA) (2018); Substance Abuse and
Mental Health Services Administration (2017, 2019a); WHO (2020).

Charlene Niemi, PhD, RN, PHN, CNE

Cocaine and Crack

In 2018, 2% (5.5 million) of 5.5 people aged 12 years or older reported
current use of cocaine and 0.3% who reported current use of crack cocaine.
Among those aged 12 to 17 years, 0.4% (11,200) used cocaine and fewer
than 0.1% (4,000) used crack (SAMHSA, 2019a).

Heroin
Heroin use has increased in recent years. Roughly 800,000 people aged 12
years or older reported heroin use in 2018 (SAMHSA, 2019a). Until 2002,
methadone was the primary medication used to treat individuals with heroin
use disorder and was dispensed through licensed treatment facilities. The
introduction of buprenorphine in 2002 allowed for an additional medication
option and also increased access to treatment because this medication could
be prescribed by physicians in their office or clinic setting. Access to
buprenorphine was further increased with the passage of the Comprehensive
Addiction and Recovery Act (P.L. 114-198), which allowed nurse
practitioners to prescribe buprenorphine. The SUPPORT for Patients and
Communities Act (Congress.gov, 2018) expanded access to this medication
even further by allowing Certified Nurse Specialists, Certified Nurse
Midwives, and Certified Nurse Anesthetists to prescribe buprenorphine for a
5-year period (American Academy of Physician Assistants [AAPA], 2018).

Hallucinogens
In 2018, about 5.6 million people aged 12 years or older reported the use of
hallucinogens, or 2% of the population. Compared with all other age groups,
the highest percentage of use was reported by people aged 18 to 25 years at
6.9% (SAMHSA, 2019a).

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Inhalants
Respondents of the NSDUH survey are asked to report the use of inhalants to
get high, but not to include accidental inhalation of a substance. In 2018,
approximately 2 million people aged 12 years or older reported use of
inhalants. Use was more common among adolescents aged 12 to 17 years
than among people in other age groups (SAMHSA, 2019a).

Methamphetamine
Most of the methamphetamine in the United States is produced and
distributed illicitly, creating a serious public health and safety problem in the
United States. Some suggest that the lull in the methamphetamine epidemic,
at its peak in 2005, is swiftly ending, as this drug now accounts for 11% of
the total number of opioid deaths (The Lancet, 2018). In 2018, about 1.9
million people aged 12 years or older reported current use of
methamphetamine (SAMHSA, 2019a). About 43,000 adolescents aged 12 to
17 years reported methamphetamine use, or 0.7% of adolescents. The next-
largest age group were 273,000 young adults aged 18 to 25 years who
reported use in 2018; 1.6 million adults aged 26 years or older reported
methamphetamine use also in 2018 (SAMHSA, 2019a).

Prescription Drugs
In the NSDUH, respondents are asked to report on any use of a prescription
drug that is not used as directed, including use without a prescription of one's
own. In 2018, this type of prescription drug use was reported by 16.9 million
of the population aged 12 years or older. In 2018, among four different
prescription drug categories, pain relievers were the most commonly
reported, with 9.9 million persons aged 12 years or older reporting having
used them in the past month, followed by prescription tranquilizers and
sedatives (6.4 million), and prescription stimulants (5.1 million) (SAMHSA,
2019a).
Of greatest concern are prescription opioid analgesics (e.g., morphine,
oxycodone), which along with heroin and fentanyl contribute to opioid-
involved deaths. In 2018, close to 70% of the over 67,000 drug overdose
deaths in the United States involved an opioid (CDC, 2020b). Various
strategies have been undertaken to prevent overprescribing of opioids
(Dowell, Haegerich, & Chou, 2016), improve drug monitoring programs
(Bao et al., 2018), increase access to naloxone for opioid overdose reversal
(Kerensky & Walley, 2017), increase linkages to harm reduction services and
treatment (Hawk & D'Onofrio, 2018), and provide fentanyl test strips (Peiper
et al., 2019). C/PHNs can assume important roles in promoting these

2145
strategies in the community and providing education to the public on the
crisis and ways to mitigate it.

2146
TOBACCO USE
Across the United States, tobacco consumption was the leading risk factor in
terms of disability-adjusted life years (DALYs) for the years 1990–2016
(Mokdad et al., 2018). In 2016, about 63.4 million people aged 12 years or
older reported tobacco use in the past month, the majority of whom smoked
cigarettes (Fig. 25-11).

FIGURE 25-11 Past Month Tobacco Use among People Aged 12

or Older: 2018. (Reprinted from Substance Abuse and Mental
Health Services Administration. (2019). Key substance use and
mental health indicators in the United States: Results from the
2018 National Survey on Drug Use and Health (HHS Publication
No. PEP19-5068, NSDUH Series H-54). Rockville, MD: Center
for Behavioral Health Statistics and Quality, Substance Abuse and
Mental Health Services Administration. Retrieved from
https://www.samhsa.gov/data/sites/default/files/cbhsq-
reports/NSDUHNationalFindingsReport2018/NSDUHNationalFin
dingsReport2018.pdf)

The use of electronic cigarettes is rapidly emerging among adolescents,

along with concerns about its impact on the health of both the individual and
the public. A literature review by Perikleous, Steiropoulos, Paraskakis,
Constantinidis and Nena (2018) reported as risk factors for e-cigarette use
among adolescents the following: being male, being an older adolescent,
being able to afford e-cigarettes, being a regular or heavy smoker, and having
peers who smoke. With e-cigarette use rising among high school students in
2018 to 3.05 million (U.S. Food and Drug Administration, 2020), C/PHNs

2147
need to be attentive to the attraction of this mode of tobacco use and provide
educational initiatives targeting youth and young adults.
The U.S. Preventive Services Task Force (2017) recommends screening
and providing brief intervention for tobacco use as part of standard routine
health care for adults and women who are pregnant. The U.S. Department of
Health and Human Services clinical practice guideline provides information
about screening and interventions that can be provided based on the
individual's willingness to quit. It is recommended that all patients be asked
whether they use tobacco and, if so, whether they want to quit.
The Agency for Healthcare Research and Quality (2012a) recommends
five major components for treating tobacco use and dependence:

“Ask” about tobacco use

“Advise” to quit
“Assess” willingness to make a quit attempt
“Aid” the person in quitting
“Arrange” for follow-up

C/PHNs are encouraged to adopt these 5As as part of their standard care
to address this major health problem in the United States and globally.
Strategies for various populations are provided on the smokefree.gov Web
site, including strategies for those who are willing to quit, those unwilling to
quit, those who have recently quit, and specific populations (e.g., veterans,
women, teens, those 60 years and older, and Spanish speakers).

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COMMUNITY-AND POPULATION-
BASED INTERVENTIONS
Interventions to promote behavioral health at the community level begin with
a community assessment to establish a community diagnosis, followed by
interventions that can address the specific public health issue identified in the
diagnosis. The Healthy People 2030 objectives serve as a starting point in the
development of an intervention. Community interventions move beyond
single interventions and outcomes at individual levels of health behavior
change.
Depicted in Figure 25-12, the five steps of SAMHSA's A Guide to
SAMHSA's Strategic Prevention Framework (SAMHSA, 2019b) can guide
C/PHNs in a comprehensive process for addressing the behavioral health
problems facing communities.

FIGURE 25-12 A guide to SAMHSA's Strategic Prevention

Framework. (Reprinted from Substance Abuse and Mental Health
Services Administration. (2019). A guide to SAMHSA's strategic
prevention framework. Retrieved from
https://www.samhsa.gov/sites/default/files/20190620-samhsa-
strategic-prevention-framework-guide.pdf)

2149
 Table 25-1 provides descriptions of each step of the process.

TABLE 25-1 Strategic Planning Framework: Step-by-Step

Guidance for the C/PHN

Source: Substance Abuse and Mental Health Services Administration (SAMHSA) (2019b).

Community coalitions that have used the Strategic Prevention

Framework include the following:

Iowa Department of Public Health substance abuse program

(https://idph.iowa.gov/substance-abuse/programs/spfrx/about): A
program designed to raise awareness about the dangers of sharing
medications and to work with the pharmaceutical and medical
communities to communicate the risks of overprescribing to youth
Kansas Prevention Coalition
(http://kansaspreventioncollaborative.org/Coalitions/Strategic-
Prevention-Framework): Using the Strategic Prevention Framework,
offers community programs and resources on prevention (the Web site
provides an overview of the framework, and the New and Highlights
section of the Web site provides links to numerous community programs
and resources)
SAMHSA provides a Collaborative Approach to the Treatment of
Pregnant Women with Opioid Use Disorder, offering communities

2150
guidance in developing interagency policies and practices to assist
pregnant women and their infants in the health, safety, and recovery
(SAMHSA, 2016).
Screening and Assessment of Co-occurring Disorders in the Justice
System provides direction and guidance to communities to assess and
address symptoms of mental health and substance abuse disorder in
offenders (SAMHSA, 2019c).
Medication-Assisted Treatment Programs in Criminal Justice Settings
are exemplified in New Jersey and Rhone Island. In an effort to stabilize
individuals over the course of their sentences and after release,
medications are prescribed to treat opioid use disorder (OUD)
(SAMHSA, 2019d).
Kentucky and Massachusetts use a relapse prevention focus, where
criminal offenders with OUD are provided naltrexone before and after
release to avoid the risk of relapse after reentry into the community
(SAMHSA, 2019d).

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SUMMARY
Substance use disorders are linked to health problems. Healthy People
2030 focuses on strategies to prevent and access to treatment to mitigate
health problems and deaths.
At the individual level, C/PHNs can detect the person's level of risk via
screening instruments, assess the individual, and intervene accordingly.
The Strategic Prevention Framework serves to guide C/PHNs in
community-level interventions to address behavioral health problems.

2152
ACTIVE LEARNING EXERCISES
1. Develop your skills in assessing health education materials. Select a
Healthy People 2030 objective related to mental health and mental
disorders, substance use, or tobacco use. Search for accessible health
education materials related to that behavioral health problem. Select
one health education flyer, brochure, booklet, or Web site. Evaluate
the material using the Suitability Assessment of Health Education
Materials Scoring Sheet available at
http://aspiruslibrary.org/literacy/SAM.pdf. Provide a summary
narrative of your scoring and justification, based on the literature for
your evaluation. Provide a list of the references used in your analysis
of the health education materials.
2. Using “Enable Equitable Access” (1 of the 10 essential public health
services; see Box 2-2 ), identify services for behavioral health in your
community or state. What services are available, and how accessible
are those services?
3. Examine the evidence related to safe consumption spaces. Assume a
position on the pro or the con side and conduct a literature search to
support that perspective.
4. Identify a health promotion topic based on one of the Healthy People
2030 objectives related to a behavioral health problem. Develop a 5-
minute presentation on the topic preparing no more than 20
PowerPoint slides. The presentation can be in person or by creating
an Ignite presentation that can be delivered online. Whichever format
you select, the following resources will be useful in developing your
talk.

https://www.youtube.com/watch?
v=yGENcskRGRk&feature=youtu.be%2F
https://speakingaboutpresenting.com/content/fast-ignite-presentation/
http://www.lauramfoley.com/ignite/

5. Research behavioral health issues in your community. Gather data

from local, state, and national agencies to determine incidence and
prevalence of behavioral health concerns and morbidity and mortality
rates. One source might be the CDC's Web-based Injury Statistics
Query and Reporting System (WISQARS). Begin by going to the
Web site: https://www.cdc.gov/injury/wisqars/index.html.

Select “Fatal Injury and Violence Data.”

2153
 Select “Fatal Injury Reports 1981–2018.”
Review the following areas and make selection(s) for each:
Year Range/Census Region
Intent or manner of the injury
Cause or mechanism of the injury
Complete the “Select-specific options” that are of interest for your
report.
Submit the request to see the results.
Click “Download Results in a Spreadsheet CSV) File.”

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!

2154
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CHAPTER 26
Working with the Homeless
“We have come dangerously close to accepting the homeless situation as a problem that we just
can't solve.”

—Linda Lingle (1953), American Politician

KEY TERMS
Chronically homeless
Continuum of care
Deinstitutionalization
Doubling up
Homeless
Housing First
Literally homeless
Period prevalence counts
Point-in-time counts
Single-room occupancy (SRO) housing
Survival sex
Trauma-informed care
Unaccompanied youth
Unsheltered (hidden) homeless

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

1. Define the concept of homelessness.

2. Describe the demographic characteristics of the homeless living in the
United States.
3. Discuss factors predisposing persons to homelessness.
4. Compare and contrast the unique challenges confronting selected
subpopulations within the homeless community.
5. Explain the effects of homelessness on health.
6. Analyze the extent and adequacy of public and private resources to
combat the problem of homelessness.
7. Assess your beliefs and values toward homelessness.
8. Propose community-based nursing interventions to facilitate primary,
secondary, and tertiary prevention in addressing the problem of

2164
homelessness.

2165
INTRODUCTION
What was once considered unthinkable in a prosperous nation is now an
expected occurrence in towns and cities across the United States. Drive
through an inner city or suburban community on any given day, and you will
see people on street corners holding signs stating “Hungry and homeless.”
Where is the public outcry in response to this scene? Has the American
conscience been anesthetized to this form of human suffering? Or is the need
simply too overwhelming and the problems too far reaching to mount an
effective campaign to prevent such a tragedy?
The purpose of this chapter is to define the concept of homelessness,
examine the factors contributing to homelessness, analyze the major issues
confronting the homeless, and examine the role of the community health
nurse (CHN) in addressing the needs of the homeless.
The McKinney-Vento Homeless Assistance Act (Title 42 of the U.S.
Code) defines as homeless a person who lacks a fixed, regular, adequate
nightly residence; this definition includes as homeless those who stay in
supervised public or private shelters that provide temporary
accommodations. Homeless individuals may also reside in institutional
settings providing temporary shelter or in public or private places that are not
designed for or used as a regular long-term sleeping accommodation for
human beings (e.g., cars, parks, campgrounds; Fig. 26-1). Such individuals
are often referred to as literally homeless. Incarcerated individuals are not
considered homeless under this definition (McKinney-Vento Homeless
Assistance Act, 1987).

FIGURE 26-1 A row of tents and belongings of some of the over

30,000 homeless people who live in Los Angeles. Homeless

2166
 individuals often struggle to find shelter.

The education subtitle of the McKinney-Vento Homeless Assistance Act

expands on the definition of homelessness when addressing homeless
children and youth. The Act includes as homeless those children who share
housing with others because of economic hardship or loss of housing, are
abandoned in hospitals, are awaiting placement in foster care, or are living in
motels, trailer parks, or camping grounds. However, children awaiting foster
care placement were removed from the definition of homeless in 2016
(National Center for Homeless Education, n.d.).
The U.S. Department of Housing and Urban Development (USDHUD)
defines homeless people as those living on the streets, in vehicles, in shelters
or parks, or in transitional housing; unaccompanied youth or families with
children who are defined as homeless under other federal statutes; or
individuals facing imminent eviction (within 14 days; National Health Care
for the Homeless Council [NHCHC], 2018). Although this definition may be
appropriate for the urban homeless, who are more likely to live on the street
or in shelters, persons living in rural areas tend to cohabit with relatives or
friends in overcrowded, substandard housing (Housing Assistance Council
[HAC], 2016). Box 26-1 outlines selected Healthy People 2030 goals that
relate to the homeless population.

BOX 26-1 HEALTHY PEOPLE 2030

Objectives Related to Homelessness

2167
Reprinted from U.S. Department of Health and Human Services (USDHHS). (2020). Healthy People
2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

2168
SCOPE OF THE PROBLEM
It is difficult to estimate the number of people who are homeless, because
homelessness is a temporary condition. Rather than trying to count the
number of homeless people on a given night, or point-in-time counts, it may
be more prudent to gauge the number of people who have been homeless
over a longer time frame, such as over the course of a year, or period
prevalence counts (Ontario Ministry of Housing, 2017; USDHUD, 2017b).
It is also difficult to locate and account for homeless people. Most
estimates of homelessness are based on the number of people served in
shelters or soup kitchens or the number of people who can easily be located
on the streets. People who spend time at places that are difficult to reach
(e.g., cars, campgrounds, caves, boxcars, wooded areas) are considered
unsheltered (hidden) homeless. Many people are unable to access shelters
because of overcrowding and limited capacity (Box 26-2). In rural areas,
there are fewer housing options and resources for the homeless. As a result,
people may be forced to live temporarily with friends or family (a practice
known as doubling up). Although still experiencing homelessness, these
individuals are not always counted in homeless statistics or considered
eligible for homeless services (NHCHC, 2019).

BOX 26-2 Population Focus

Tent Cities and Solutions for the Homeless
After the Great Recession of 2007 to 2008, tent cities began springing
up across many larger cities in the United States, some of them with
mutually determined codes of conduct and social structures. These
temporary communities were a similar phenomenon to the shantytowns
of the Great Depression, and many cities have responded to these
temporary encampments by criminalizing them, citing concerns for
public health and safety (Herring, 2015; National Law Center on
Homelessness and Poverty [NLCHP], 2017).
Imagine a world where it is illegal to sit down. Could you survive if
there were no place you were allowed to fall asleep, store your
belongings, or to stand still? Homeless people, like all people, must
engage in activities such as sleeping or sitting down in order to survive.
Yet in communities across the nation, these harmless, unavoidable
behaviors are treated as criminal activity under laws that criminalize
homelessness (NLCHP, 2017).

2169
 Between 2007 and 2016, the number of homeless encampments
reported by the media has increased 1,342% (NLCHP, 2017).
Encampments have been reported in every state across the nation and in
the District of Columbia. Most of these temporary communities are
illegal and under constant threat of eviction. The dramatic increase in
encampments is a reflection of the growth in homelessness and the lack
of accessible shelter.
Why do people live in tent cities? Most cities in the United States
do not have sufficient shelter beds to accommodate the number of
homeless in need of shelter. Many shelters limit admission based on
gender. Others do not allow children. Some shelters do not allow
personal belongings or have no provision for their safe storage. Other
shelters lack accommodations for persons with disabilities. Many
shelters have strict curfews that may make it difficult to hold down a
job. Very few shelters allow pets (NLCHP, 2017).
Some states have adopted more tent city–friendly policies.
Innovations in addressing the tent city crisis include hosting permanent
encampments with colocated service centers, engaging religious
organizations to temporarily host tent cities on their properties, and
providing permits for temporary encampments on city property
(NLCHP, 2017).

1. Have you seen tent cities in your community? How do you feel
when you see them?
2. What do you think could be done to address some of the issues
raised by the proliferation of tent cities? Debate the issue with
classmates.
3. How could C/PHNs be involved in helping to design feasible
population-focused interventions?
Source: Herring (December 2015); NLCHP, 2017.

The USDHUD, in its Annual Homeless Assessment Report to Congress,

publishes the latest counts of homelessness nationwide. In 2017, on a single
night in January, there were an estimated 553,742 sheltered and unsheltered
homeless people across the nation (Fig. 26-2). Approximately 48% of people
experiencing homelessness were in unsheltered locations. The number of
homeless people in the nation decreased by 14% from 2007 to 2017, with the
number of people in unsheltered locations declining by 25% and the number
of people in sheltered locations declining by 8%. From 2016 to 2017, the
number of homeless increased in major cities but declined elsewhere in the
United States. From 2007 to 2017, the rate of homelessness has declined
across all categories except for the sheltered homeless, which has increased
by 4% in major cities (USDHUD, 2017b).

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 FIGURE 26-2 Estimates of homeless people by state, 2019.
(Reprinted from U.S. Department of Housing and Urban
Development (USDHUD). (2019). The 2019 annual homeless
assessment report to Congress. Retrieved from
https://files.hudexchange.info/resources/documents/2019-AHAR-
Part-1.pdf)

Two thirds of the homeless are adults in households with no children.

The remaining one third (33%) are homeless families (USDHUD, 2017b).
Because of the transient nature of homelessness and the difficulty involved in
locating and counting the homeless, it is unlikely that researchers will ever
be able to estimate the exact magnitude of homelessness in America (NCH,
2018a).
There is a direct relationship between poverty and homelessness. In
general, homelessness is decreasing due, in part, to the strides made over
recent years to increase federal funding for homeless prevention and
assistance programs. Still, only one in five families eligible for federal
housing assistance receive the help they need (National Low Income
Housing Coalition [NLIHC], 2019). Despite improvements in employment
and in the economy, those who are in poverty, living with friends and family,
and paying over half their income for housing continue to be at risk for
homelessness. Housing programs for the homeless have removed many
homeless people from the streets, but the lack of affordable housing
continues to present formidable challenges to eliminating homelessness
(National Alliance to End Homelessness [NAEH], 2017, 2020e).
In 2016, The U.S. Conference of Mayors Task Force on Hunger and
Homelessness reported its survey findings of 32 cities in 24 states across the
nation. The survey revealed that the majority of cities followed the national
trend of a declining rate of homelessness. The need for housing assistance
and the lack of affordable housing were identified as the most pressing issues

2171
requiring improved resources to reduce the rate of homelessness (United
States Conference of Mayors, 2016).

2172
Demographics
Poverty is directly linked to homelessness (Fig. 26-3). Demographic groups
more likely to be poor are also at greater risk of becoming homeless.

FIGURE 26-3 Volunteers sharing food with homeless people.

Raising awareness about homelessness is an important step in
seeking community solutions.

Age
In 2017, 88% of individuals experiencing homelessness were adults
over 24 years of age, 10% were 18 to 24 years old, and only 1% were
under 18 years of age.
Among the unsheltered homeless, 87% are over 24 years old and 1.6%
are under 18 years of age (USDHUD, 2017b).

Gender
The majority of homeless individuals are unaccompanied adult men.
Men are more likely than women to be unsheltered.
Approximately 61% of people experiencing homelessness are men and
39% are women (USDHUD, 2017b).
From 2016 to 2017, homelessness declined by 1% among women but
increased by 1% among men.
Fewer than 1% of homeless individuals identify themselves as
transgender or as not male, female, or transgender (USDHUD, 2017b).

2173
Ethnicity
The racial and ethnic makeup of the homeless population varies based on
geographic location.

Nationally, 47% of people experiencing homelessness are non-Hispanic

white, whereas approximately 41% are African American and 22% are
Hispanic or Latino.
Persons in sheltered situations are more likely to be African American,
whereas those in unsheltered settings are more likely to be white
(USDHUD, 2017b).
Compared with the U.S. population, the sheltered homeless are more
likely to be unaccompanied adult males, African Americans, and
disabled (USDHUD, 2017c).

Families
Families with children represented 33% of the homeless population in
the United States in 2017.
Over 20% of people experiencing homelessness are children.
Approximately 59% of homeless people in families are children (under
18 years of age).
More than 90% of homeless people in families reside in shelters.

The number of homeless people in families declined by 21% from 2007

to 2017. The number of homeless families declined by 26%, with the
majority of the decline being in families with children in unsheltered
locations (USDHUD, 2017b).
Although nearly 78% of adults experiencing sheltered homelessness as
part of families with children are women, men are increasingly being
represented in sheltered homeless families (USDHUD, 2017c). During
recessions and periods of economic decline, more two-parent families and
families headed by single fathers are likely to become homeless (Fig. 26-4).
Because organizations serving homeless families are generally geared to
serving single women with children, it may be difficult for intact families
and families headed by men to access shelter (Zobel, 2016).

2174
FIGURE 26-4 Homeless family sitting on the street. Families with
children represent about one third of the homeless population in the
United States.

2175
Contributing Factors
Persons are predisposed to homelessness because of a complex array of
factors that result in individuals having to choose between necessities of
daily living. Scarce resources limit choices. What would you do if you had to
choose between eating and buying your child's medication? Housing
consumes a huge portion of one's income and is often the first asset to be
lost. Many families find they are only a paycheck away from homelessness
(Boxes 26-3 and 26-4).

BOX 26-3 PERSPECTIVES

A Homeless Couple's Viewpoint on Living in

Their Car
My name is Sally. Sam and I are in our fifties and have been homeless for 2
years. We became homeless when my husband's company downsized, and
he lost his job. I had to go on medical disability because of my brittle
diabetes. I could no longer work, and the medical bills just kept piling up.
Eventually, we were unable to pay our rent and were evicted from our
home. We have been living in our car. We park in the local SuperMart lot at
night. This place is great. It is located in a safe area of town, and it is open
24 hours a day, so we always have access to restroom facilities. We stayed
in a county shelter for a while. The social worker there tried to help us find
housing, but we were afraid to go into the parts of town where the
subsidized housing was located. The criminal activity there was so
pervasive that we just figured we would be safer living in our car. We have
been married for over 30 years, but we were separated at the shelter and
told we could not demonstrate any physical affection. When we tried to
apply for food stamps, we were told we needed to produce our rent and gas
and electric bills, or we would be ineligible to receive this benefit. I kept
telling them that we live in our car. We don't pay rent! We don't have a gas
and electric bill! Many times, we were turned down from housing and other
benefits, because we did not meet the eligibility criteria. We were not single
parents. We had no children. We did not suffer from a severe mental health
or addiction disorder. We were not veterans. It is so frustrating. There are
resources, but there are so many barriers to accessing them.

2176
 Sally

BOX 26-4 What Do You Think?

Street or Shelter? Which Would You Choose?
Many people wonder why so many homeless individuals choose not to use
shelters. Walker (2018) discussed the following reasons why homeless
persons may be reluctant to utilize shelter services: (1) lack of sufficient
beds and overcrowding (many shelters require you to arrive at prescribed
times and to wait in line to secure a space at night; if you have a job, you
cannot always arrive in time, or you may work at night and need a place to
sleep during the day); (2) fear of communicable diseases (e.g., bedbugs
and other contagious diseases); (3) fear of having your belongings stolen;
(4) having to leave your pets behind; (5) fear for one's safety and concerns
regarding being attacked or abused; (6) fears of being proselytized or
coerced to adopt particular faith perspectives; (7) having to be separated
from one's spouse or loved ones, including older male children (who may
not be allowed in a family shelter); and (8) difficulty adhering to sobriety
requirements (for individuals who are active in their addiction).

1. What do you think might be other reasons an individual would

choose to sleep outside rather than in a homeless shelter?
2. How could some of these issues be effectively addressed?
3. How does your city address these issues and the overall problem of
homelessness?
Source: Walker (2018).

Poverty
In 2016 (Semega, Fontenot, & Kollar, 2017):

Nearly 41 million people (or 12.7% of the U.S. population) were living
in poverty.
Eighteen percent of children (under 18 years old) lived in poverty.
Poverty rates were highest among single female heads of household.

Factors impacting poverty include declining wages, loss of jobs that offer
security and carry benefits, an increase in temporary and part-time
employment, erosion of the true value of the minimum wage, a decline in
manufacturing jobs in favor of lower-paying service jobs, globalization and

2177
outsourcing, and a decline in public assistance. As wages drop, the potential
to secure adequate housing wanes (NCH, 2018c, 2019d).
Compounding the problem are a lack of affordable housing (particularly
single-room occupancy [SRO] housing or housing units intended to be
occupied by one person) and limited funding for housing assistance. A
household seeking to afford a two-bedroom rental home in the United States
must earn at least $21.21 per hour. This figure is nearly $14 higher than the
federal minimum wage of $7.25 (NLIHC, 2018). The Raise the Wage Act of
2017 is expected to gradually raise the minimum wage to $15 per hour by
2024 (Economic Policy Institute, 2019).
When rental costs increase and the number of available low-rent units
declines, the housing gap widens. Moreover, federal support for housing
assistance is unable to keep pace with the high demand for housing (NCH,
2018a). As a result, many persons must pay high rents to obtain shelter. This
situation leads to overcrowding and substandard housing. Because the
demand for housing assistance exceeds federal housing assistance resources,
there are often long waiting lists. Waiting lists may close when demand for
housing exceeds the supply of subsidized units available for occupancy
(NCH, 2019c; USDHUD, n.d.).

Lack of Affordable Health Care

In the absence of affordable health care coverage, a serious illness or
disability can lead to job loss, savings depletion, and even eviction. In 2016,
nearly 28 million Americans (9% of the population) were without health care
coverage (Kaiser Family Foundation, 2020).
The Affordable Care Act has expanded Medicaid coverage to millions of
previously uninsured people, reducing the number of uninsured in the United
States from 44 million in 2013 to <28 million in 2016 (Kaiser Family
Foundation, 2019).
The uninsured are less likely to receive preventive care or care for
chronic health conditions. They are more at risk for preventable
hospitalizations and missed diagnoses. Nearly half of all bankruptcies in the
United States are due, in part, to medical debts (Kaiser Family Foundation,
2019). Those who are able to qualify for medical assistance may be reluctant
to seek employment, fearing termination of benefits. Many others have
limited coverage that requires higher co-pays or deductibles and does not
cover major catastrophic illnesses. A catastrophic adverse health event can
plunge one into a homeless condition.

Employment

2178
Low-income wage earners may hold jobs with nonstandard work
arrangements. Temporary employees, day laborers, independent contractors,
and part-time employees are examples of those with work arrangements that
tend to pay lower wages, offer few or no benefits, and have less job security.
For persons with few or no job skills, it is virtually impossible to
compete for jobs that offer a living wage. Barriers to employment among the
homeless include a lack of education or job skills; a lack of transportation,
childcare, or other supportive services; a lack of access to technology; and
disabilities that make it difficult to pursue or retain employment. To
overcome homelessness and maintain employment, one must not only obtain
a job that pays a living wage but also have access to supportive services such
as childcare and transportation (NCH, 2018c).

Domestic Violence
Domestic violence is a major cause of homelessness among women. For
victims of domestic violence, the choice is often between living in an abusive
situation and leaving to face life on the streets. More than one third of
domestic violence survivors report being homeless following separation from
their intimate partners.
Victims of domestic violence are often isolated from social support
networks and financial resources, rendering them especially vulnerable. They
may lack a steady income or a stable employment record and often
experience anxiety, depression, panic disorder, or substance abuse disorders.
A major challenge facing service providers of homeless domestic violence
victims is the need to ensure a safe and secure environment and to protect
client confidentiality (NAEH, 2020b, 2020c).

Mental Illness
Untreated mental illness may precipitate homelessness, and
homelessness is a significant risk factor for poor mental health (Stafford
& Wood, 2017).
Approximately 112,000 homeless persons across the United States
reported a severe mental illness in 2017 (USDHUD, 2017a).
In January 2016, 20% of people experiencing homelessness had a
serious mental illness (Substance Abuse and Mental Health Services
Administration [SAMHSA], 2017a).

Deinstitutionalization (being released from institutions into the

community) has contributed to the number of severely mentally ill persons
represented in the homeless population (Howell, 2017). Some mentally ill
persons self-medicate their disturbing symptoms using street drugs, placing

2179
them at increased risk of addictions and diseases transmitted through
injection drug use. Mental illness and substance abuse are often comorbid
conditions, which, coupled with poor physical health, makes it especially
difficult to secure employment and safe, affordable housing (SAMHSA,
2017a).

Addiction Disorders
Rates of alcohol and drug abuse are disproportionately high among the
homeless. In January 2016, 20% of people experiencing homelessness had a
serious mental illness, and a similar percentage had a chronic substance use
disorder (SAMHSA, 2017a).
For persons already at risk for homelessness, the behaviors associated
with an addictive disorder can create instability and jeopardize family and
employment support nets. Once homeless, persons may resort to drugs or
alcohol to dull the pain of being homeless and ease the feelings of
hopelessness that accompany such a desperate state. They may also turn to
chemical substances to self-medicate the disturbing symptoms of an
untreated mental illness. Fragmentation of services, limited access to care,
lack of transportation, social isolation, and complex treatment needs make it
difficult to receive the services needed to achieve a successful recovery
(NAEH, 2020f).
Many shelters require sobriety to access services. There may be long
waiting lists for addiction treatment, and homeless people who do not have a
phone and are difficult to locate may be dropped from the waiting list. Lack
of transportation and lack of documentation needed to access programs (i.e.,
birth certificates, social security cards) further exacerbate the problem.
Denial of Supplemental Security Income or Social Security Disability
Insurance to persons with substance abuse-related disabilities creates a huge
barrier to achieving recovery support, proper medical care, and housing and
income assistance. Moreover, the federal programs targeting homelessness,
mental health, and addictions services (Box 26-5) lack the funding necessary
to effectively address this problem on a national level.

BOX 26-5 PERSPECTIVES

A C/PHN's Viewpoint on Caring for the Homeless

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I can't believe I am sitting around this table. What am I doing here? How
did I end up on the Board of Directors of an organization that houses one of
the largest residential addiction recovery programs for homeless men in the
country? I have been a public health nurse for years. I know how to take
care of homeless patients. But this is a whole different ball game. I'm
looking at budgets and learning about capital campaigns. I even testified
before a gubernatorial commission to advocate for funding for homeless
services. And now I am chairing a Board level committee that is analyzing
census tract data to determine the impact of its wellness center on public
health. We are looking at emergency department utilization rates and rates
of hospitalization for substance-related illnesses to see if our Wellness
Center has an impact on our clients and the surrounding community. If we
can demonstrate that our programs reduce hospitalizations and emergency
room visits, we may be eligible to apply for population health funding and
to partner with local hospitals in much bigger ways to make a positive
impact in our community. This is exciting stuff!

Stan, C/PHN

Additional Variables
Additional variables impacting homelessness include personal and financial
crises, natural disasters, immigration and refugee crises, and personal choice.
For example, natural disasters or immigration crises may displace previously
independent and self-sufficient individuals and families, rendering many
homeless and in need of emergency shelter. See more on disasters and their
aftermath in Chapter 17.

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Homeless Subpopulations
Although many of the struggles the homeless face are universal, there are
subpopulations within the homeless community that are uniquely vulnerable.
Often, these groups face additional burdens because of their special needs
and challenges.

Homeless Men
Approximately 61% of people experiencing homelessness are men
(USDHUD, 2017b). The majority of homeless men are single adults.
Some men find themselves in a cycle of intermittent homelessness as
they move back and forth between prisons, treatment centers, shelters,
temporary housing, and the streets. Other men are at risk for becoming
chronically homeless. Nearly one quarter of the homeless population in the
United States is chronically homeless (USDHUD, 2017b). A chronically
homeless adult is someone who has been homeless for long periods of time
or has experienced repeated episodes of homelessness.
These individuals have a diagnosed disability such as mental illness,
substance abuse, or a chronic medical condition and have been homeless for
at least a year or have experienced at least four episodes of homelessness in
the past 3 years. In 2017, the Annual Homeless Assessment Report to
Congress recorded nearly 87,000 chronically homeless individuals in its
point-in-time count (an 18% decline since 2010). Nearly 70% of these
individuals were unsheltered (i.e., living on the street or in places not fit for
human habitation; USDHUD, 2017b).
Homeless men are more likely to be treated with disdain than other
homeless subgroups. Some people perceive the homeless male as largely to
blame for his plight, believing that he is able bodied and should be able to
work. Moreover, homeless men may have disabilities that are not severe
enough to warrant eligibility for health and social services. Often health and
social programs give priority to women and children (Myrick, 2016).

Homeless Women
Women, as single parents, lead most homeless families in the United States
(Fig. 26-5). Nearly 80% of sheltered homeless families are led by women
(USDHUD, 2017c). Domestic violence is a major cause of homelessness
among women (USDHHS, 2016).

2182
 FIGURE 26-5 Homeless poor woman and her daughter asking for
help. Most homeless families are headed by single female heads of
household.

Lack of affordable housing forces many women to choose between living

in an abusive home and facing life on the streets. Domestic violence victims
often have poor credit and employment records due to the disruption caused
by family violence. If violence is discovered in the home, landlords may
evict tenants, forcing the family onto the streets (Family & Youth Services
Bureau, 2016). Once on the street, a woman faces the risk of greater abuse.
Moreover, the increased risk for exposure to violence and sexual assault on
the streets increases the risk for sexually transmitted infections and traumatic
injuries.

Homeless Children
In 2017, there were nearly 41,000 unaccompanied homeless children
and youth (those under the age of 25 years) in the United States, of
whom 12% were under the age of 18 years (Fig. 26-6).
One in 20 children under 6 years of age was homeless in 2014 and 2015
(USDHHS, 2017).
From 2007 to 2016, the number of children in families living in poverty
increased by 13% (USDHUD, 2017c).

2183
 FIGURE 26-6 A young homeless boy sleeping on a bridge.

The majority of homeless children and youth live in shelters, share

housing with friends or relatives, or live in motels or campgrounds.
Compared with their housed counterparts, homeless children are more likely
to become ill, go hungry, and experience emotional and behavioral disorders
(Fig. 26-7). They are also more likely to experience developmental delays
and learning disabilities. Children in homeless families are more likely to
experience parental separation, by being placed in either foster care or the
care of friends or relatives. More than 25% of homeless children have
witnessed violent acts (American Institute on Research, 2020; Child Trends
Data Bank, 2015).

FIGURE 26-7 A 3-year-old homeless girl. Homeless children are

more likely to go hungry than their housed counterparts.

Education is compromised when one is homeless. Homeless children are

more than twice as likely to repeat grades in school as other children and

2184
more likely to drop out or be suspended or expelled (Child Trends Data
Bank, 2015; NAEH, 2020a). They are also less likely to graduate from high
school or college than their housed counterparts (Hayes, 2016). Barriers to
education include transportation to and from the shelter, lack of academic
and medical records required for registration, unstable living arrangements
necessitating multiple moves, and urgent needs for food and shelter that take
priority over education (Family & Youth Services Bureau, 2016).
Homeless children are more likely to get sick than other children. Not
only are acute and chronic health problems more severe in homeless
children, but these children are less able to access medical and dental care.
Asthma, hyperactivity/inattention disorders, and behavioral problems are
more prevalent in homeless children than in the general population (Child
Trends Data Bank, 2015).

Homeless Youth
On a single night in January 2016, nearly 36,000 unaccompanied youth were
experiencing homelessness in the United States (USDHUD, 2017c).
Unaccompanied youth are defined as persons under 25 years of age who are
not accompanied by either a parent or guardian and are not themselves a
parent (USDHUD, 2017b).
These youths may have run away from home or been evicted by their
parents. There may be conflicts in the home that make it dangerous for them
to return home. Many have been victims of abuse and have spent time in
foster care. They may be overlooked during homeless counts because they
are often difficult to locate (Child Trends Data Bank, 2015). For more
information on the road to youth homelessness, see Figure 26-8.

2185
FIGURE 26-8 The road to youth homelessness. (Retrieved from
https://nationalhomeless.org/wp-

2186
 content/uploads/2014/12/Infographic1-FINAL.jpg. Used with
permission.)

In a national survey, nearly one third of youth experiencing homelessness

had experiences with the foster care system and nearly half had been
incarcerated or in juvenile detention (Morton, Dworsky, & Samuels, 2017).
Foster care placement is associated with homelessness among youth.
Moreover, some youth who are discharged from residential or foster care
with inadequate housing or income support may find themselves homeless
(Ahmann, 2017).
Homeless adolescents may have difficulty accessing emergency shelter
because of shelter policies that prohibit older youth from the facility or
because of a lack of bed space. Due to lack of education or job training skills,
many resort to prostitution or survival sex (exchanging sex for food, shelter,
or other basic necessities). As a result, homeless youth are at higher risk for
sexually transmitted infections. Homeless youth also suffer
disproportionately from mental health disorders (Cima & Parker, 2017;
NCH, 2019b; Oppong Asante, Meyer-Weitz, & Petersen, 2016).
It is not uncommon for homeless youths to be arrested for running away,
breaking curfews, or being without supervision. As young people age out of
the foster care system, they find themselves on the street with inadequate
support systems and little opportunity for housing or employment (Box 26-6;
Ahmann, 2017).

BOX 26-6 STORIES FROM THE

FIELD
Crisis Shelter Intake of Roberto, a Homeless
Youth
I sat across from Roberto in a darkened, gritty community room at the
homeless teen drop-in center located in an edgy part of downtown. He
had just gone through an hour-plus worth of intake questions from the
shelter staff; he was tired of questions, though grateful to get one-to-one
time with a caring adult and very happy to have food in his belly. The
intake questionnaire painted a picture of how he landed in this shelter as
a 16-year old: a history of being in foster care while in elementary
school; a diagnosis of anxiety disorder; a housing history mostly living
with a loving, single parent who struggled to pay for a place in this
gentrified city; and an academic record moving from school to school
with four siblings whom he cared about a lot. Still, he told the intake

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 workers of wishes and hopes of going to college, continuing with his
love of art, and finding his own housing “to take the burden of having
another kid at home” off his mom.
I ran through his HEADDS assessment screening tool and a brief
PHQ-9 to understand the background and status of his physical and
mental health. Roberto told me about his extended family whom he
loved very much but couldn't live with right now. He liked school and
got decent grades, though he worried about paying for college. He
played soccer as an extracurricular, but rarely stayed at a school long
enough to become a starter on the varsity teams. He stayed away from
drinking and drugs because his father had been a drunk and left the
family while he was young. And despite having an on-again, off-again
girlfriend, says he adheres to his Catholic faith and has never had sex.
On his PHQ-9, he scored “moderate depressive” symptoms and noted
his anxiety has been “pretty high” the past couple weeks, and especially
today being in this new place, not knowing anyone in the shelter. He
repeatedly says “thank you” as staff walk by to welcome him to the
center and shows extreme gratitude to me as we wrap up our discussion.

1. What are some other critical pieces of information would you

like to know about Roberto before you take him back to the
housing staff for case management planning?
2. What 1 to 2 health or social concerns do you want to address
with him right now using motivational interview techniques?
What are Roberto's top health concerns you would like to
include in his case management plan for this shelter stay?

Scott Harpin, PhD, MPH, RN, APHN-BC, FSAHM

Homeless Families
Poverty and the lack of affordable housing place families at risk of becoming
homeless. Declining wages, changes in welfare programs, unstable
employment, domestic violence, and a struggling economy have all
contributed to the rise in family homelessness. Racial disparities and the
challenge of single parenting also contribute to the growing trend in family
homelessness (NAEH, 2020a).
Homelessness often breaks up the family unit. Families may be separated
by shelter policies that prohibit admission to older boys or men. Sometimes,
parents are forced to leave their children with family or friends or to place
them in foster care to shelter them from becoming homeless (Child Trends
Data Bank, 2015; United States Interagency Council on Homelessness,
2018).

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 A child is at greater risk for homelessness if the child's father becomes
injured or ill, experiences a job loss, has a substance abuse issue, or becomes
involved with the criminal justice system. Fifty percent of fathers of
homeless children are unemployed, and 43% have problems with drugs or
alcohol. Homeless children are at a high risk of being placed in foster care,
and a personal history of foster care predicts family homelessness during
adulthood. To assist homeless families, attention must be focused on
promoting affordable housing; supporting education, job training, and
childcare for parents; promoting access to school; expanding violence
prevention and treatment services; and preventing unnecessary separation of
families (American Institute on Research, 2020; Lenz-Rashid, 2017; NCFH,
2014; United States Interagency Council on Homelessness, 2018).

Homeless Veterans
According to the 2017 Annual Assessment Report to Congress, 9% of
homeless adults are veterans (USDHUD, 2017b).
Female homeless veterans represent approximately 9% of the homeless
veteran population (Box 26-7; USDHUD, 2017c).
Homelessness among veterans declined 45% from 2009 to 2017
(USDHUD, 2017b).
In 2009, the U.S. Department of Veterans Affairs established a goal to
end homelessness among veterans by 2015.

BOX 26-7 PERSPECTIVES

A Homeless Female Veteran's Viewpoint

I am a female veteran, recently discharged from active duty service during
which I was deployed to Iraq. I am now homeless. I am one of thousands of
veterans who sleep on the streets of America every night. I did not know
that I was at risk for homelessness when I joined the military; in fact, I
thought a military career or enlistment would help me be successful in life. I
did not know that women veterans are three to four times more likely to
become homeless than nonveteran women. Or, that posttraumatic stress
disorder (PTSD) is twice as likely to be diagnosed in women as in men.
Considering that 14% of all deployed military personnel to Iraq and

2189
Afghanistan are women, I guess I should have known this was a possibility
for me. But I was not prepared for what happened to me.
I am also a victim of sexual trauma, which is a trigger for PTSD, and this
has profoundly impacted my ability to return to a normal life as a veteran.
Now, I never feel safe and I am not able to trust anyone or anything. I
know you look at me and wonder why I am in this position. I am sure that
you don't understand why I do not seem to be able to change my situation.
Believe me, I have tried.

1. What resources are available in the community for homeless female

veterans?
2. Are there barriers to accessing these resources for certain veterans?
3. What are some of the common assumptions and stereotypes
circulating in your community about homeless veterans?
4. What would you want to include in your assessment in order to
identify risks and to implement treatment planning for homeless
veterans like Sarah?

Sarah, a veteran

The U.S. Department of Veterans Affairs administers programs that

provide long-term care, emergency shelter, 2-year transitional housing, group
homes, and work therapy for homeless veterans. These programs provide
case management, residential treatment, and other services to homeless
veterans and improve housing, employment, and access to care for the
homeless veteran population. Unfortunately, the programs are often unable to
keep pace with existing needs (NCH, 2019a; National Coalition for
Homeless Veterans, n.d.).

The Rural Homeless

Because there are fewer shelters in rural areas, homeless persons living in
rural areas are less likely to live in shelters or in the streets and more likely to
live in cars, substandard housing, or “doubled up” with friends and family.
As a result, they may not be considered “homeless” for reporting purposes.
Moreover, the communities in which they live may not be able to access as
much federal funding, because the statistics do not adequately reflect the
magnitude of the problem.
Families with single mothers and children compose the largest segment
of the rural homeless population. Native Americans and migrant workers are
more likely to be among the rural homeless.

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 Like urban homelessness, rural homelessness is largely a result of
poverty and lack of affordable housing. Although housing costs are lower in
rural areas, incomes are also lower (HAC, 2016; 2017; National Advisory
Committee on Rural Health and Human Services, 2014). Homelessness in
rural areas may be precipitated by structural or physical housing problems
that force families to relocate to safer but more expensive housing (Fig. 26-
9). In addition, the lack of job opportunities, the distance between low-
income housing and job sites, the lack of transportation, rising rents,
geographic isolation, and the lack of resources compound the problem. To
address the needs of the rural homeless, the definition of homelessness needs
to be expanded to include people living in temporary or substandard housing
(HAC, 2016, 2017; National Advisory Committee on Rural Health and
Human Services, 2014).

FIGURE 26-9 Rural housing may be structurally unsound or

substandard.

The Older Homeless

Only 4.7% of sheltered homeless individuals were 62 years or older in
2016 (USDHUD, 2017c).
Even so, as the population ages, many more adults are aging into
poverty (Goldberg, Lang, & Barrington, 2016).
Although the percentage of older individuals in shelters is low, it has
increased from 2.9% in 2007 to 4.7% in 2016 (USDHUD, 2017c).
The percentage of individuals aged 51 to 61 years who are housed in
shelters also increased from nearly 14% in 2007 to nearly 18% in 2016
(USDHUD, 2017c).
Some researchers define the “older homeless” as homeless persons 50
years or older because of the declining physical health that accompanies

2191
 street living (NCH, 2012b).

Many older people live on a fixed income. At the same time, housing has
become increasingly more unaffordable. Moreover, the cost of health care
continues to rise, leaving older adults at higher risk of poverty. Their
restricted income renders them more vulnerable to unexpected financial
crisis and even homelessness. The Social Security benefits to which many
are entitled are inadequate to cover housing costs. Moreover, the waiting list
for affordable housing for seniors is often 3 to 5 years (Goldberg et al., 2016;
NCH, 2018b). Isolation also contributes to homelessness. Many older people
live alone and lack a support network.
Homeless adults 50 years and older have health issues similar to those of
housed adults who are 15 to 20 years older. Homeless older adults, compared
with the general population, are more likely to experience difficulty in
activities of daily living at a younger age. Shelter conditions, such as the use
of bunk beds and shared bathing facilities, can also increase the risk of falls
and injury.

Lesbian, Gay, Bisexual, and Transgender Homeless

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) persons often
experience difficulty finding shelters that accept them. They are sometimes
required to identify themselves as a particular gender. Transgender
individuals may be turned away from shelters or subjected to physical,
sexual, or verbal abuse. They are more likely to be victims of violence,
abuse, and exploitation than their gender-conforming peers (NCH, 2018e).
Transgender youth account for 2% of the unaccompanied homeless youth
population (USDHUD, 2017b). LGBTQ youth have a 120% increased risk of
becoming homeless compared with youth who identify as heterosexual or
cisgender (Morton et al., 2017).

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HEALTH CARE AND THE
HOMELESS
Acute and chronic health problems are prevalent among the homeless
population, and they contribute to and result from homelessness. Conditions
such as HIV/AIDS, diabetes, and heart disease are three to six times more
prevalent in the homeless population than among the general population
(NAEH, 2020d). Chronic health conditions require ongoing monitoring and
are often difficult to treat in a population that is transient and lacks stable
housing (NCH, 2018d; NHCHC, 2019).
Persons with HIV/AIDS are at higher risk of homelessness, because
HIV-related illness can impact job stability. Moreover, health care costs
associated with treating the illness can exact an enormous financial burden
on a low-income family. Insufficient funds to adequately house the poor with
HIV/AIDS may also contribute to homelessness among HIV-infected
individuals. Substance abuse and sexual exploitation among the homeless
increases the risk of HIV infection. Moreover, it is difficult to maintain
adherence to complex HIV/AIDS medication regimens without access to
good food, bathrooms, refrigeration, and clean water (Aidala, et al., 2016;
NCH, 2012a).
Poverty, substance abuse, poor nutrition, and coexisting medical and
psychiatric illnesses also predispose the homeless to severe oral health
problems. Persons with poor access to dental treatment and preventive
services have higher rates of oral disease. Poor oral health is also associated
with lower levels of education and income (United States Department of
Health and Human Services, 2019).
It is difficult for the homeless to adhere to complex treatment regimens.
For example, where would a homeless person find a refrigerator to store
insulin? Where would someone keep supplies for dressings? How could
someone with no access to transportation keep regular appointments with
health care providers? How does a homeless person keep track of multiple
appointment dates? How is a shelter resident who receives the typical shelter
diet high in carbohydrates, fats, and sodium to adhere to a low-salt or
diabetic diet?
“Health Care for the Homeless” was a model for homeless health care
developed through a 19-city demonstration project funded by the Robert
Wood Johnson Foundation and the Pew Memorial Trust. In 1987, federal
legislation (the McKinney-Vento Homeless Assistance Act) was passed that
authorized federal funding for these programs. Grants are awarded to

2193
community-based organizations that deliver high-quality health care to
homeless populations. Health Care for the Homeless projects exist across the
nation to provide comprehensive primary care and supportive services,
including substance abuse treatment, to medically underserved populations
(Box 26-8; NHCHC, 2018).

BOX 26-8 Evidence-Based Practice

Impact of Cell Phone Use on Coping and Social
Connectedness Among Homeless Youth
Tyler and Schmitz (2017) examined the impact of cell phone data
collection use on maintaining social connectedness and informational
awareness among homeless youth in two mid-western cities in the
United States. Participants completed a baseline interview and were
then given a disposable cell phone that was activated for 28 to 30 days.
Text questions were sent to them from an automated system.
Participants were asked to respond to the text questions (11 texts per
day) and received cash and/or gift cards for their participation.
A follow-up in person interview was used to assess benefits and cell
phone usage patterns. Data revealed that the youth reported using the
study phones to seek employment and housing and to schedule
appointments. The phones also served as a source of comfort for them,
as they had a lifeline for communicating with others in the event of an
emergency. The cell phones also enhanced the participants' feelings of
independence and autonomy and promoted a greater sense of emotional
and social connectedness. The researchers concluded that cell phone
ownership among homeless youth can promote positive mental health,
improve coping skills, strengthen social support systems, and promote
access to vital resources.

1. What creative outreach approaches might the community health

nurse (CHN) develop to improve coping skills, enhance
communication and connectedness, and promote greater access
to resources for the homeless?
2. What new technologies or communication devices might be used
to enhance outreach efforts?
3. How can creative approaches be used to improve, not only health
care delivery, but the delivery of other supportive services?
4. How might the CHN use research evidence to make a case for
funding technologies that enhance communication and service
delivery in the homeless population?
Source: Tyler and Schmitz (2017).

2194
RESOURCES TO COMBAT
HOMELESSNESS
Both public and private sectors have promoted a variety of initiatives to
address the problem of homelessness. These initiatives are intended to
impact homelessness on the local, state, and national levels and to ensure a
coordinated, comprehensive, and systematic approach to addressing the
problem of homelessness.

2195
Public Sector
The McKinney-Vento Homeless Assistance Act (PL100-77) was the first and
only major piece of federal legislation intended to address the problem of
homelessness on a national level. This landmark legislation Act, passed by
Congress in 1987, originally consisted of 15 programs to address the major,
pressing needs of the homeless. These needs included emergency shelter,
transitional and permanent housing, job training, primary health care,
education, and housing (NCH, 2006; NLIHC, 2019).
The current Act has been amended over the years to expand its scope and
strengthen its impact. In particular, the amendments made to the Act in 1990
represented significant milestones in advocating for the needs of the
homeless. These amendments included the creation of the Shelter Care Plus
program, which provided for housing assistance for persons with disabilities,
mental illness, AIDS, and drug and alcohol addiction. Another amendment
created a demonstration program within the Health Care for the Homeless
program to provide primary care and outreach to at-risk and homeless
children. In addition, the Community Mental Health Services Program was
amended and retitled: the Projects for Assistance in Transition from
Homelessness.
Finally, the amendments made in 1990 strengthened access to public
education for homeless children and youth. The McKinney-Vento Act
authorized the U.S. Department of Education to administer the Education for
Homeless Children and Youth program, which provides grants to schools to
assist in identifying children who are homeless and to provide services to
help them succeed in school (NLIHC, 2019). States are required to provide
grant funding to local educational institutions to insure access to a free,
appropriate education for homeless youth and children (NCH, 2006; NLIHC,
2019).
Over the years, Congress has appropriated funding to enable
implementation of this federal legislation. The extent of federal funding has
fluctuated over the years. Moreover, rising rental housing costs limit the
impact of these limited resources. Although homeless advocates
acknowledge that the Act was an important step in addressing homelessness,
the lack of adequate funding over recent years threatens its impact on a
national level (NLIHC, 2019).
The USDHUD oversees a number of programs established in the
McKinney-Vento Act that provide rental, homeownership, and supportive
housing for older, low-income, and disabled persons. The Department also
manages grants for community development initiatives and helps to
strengthen the housing market (NLIHC, 2019).

2196
 In many communities, this housing assistance is based on a continuum
of care model, in which programs are developed to assist persons to
transition from emergency to transitional to permanent housing. Emergency
shelters provide temporary overnight shelter, whereas transitional housing
provides up to 24 months of housing and supportive services. Rapid
rehousing programs provide short-term rental assistance and supportive
services, whereas permanent housing provides long-term housing and
supportive services (NAEH, 2020h).
In recent years, a Housing First philosophy has guided much of the
publicly funded housing initiatives. In a Housing First approach, housing is
viewed as an immediate priority. The goal of Housing First is to end
homelessness by providing stable, permanent housing as soon as possible
and to provide supportive services to enable people to maintain their housing.
Housing or supportive services are not contingent upon adherence to rigid
rules or policies or to the maintenance of sobriety (NAEH, 2020h). See Box
26-2 on tent cities and successful approaches to Housing First.
The Homeless Emergency Assistance and Rapid Transition to Housing
(HEARTH) Act of 2009 increased funding for McKinney-Vento programs
that provide emergency, transitional, and permanent housing and supportive
services to the homeless and resources to local school districts to coordinate
services for homeless children (NCFH, 2014). The HEARTH Act also
consolidated homeless programs at USDHUD and made the homeless
assistance system more performance based (NLIHC, 2019).
On March 23, 2010, President Barak Obama signed into law the
Affordable Care Act, federal legislation that extends health insurance
coverage and gives states the option to expand Medicaid coverage to low-
income individuals regardless of disability or family status. This landmark
legislation enabled homeless individuals in many states to secure health care
coverage (NAEH, 2020g). See Chapter 6.
Another significant milestone in federal initiatives to reduce
homelessness occurred in 2001 when the federal government adopted the
goal of ending chronic homelessness in 10 years. To meet this goal, annual
funding was appropriated to create new permanent supportive housing. These
resources helped to stimulate the production of housing. Many communities
followed the lead of the federal government and developed their own 10-year
plans (Burt, 2006; McEvers, 2016).
In 2010, the U.S. Interagency Council on Homelessness published the
nation's first comprehensive federal strategic plan to prevent and end
homelessness. The document, entitled “Opening Doors,” outlined a
comprehensive and ambitious plan aimed at eliminating homelessness on a
national level. The goals of the plan included ending chronic homelessness in
10 years, preventing and ending homelessness for families, youth, and

2197
children in 10 years, preventing and ending homelessness among veterans in
5 years, and establishing a path to end all types of homelessness (USICH,
2015). This plan was updated and amended in 2012 and 2015. Progress
reports on the plan attest to the effectiveness of this federal, coordinated
initiative in reducing homelessness across the nation (USICH, 2017). Table
26-1 summarizes the nine titles of the McKinney-Vento Act. Table 26-2
presents selected federally sponsored programs for addressing the needs of
the homeless.

TABLE 26-1 McKinney-Vento Homeless Assistance Act Titles

I to IX

Source: National Association for Education of Homeless and Youth (2018); National Coalition for the
Homeless (2006).

TABLE 26-2 Federally Sponsored Programs for the Homeless

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Source: NHCHC (2018); SAMHSA (n.d.a, n.d.b, 2016, 2017a, 2017b).

2199
Private Sector
The private sector has made a concerted effort to organize communities in
the battle against homelessness by forming coalitions, alliances, and
memberships that champion the causes of the homeless. These organized
efforts are carried out at the national, state, and local levels to positively
impact the problem of homelessness in communities across the nation. Table
26-3 presents a list and descriptions of selected resources in the private sector
to combat homelessness.

TABLE 26-3 Private Sector Initiatives to Combat

Homelessness

2200
ROLE OF THE C/PHN
C/PHNs maintain a long tradition of providing care to vulnerable populations
and play a vital role in addressing the health needs of the homeless. Settings
for care include shelters, clinics, soup kitchens, churches, community
centers, social service agencies, and even the streets.
Trust is an essential ingredient in the development of a therapeutic
relationship with the homeless. However, it is sometimes difficult to establish
trust with clients who have experienced negative encounters with the health
care system. Often these negative perceptions are intensified by limited
resources, inadequate access to care, or prejudicial views. As with other
vulnerable populations, the homeless struggle with feelings of powerlessness,
loss of control, and low self-esteem.
This lack of trust and self-esteem among the homeless often comes from
experiencing disproportionately harsh consequences for violating the law.
Behaviors that would ordinarily be considered lawful in the privacy of one's
home become criminal activity when they are exhibited in public. For
example, the homeless can be arrested for loitering, sleeping, urinating, or
drinking alcohol in public. These behaviors can trigger a criminal record,
thereby jeopardizing future employment or housing opportunities. Moreover,
parents can be incarcerated for failing to pay child support (National
Conference of State Legislators, 2018). Consider a man who is laid off from
a low-wage job. He is unable to pay child support and is arrested. His
violation generates a criminal record and compromises his ability to secure
employment in the future. He becomes trapped in a cycle of poverty and
homelessness that is difficult to escape.
To effectively address the multifaceted problems associated with
homelessness, a comprehensive and holistic approach is needed (Boxes 26-9,
26-10, 26-11). As such, the CHN is responsible for implementing primary,
secondary, and tertiary preventive measures to prevent homelessness or to
assist those who are homeless to obtain needed services (Box 26-12).

BOX 26-9 QSEN: Focus on Quality

Quality Improvement for Homeless Populations
Quality Improvement: Use data to monitor the outcomes of care processes
and use improvement methods to design and test changes to continuously
improve the quality and safety of health care systems (Cronenwett et al.,
2007, p. 123).

2201
(See https://qsen.org/competencies/pre-licensure-ksas/#quality_improvement
for the definition and knowledge, skills, and attitudes associated with this
QSEN competency.)
It is likely that you evaluate the quality of the care given to your patients
in the acute care setting every day you are in a patient care environment.
Biomarkers such as improvements in blood pressure and hemoglobin A1C
levels, reduction in pain, or changes in function such as improvement in
activities of daily living may serve as indicators of success when measuring
the effectiveness of one's nursing interventions. But how is success measured
when one is caring for large and diverse population groups such as the
homeless?
To measure change in this context, one must first define what is meant by
“success.” For example, what are the markers for success when working with
a population of homeless teen mothers? What about a population of homeless
men with decade long histories of active addiction? Literature reviews,
surveys, or focus groups may help point to measures of success. Interviews
with key stakeholders also provide insight as to the most important measures
for evaluating program effectiveness in a population.
Lashley (2018) examined the impact of length of stay among homeless
men in recovery from chemical addiction in a faith-based recovery program
on four quality of life indicators. A time series design was used to measure
changes at program admission and at 3-, 6-, and 9-month intervals. Nicotine
dependence, self-esteem, depression, and physical activity were evaluated at
distinct times throughout the 1-year program to determine whether length of
stay in the program impacted these measures. Each variable was measured
using standardized instruments. The researcher found that self-esteem,
depression, and physical activity all improved over time. Nicotine
dependence scores also declined but not at a rate that was statistically
significant. The author concluded that time spent in this recovery program
had a significant impact on three of the four quality of life indicators.

1. What outcomes do you believe are most important to track when

caring for homeless populations?
2. How might you engage a target population to actively participate in
the evaluation process?
Source: Cronenwett et al. (2007); Lashley (2018).

BOX 26-10 What Do You Think?

2202
Reflecting on Personal Beliefs and Values About
Homelessness
Every nurse encounters new situations with prior assumptions, biases, and
preunderstandings. When considering work with the homeless, it is
important to clarify one's own beliefs and values about poverty,
homelessness, addictions, and mental disorders.

1. What has been your experience with the homeless?

2. Have you ever observed a homeless individual asking for money or
holding up signs at a busy intersection?
3. What thoughts and feelings do encounters such as these provoke?

It may be helpful to interview people who work with the homeless or

to visit clinics, shelters, or other settings where the homeless congregate or
access services.

1. How are homeless people treated?

2. What is a typical day like for someone who is homeless?
3. How often do homeless persons hear their names?
4. How often are they touched in a way that is therapeutic, respectful,
and affirming?

By reflecting on your personal values and by allowing yourself to get

closer to the people and places that are a part of the experience of
homelessness, you will gain a deeper understanding of the homeless
condition and be better equipped to serve those suffering from
homelessness.

BOX 26-11 PERSPECTIVES

A Nurse's Viewpoint on Working With the

Homeless
When I first decided to visit the homeless men's shelter, I was scared to
death. Here I was, a veteran nurse with over 20 years of experience, but I
was afraid. But, I thought to myself—afraid of what? I couldn't tell you. I

2203
suppose I harbored the stereotypes that most of us associate with homeless
addicts. I remember passing this shelter years ago, looking out at the men
hanging out on the street corner, and thinking to myself “Please God, don't
let my car break down!” I remember thinking, “I would never step foot in a
place like that.”
Well, I believe God has a sense of humor. He was equipping me for work I
could not have ever imagined. My views about homelessness were
challenged to the core when I peered into the faces of those men, heard their
stories, and began to feel their pain. Theirs were stories of broken lives and
lost hope but also of courage in the face of suffering and the will to survive
in the midst of great adversity. These men were as diverse as their stories.
They were from all walks of life. They possessed incredible gifts and
talents. They were musicians, artisans, businessmen, writers, and poets.
So here I am. Doing what I can to bring hope and healing. The irony is I
came to bring hope and yet I am the one who is being healed. Healed in the
broken areas of my life. I am so grateful to God for giving me this unique
opportunity. It is a great privilege to serve these men.

Rita, C/PHN

BOX 26-12 C/PHN USE OF THE

NURSING PROCESS
An On-Site Nursing Clinic for Homeless Women
and Children
Sheila Hendricks, a public health nurse for the Manchester City Health
Department, and her colleagues were brainstorming ideas for how to reach
the growing population of homeless women and children in their
jurisdiction. They arranged a meeting with the director of a local rescue
mission in the area. The mission provided emergency shelter to 100
homeless women and children each night. The community health nurses
negotiated with the rescue mission to establish an on-site nursing clinic
twice a week that would provide health education, screenings, and referrals
on a drop-in basis.

Assessment
After the clinic was in operation for 2 weeks, Sheila identified poor
nutrition, lack of primary care services, depression, high rates of sexually
transmitted infections, and addictions as priority health issues in the
population.

2204
Plan
Problem statement (in order of priority):

Client does not have access to health and social services due to
transportation, no insurance and comunity resources.
Family difficulties with coping from addition, mental health, intimate
partner violence, and hazards associated with street living.
Client has not meet nutritional requirements due to addiction, chronic
health issues, and limited resources for nutritional foods.

GOAL: To promote access to care by linking clients to essential health and

social services
RATIONALE: If clients are able to access needed services, the other
diagnoses can potentially be addressed (i.e., need for counseling, health
care, housing, education).

Implementation
Primary care services provided by nurse practitioner at the shelter
HCH Clinic referrals made for more extensive follow-up
Social worker engaged to assist clients in applying for housing and
public assistance
Referrals to local community mental health center for counseling
Nurse-led health education and counseling sessions and on-site
screenings with referrals to health department clinic as needed

Evaluation
90 days after the clinic had been in operation:

65 women and 28 children had frequented the clinic over the past 3
months. All 65 women received health promotion teaching and a
resource packet for further reference.
80% of clients who required referrals to outside agencies were
successful in accessing care.
25 women and 15 children were under the care of the nurse
practitioner for acute or chronic health conditions.
10 cases of latent tuberculosis (TB) infection identified through TB
testing with referrals to the City Health Department TB clinic for
follow-up treatment.
7 abnormal PAP smears identified, and 8 clients diagnosed with
sexually transmitted infections.
15 clients diagnosed HIV positive. 15 referrals to City Health
Department or the local Health Care for the Homeless Clinic for

2205
treatment.
40 women applied for social service benefits. Awaiting receipt of
benefits.

2206
Primary Prevention
Primary prevention includes advocating for affordable housing, employment
opportunities, and better access to health care to prevent the downward spiral
into homelessness. Strategies for preventing homelessness may include
financial counseling to assist clients to better manage their money, assistance
in locating sources of legal or financial aid to prevent eviction (i.e., loans or
grants for emergency funds to help pay for rent, utilities), or assistance in
accessing social services, temporary housing, or health care to avoid a
housing, health, or family crisis (Anderson & McFarlane, 2018).
Health education that addresses primary prevention may focus on
positive parenting skills, violence prevention, anger management, coping
skills, healthy eating, or principles of basic hygiene. Immunization programs
can help to prevent communicable disease in this high-risk population.
Counseling victims of intimate partner violence and helping them to locate
safe shelter can also aid in the prevention of homelessness (Anderson &
McFarlane, 2018). Addiction treatment is also important to prevent the likely
consequences of untreated addiction: death, incarceration,
institutionalization, or homelessness.

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Secondary Prevention
The focus of secondary prevention measures is on the early detection and
treatment of adverse health conditions. This requires a thorough assessment
of client needs, including the need for housing, health care, education, social
services, and employment (Box 26-13). Clients also benefit from secondary
prevention measures such as screening for communicable and chronic
diseases (i.e., hepatitis, tuberculosis, sexually transmitted infection, HIV,
hypertension, diabetes, cancer).

BOX 26-13 PERSPECTIVES

A C/PHN's Holistic Approach to Homelessness

I got a referral from our communicable disease coordinator regarding a
homeless client with a lesion on his lower leg (wound botulism). I quickly
learned that he had a long history of drug abuse, suicide attempts (13
known), and repeated hospitalizations for this wound. He was discharged
from the hospital each time because he had no insurance, and he was also
misdiagnosed.
I finally located him living on a friend's property in a disheveled travel
trailer with a leaky roof and broken windows. It was a rainy week; during
the winter months, and he and his small dog were trying to keep warm and
dry. He used the oven for heat and a nearby field as his bathroom. His only
relatives lived out of state, and he dumpster dived for food. He ate food
from expired cans, when he could find them. He knew about the local food
lunch program and health care at our county clinic, but he was seldom able
to utilize these services, because of lack of transportation and difficulties
with ambulation related to his leg wound.
As a C/PHN, your view of the patient is holistic and goes beyond the
diagnosis. My C/PHN partner and I did the following:

Reviewed his wound care.

Assisted him in getting his medication, with money from the local
Coordinating Council and Ministerial Association.
Referred his case to two churches who provided him with assistance
from their food pantries and a Pizza Hut gift card for his birthday (to

2208
 cheer him up).
Obtained tarps for his trailer, and a sleeping bag from a local service
group.
Assisted him with a disability application.
Connected him to a mobile mental health unit and; updated his
immunizations.
We arranged for transport to another hospital for treatment, as the
patient refused to go back to the original hospital that had
misdiagnosed him and kept discharging him.

I remember that, after I graduated with my BSN, someone asked me

why I was leaving the recovery room to go into public health nursing. At
that time, I told the person “I didn't want my varicose veins popping out of
my support hose before I retired.” But, I love public health nursing and am
so glad that I made this choice. And, as I am planning my retirement, I can
truly say, “It's been quite a ride”!

Susan, a District C/PHN

Barriers to accessing services and the extent of community resources

available to the homeless also need to be assessed (Anderson & McFarlane,
2018). Resources such as shelters, soup kitchens, medical clinics, social
service agencies, and supportive housing should be readily accessible to the
homeless population. Providers servicing homeless populations should be
educated in trauma-informed care, a homeless service delivery model that
recognizes the traumatic experiences associated with homelessness and the
traumatic events that led to living on the streets. Strength-based interventions
and skill building are used to assist homeless clients in regaining control of
their lives (Davies & Allen, 2017).
Lack of transportation can be a major barrier to accessing care. Some
programs have responded to this need by adopting mobile health vans that
provide care on street corners and in neighborhoods (Yu, Hill, Ricks, Bennett
& Oriol, 2017). Clinics have also been established in shelters to facilitate
client access (Chatterjee et al., 2017). These clinics are often managed by
nurses. Nurse-run community-based clinics are an effective means of
promoting optimum care among disenfranchised populations (Randall,
Crawford, Currie, River & Betihavas, 2017). Nursing students also play an
important role in promoting access to care for the homeless.
The CHN should also consider the role of faith-based communities in
providing physical and spiritual support to the homeless. Many places of
worship have responded to the crisis of homelessness by offering food,
shelter, counseling, medical care, and social services within the context of

2209
the faith community. Clinics have been built within faith communities to
promote access to care (Box 26-14).

BOX 26-14 STORIES FROM THE

FIELD
Faith-Based Outreach
As a faith community nurse working in a large church congregation,
you are invited to develop an outreach program to minister to the needs
of an inner-city mission that is receiving financial support from the
church. Approximately 500 homeless men in recovery from chemical
addictions frequent the mission daily. Staff and residents have expressed
concerns regarding a recent outbreak of boils among residents.
Assessment data reveal the following issues:

Approximately 80% of clients have a history of injection drug use.

Clients sleep in dormitory-style accommodations and share
bathroom facilities.
An on-site barbershop operated by the residents provides haircuts
for a nominal fee.
Clients have access to a small recreational area with donated
exercise equipment.
Laundry is typically washed in cold water, and at times the laundry
runs out of detergent.

Consider the following questions:

1. What additional data would you wish to gather to address the

outbreak of boils at the shelter? How would you collect these
data?
2. What host, agent, and environmental factors may have
contributed to the outbreak of boils?
3. Discuss appropriate nursing interventions to address the
outbreak. Consider the following levels of prevention: primary,
secondary, and tertiary.
4. What advocacy role might the community health nurse play in
addressing this issue?

2210
Tertiary Prevention
Tertiary preventive measures attempt to limit disability and to restore
maximum functioning. The goal is to provide rehabilitative care and support
to clients who are already experiencing the consequences of homelessness.
Often, homeless individuals have chronic health conditions that have gone
untreated for long periods of time. This neglect in attending to health needs
results in significant disease morbidity. Treating complications of advanced
disease, providing rehabilitative and respite care, and offering counseling and
support are important tertiary preventive strategies.

2211
Case Management
At each level of prevention, the C/PHN functions as a case manager and
coordinator of care to ensure seamless delivery of services as people
transition from one level of care to another. It is often difficult for the
homeless to keep track of multiple appointments, negotiate the bureaucracy
of multiple agencies and services, and maintain communication with
providers through follow-up phone calls, letters, or visits. With no permanent
address or phone, homeless clients encounter obstacles to adhering to
recommendations to follow up on test results or to notify their provider if
symptoms persist or worsen. The C/PHN can help to bridge these gaps in
service delivery and promote more effective adherence to therapeutic
regimens.

2212
Advocacy
Advocacy is a vital dimension of the C/PHN's role in working with the
homeless. Advocacy entails working with different sectors of the community
to develop innovative models for responding to the crisis of homelessness.
Advocacy creates the broader system-wide changes needed to end
homelessness (NCH, 2019e). The C/PHN acts as an advocate at each level of
prevention to effect positive change (Box 26-15). For example, the nurse
may advocate for mental health and substance abuse services to promote
mental health and prevent homelessness (primary prevention). Alternatively,
he or she may advocate for legislation to fund supportive housing, health
care, or social services to benefit the homeless chronically mentally ill
(tertiary prevention). The C/PHN can also assume an advocacy role by
becoming involved in local, state, or national coalitions or organizations
devoted to protecting the rights of the homeless or by speaking out on
legislation that impacts the homeless (NCH, 2019e; NLIHC, 2019).

BOX 26-15 Levels Of Prevention Pyramid

Preventing Illness Among Homeless Male
Addicts
SITUATION: Promoting health and preventing illness among homeless
male addicts
GOAL: To apply the three levels of prevention to avoid adverse health
conditions, promptly diagnose and treat disorders, and assist the homeless
male addict population to maintain or regain optimal health
Tertiary Prevention
Provide case management of chronic health conditions.
Advocate for expansion of counseling, rehabilitative services, and
addictions treatment programs for the homeless.
Advocate for supportive and transitional housing to enable homeless
residents with addiction disorders to successfully transition back into
the community.

Secondary Prevention
Conduct mass screenings for diseases commonly found in homeless
male population (tuberculosis, HIV, hepatitis, prostate cancer,
colorectal cancer).

2213
Develop programs for health screening and early diagnosis and
treatment in the community that are culturally sensitive and
accessible to the homeless (i.e., mobile vans, faith community, or
shelter-based clinics).

2214
SUMMARY
A homeless person is one who lacks a fixed, regular, adequate nightly
residence; this definition includes as homeless those who stay in
supervised public or private shelters that provide temporary
accommodations.
Although accurately estimating the number of homeless in the United
States is challenging, a count performed on one night in 2017 indicated
that there were 553,742 sheltered and unsheltered homeless people
across the nation.
Poverty, a lack of affordable health care, low-income and low-benefit
employment, domestic violence, mental illness, addictions, personal and
financial crisis, natural disasters, immigrant and refugee status, and
personal choice are factors that may predispose persons to
homelessness.
Each subpopulation within the homeless community faces its own
unique challenges with homelessness, including men, women, children,
youth, families, veterans, rural homeless, older persons, and LGTB
persons.
Acute and chronic health problems plague the homeless and are difficult
to treat because of the challenges associated with being homeless.
Both the public and private sectors have launched concerted efforts to
combat the problem of homelessness through the passage of federal
legislation and through the formation of national, state, and local
coalitions and alliances to champion the cause of the homeless.
The C/PHN delivers primary, secondary, and tertiary preventive
measures to prevent homelessness or to assist those who are homeless to
obtain needed services.
The C/PHN serves as a case manager to coordinate care and to assist
clients to negotiate the bureaucracy of multiple agencies and services.
The C/PHN acts as an advocate to promote the rights of the homeless
and to speak out on legislation impacting homelessness.

2215
ACTIVE LEARNING EXERCISES
1. Reflect in writing on the meaning of “home.” Share your reflections
with classmates either face to face or online. How similar are your
responses?
2. Interview a homeless person regarding the most difficult choices he or
she has had to make. What were the conditions surrounding these
choices?
3. Volunteer to work at a soup kitchen or homeless shelter. Observe
carefully the faces, sounds, attitudes, and activities. What is it like
there? What would it be like to receive rather than give service?
4. Using “Assess and Monitor Population Health” (1 of the 10 essential
public health services; see Box 2-2 ), analyze online census data to
determine the rates of homelessness in your county, state, or region.
How many people are homeless? What is the age and gender
distribution? What policies exist to address the issue of homelessness
in your community? Consider how you might address these issues in
a letter or visit to your local city, county, or state legislator.
5. Perform a windshield survey in a low-income community. What
resources are lacking? Where is the nearest bank, school, grocery
store, or health clinic? What are the conditions of the roads, homes,
and other buildings? How do you feel as you drive through the
community? What do you think it would be like to live there?

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2216
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http://portal.hud.gov/hudportal/HUD?
src=/program_offices/public_indian_housing/programs/hcv/about/fact_sheet
United States Department of Housing and Urban Development. (2017a).
HUD 2017 Continuum of care homeless assistance programs homeless
populations and subpopulations. Retrieved from
https://www.hudexchange.info/resource/reportmanagement/published/CoC_P
opSub_NatlTerrDC_2017.pdf
United States Department of Housing and Urban Development. (2017b). The
2017 annual homeless assessment report (AHAR) to Congress. Retrieved
from https://files.hudexchange.info/resources/documents/2017-AHAR-Part-
1.pdf
United States Department of Housing and Urban Development. (2017c). The
2016 Annual Homeless Assessment Report (AHAR) to Congress. Retrieved
from https://www.hudexchange.info/resources/documents/2016-AHAR-Part-
2.pdf
United States Interagency Council on Homelessness. (2017). Fiscal Year
2017 performance and accountability report. Retrieved from
https://www.usich.gov/resources/uploads/asset_library/FY2017_USICH_PA
R_FINAL.pdf
United States Interagency Council on Homelessness. (2018). Homeless in
America: Focus on Families with Children. Retrieved from

2222
https://www.usich.gov/resources/uploads/asset_library/Homeslessness_in_A
merica_Families_with_Children.pdf
United States Interagency Council on Homelessness. (2015). Opening doors:
Federal strategic plan to prevent and end homelessness. Retrieved from
https://www.usich.gov/resources/uploads/asset_library/USICH_OpeningDoo
rs_Amendment2015_FINAL.pdf
Yu, S., Hill, C., Ricks, M, Bennett, J., & Oriol, N. (2017). The scope and
impact of mobile health clinics in the United States: A literature review.
International Journal of Equity and Health, 16, 178. doi:10.1186/s12939-
017-0671-2
Walker, C. (2018). Why so many homeless refuse to stay in overnight
shelters. Retrieved from https://www.westword.com/news/reasons-why-
denvers-homeless-sleep-outside-and-not-in-overnight-shelters-10987893
Zobel, S. (2016). LA family housing supports single fathers with children.
Substance Abuse and Mental Health Services Administration. Retrieved from
https://www.samhsa.gov/homelessness-programs-resources/hpr-
resources/single-fathers-children-shelters

2223
2224
CHAPTER 27
Rural, Migrant, and Urban Communities
“No city should be too large for a man to walk out of in a morning.”

—Cyril Connolly (1903–1974), British Critic

“Globalization is exposing new fault lines—between urban and rural communities, for example.”

—Ban Ki-moon, United Nations Secretary General

KEY TERMS
Built environment
Critical access hospitals (CAHs) Federally qualified health centers Frontier
area
Health professional shortage areas (HPSAs) In-migration
Medically underserved areas Medically underserved population Migrant
farmworkers
Migrant streams
Nomadic migrant workers
Out-migration
Population density
Rural
Rural health clinics
Seasonal farmworkers
Sustainable communities
Urban
Urban health
Urbanized area
Urban planning
Urban sprawl

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Define the terms rural, frontier, migrant, and urban.
2. Discuss the population characteristics of rural residents.
3. Describe five barriers to health care access for rural clients.
4. Describe the lifestyle of migrant farm workers and their families.

2225
 5. Identify at least three health problems common to migrant workers and
their families.
6. Discuss barriers and challenges to migrant health care.
7. Identify common health disparities found among rural and urban
populations.
8. Propose intervention strategies at the aggregate or community level to
assure a healthier built environment in both rural and urban areas.
9. Explain the concept of social justice and how it relates to public health
nursing in rural and urban areas.
10. Compare and contrast the challenges and opportunities related to rural
and urban community health nursing practice.

2226
INTRODUCTION
As a community/public health nurse (C/PHN), I enjoyed making home visits
to see Alison. She was quiet at first, but slowly she would open up about
herself when she knew I was there to help her and not judge. Alison lived in
a small duplex in a big city in California surrounded by dense housing, a
busy street that never slept, and constant noise—babies crying, sirens, and
people's voices. She was used to the noises now, but it wasn't always that
way, she said. Over 60 years ago, Alison moved here as a young bride of 20;
the city provided opportunity for her and her husband to find work and raise
a family. Many young families had moved there from the country. It was full
of people even then, though not nearly the population it was when I spoke
with her. Alison and her husband Jim moved from one of the rural
communities further south. They left their families to start their own with
hopes and dreams. Alison sighed as she shared stories of her childhood,
staring off into the distance as she remembered the time her sister almost
died because the family had to drive 90 minutes to a hospital as none existed
in their small community. Although Alison said she missed the slow pace of
a small community, she stated she might not have advanced her education
had she not had access to a college in the big city.
Alison's story illustrates how different rural and urban life can be. About
half of the population live in what is known as the suburbs, but the remainder
live in one of two diametrically opposed areas: rural or urban (Fig. 27-1).
There is a good chance that many of you reading this book live either in very
densely populated, bustling urban areas or in sparsely populated, somewhat
isolated rural areas. Public health nursing in urban and rural areas requires
not only general public health nursing knowledge and skills but also a unique
understanding of how these distinctive environments affect the health of the
populations living there. Where you live can and does markedly affect your
health outcomes, with rural and urban areas having distinctive problems and
issues.

2227
 FIGURE 27-1 The Denver Tech Center skyline.

Rural nursing practice offers many opportunities. Nurses are respected

community members—their judgment and opinions count. Rural nurses are
key members of the health care team. They can make a difference in the lives
of their neighbors, friends, and community. Rural C/PHNs often struggle
with helping clients gain access to quality health care and the inherent
transportation problems found in isolated areas. The challenges are many, but
the rewards are great.
Urban C/PHNs often specialize in particular areas of interest. They deal
with different types of problems, such as homelessness, overcrowding,
bioterrorism threats, and violent crime. They are often called upon to
advocate for their most vulnerable clients, and they develop collaborative
relationships with other professionals. Urban community health nursing can
also be very rewarding and satisfying.
An aggregate at risk, migrant workers suffer higher frequency of illness,
greater complications, and more long-term debilitating effects. Exacerbated
by a magnitude of environmental and work stressors, the health of migrant
families is also compromised by limited access to health care, mobility,
language and cultural barriers, low educational levels, and few economic and
political resources. Because migrant health needs are largely manageable
within community settings, C/PHNs are ideal health providers. C/PHNs must
advocate for the health of migrant workers, who have very little economic or
political power, and also guide them through the complexities of a changing
health care system.
This chapter addresses the special health needs and concerns of rural,
migrant, and urban clients and the ways in which a community health nurse
can address those needs. After reading the chapter, you may come to
appreciate the many advantages that rural nurses enjoy and consider rural
nursing as a practice choice or you may find that being a C/PHN in an urban
area offers you more opportunities for specialization and networking. Either

2228
way, your contributions can improve the health of populations living at both
extremes.

2229
DEFINITIONS AND
DEMOGRAPHICS
Definitions
The U.S. government provides several definitions of rural. It is important to
understand the terms and how they are used in federal programs and grant
funding. The U.S. Department of Agriculture (USDA) (2020) rural–urban
continuum examines metropolitan and nonmetropolitan areas on the basis of
counties, and this provides different data apart from census reports (U.S.
Census Bureau, 2016a). Nonmetropolitan areas have some type of
combination that includes “open countryside,” rural towns (<2,500 people),
and urban areas (2,500 to 49,999 people; Fig. 27-2). State and federal
agencies recognize county-level jurisdictions and governments and depend
upon employment, income, and population data that are available on an
annual basis. Many states have offices of rural health or other agencies
dealing with issues specific to rural populations.

FIGURE 27-2 2013 urban–rural classification schemes for

counties, 2017. (Reprinted from Centers for Disease Control and
Prevention, National Center for Health Statistics. (2020). Retrieved
from https://www.cdc.gov/nchs/images/popbridge/URv3.png)

2230
For the purposes of this chapter, rural is defined as communities with
fewer than 10,000 residents and a county population density of <1,000
persons per square mile. This definition of rural is arbitrary because
rural clients do not merely consider population density or community
size when defining their ruralness.
They have a multitude of reasons for defining their community as rural,
such as distance from a large city, major occupations in the area (e.g.,
agriculture), or number of students in the local schools. If you have
access to a small community, ask some of the residents the reasons why
they consider their community to be urban or rural (USDA, 2019a; Fig.
27-3).
The term frontier area is used to designate sparsely populated rural
places that are isolated from population centers and services, but
specific definitions vary (Rural Health Information Hub [RHIH],
2018a). A common definition of a “frontier and remote area” (FAR) is
one with six or fewer persons per square mile, but others include not
only population density but also distance and travel time to market
service areas.
For instance, 60 miles or 60 minutes of driving on paved roads to the
nearest 75-bed (or greater) hospitals could constitute a frontier area. The
USDA (2019b) has developed FAR codes, based upon urban–rural
census data and delineated by ZIP codes.
There are four levels of FAR codes; level one includes a good number
of people living far from city areas where higher-level goods are
available (e.g., regional airport hubs, stores with major household
appliances, advanced medical care), whereas level four includes fewer
people with a more significant level of remoteness (e.g., decreased
access to stores selling gas or groceries, or basic medical care).
The other two levels may also have access to movie theaters, car
dealerships, and clothing stores. This is helpful to researchers and public
health agencies in determining rural–urban status and designing
programs to meet specific needs. Rural–urban commuting area (U.S.
Census Bureau, 2019) is also used to designate remote areas (RHIH,
2020a).
It is estimated that 3 million people (4% of population) live in frontier
areas that comprise 56% of the U.S. land areas. States with more than
10% of their population in a frontier area include Idaho, Nebraska,
Maine, Arkansas, Oklahoma, Alaska, Arizona, Montana, Wyoming,
New Mexico, Colorado, North Dakota, and South Dakota (National
Center for Frontier Communities, 2019).

2231
 FIGURE 27-3 Change in rural and urban population size: 1910 to
2010. (Reprinted from U.S. Census Bureau. (2020). Measuring
America: Our changing landscape. Retrieved from
https://www.census.gov/library/visualizations/2016/comm/acs-
rural-urban.html)

Health issues of concern in rural areas may be of even greater concern

for frontier areas. Sparsely populated areas may be less able to attract health
care professionals.

The term health professional shortage areas (HPSAs) is used to

identify urban or rural geographic areas, population groups, or facilities
with chronic shortages of medical, dental, or mental health
professionals. The federal government determines which areas are
HPSAs. As of 2015, there were 15,557 in the United States. Over 59
million people live in areas that have been designated as HPSAs for
primary care, representing about 60% of need met. Over 90.3 million
live in mental health HPSAs, and 47.4 million are in areas with
shortages of dentists (Health Resources and Services Administration
[HRSA], 2020; see also https://www.kff.org/other/state-
indicator/primary-care-health-professional-shortage-areas-hpsas/?
activeTab=map&currentTimeframe=0&selectedDistributions=total-
primary-care-hpsa-

2232
designations&sortModel=%7B%22colId%22:%22Location%22,%22sor
t%22:%22asc%22%7D).
In medically underserved areas, residents experience a shortage of
health services; these areas are determined by the federal government
using a score based on the shortage of primary care physicians, high
infant mortality rates, high percentage of the population living below
the poverty level, and a high proportion of residents over age 65.
A medically underserved population includes those with economic
and cultural/linguistic barriers to primary health care services (Fig. 27-
3; HRSA, 2020).

2233
Population Statistics
The number of persons living in urban areas of the United States tripled since
the mid-1800s, to almost 60 million in 2000, and grew 10.8% from 2000 to
2010 (Table 27-1). About 81% of the total population can be found in urban
areas (U.S. Census, 2016b).

TABLE 27-1 A National Rural Health Snapshot: Rural Versus

Urban

All information in this table is from the Health Resources and Services
Administration and Rural Health Information Hub.
National Rural Health Association. (2018). About rural health care.
Retrieved from https://www.ruralhealthweb.org/about-nrha/about-rural-healthcare

California, Arizona, and Texas showed the largest growth in suburbs of

large metropolitan cities. During the same period, rural population
growth was 4.5% with 46% to 60% of rural counties losing residents.
An all-time high of 51% of the population live in the suburbs.
Only 16% of the U.S. population is characterized as rural, the lowest
ever. The primary cause for this shift is thought to be children leaving
home for larger cities with better employment opportunities.
Rural areas are caught in a vicious cycle, because of individuals moving
away to find jobs and businesses reluctant to relocate to rural areas
because of a smaller pool of potential workers. States with the largest
percentage of rural population are Maine (61%), Vermont (61%),
Mississippi (51%), and West Virginia (51%) (U.S. Census Bureau,
2016b).

2234
Rural areas have lower rates of poverty (11.7% compared to 14% for
urban) but were less likely to have a bachelor's degree (19.5% compared
to 29% for urban); however, compared with urban households, rural
households had lower median income (U.S. Census, 2016b).
Rural employment has grown slower than urban employment and was
the slowest to recover from the recession in 2007. Many Americans
living in rural communities continue to face barriers that prevent them
from attaining the quality of life they deserve. Access to adequate
transportation is difficult for many rural Americans. Insufficient access
to medical care can lead to health problems; this can be exceptionally
hard to overcome for Americans living in rural areas. In addition, too
many rural Americans do not have necessary broadband access needed
to engage in the modern economy (Council of Economic Advisors,
2018).
For instance, as of 2014, 39% of the rural population lacked access to
broadband at speeds necessary for advanced telecommunications and
data transfer capability. This e-connectivity gap not only prevents rural
Americans from participating in the global marketplace but also limits
urban Americans.
Rural e-connectivity supports economic development for the whole
nation through access to capital and global markets, job training and
workforce development, innovation and technology, and enhanced
quality of life (USDA, 2017).
In addition, there is also a higher percentage of elderly and those living
in poverty, along with higher rates of chronic illness (about half have
one chronic illness or more) and more rural residents reporting poor to
fair health (Seright & Winters, 2015).
Rural residents are less likely to receive recommended preventive
services, and they make fewer visits to health care providers. They also
have fewer physicians (10% of total), and there is continuous concern
about recruitment of health care professionals in rural areas of the
United States and other countries beyond what incentives (e.g.,
scholarships, forgivable loans) can offer (Rural Health Information Hub,
2018b). Specialized medical care is rarely found in rural areas. Of the
2,000 rural hospitals, 75% of them have 50 or fewer beds; most are
designated critical access hospitals (CAHs) as they have 25 or fewer
beds (Rural Health Information Hub, 2018a). CAHs must provide 24-
hour emergency care, with either MD on site or RN on site with MD on
call and able to arrive within 30 minutes. They must also have 25 beds
maximum and be over 35 miles from the next hospital or 15 miles if the
terrain is difficult (Seright & Winters, 2015).

Recent solutions have been formulated to address these issues:

2235
The National Health Service Corp (NHSC) Program addresses long-
standing primary care health professional shortages by providing
physicians, APRNs, and other health professionals with scholarships
and repayments of student loans in return for at least 2 years' service in
communities facing shortages.
Area Health Education Centers (AHECs) were developed by Congress
in 1971 to recruit, train, and retain health care professionals committed
to underserved populations, which includes rural areas. There are over
56 AHECs with more than 235 centers operating in almost every state.
Many work collaboratively with medical schools, nursing programs, and
allied health schools to improve health for underserved and
underrepresented populations.
Federally qualified health centers make up one of the largest health
care systems for rural America and are frequently the only source of
primary and preventive services in their communities. Fifty-three
percent of these community health centers are located in rural and
frontier areas. Nurses play a central role in all three of these initiatives,
providing both direct primary and preventive care (Rural Health
Information Hub, 2018a).

2236
Changing Patterns of Migration
Population changes in rural areas are usually related to natural increase
through births or decrease through out-migration, the process of
residents moving out of rural communities and into urban places. When
America was a more rural country, there was more natural increase than
out-migration, which caused continued growth in the rural population.
Since the beginning of the 21st century, more rural counties have
experienced out-migration, and rural towns in some areas have
disappeared; this trend has slowed but continues overall (USDA,
2019a).
The lack of in-migration is related to a decrease in retirees moving to
rural areas, problems recruiting professionals and managers for local
manufacturing companies, poverty, and low quality of life (USDA,
2017). Population trends have many implications for the health services
needed by rural people. The patterns of rural migration change like
shifting sand, adding to the challenge of planning resources for rural
communities (U.S. Census Bureau, 2019).
Although other sectors of the American economy have largely
recovered from the Great Recession (Fig. 27-4), rural America has
lagged in almost every indicator (Fig. 27-5). Today, rural areas are more
economically diverse than in the past, reflecting the national trend to
greater reliance on service jobs. While traditional rural occupations such
as agriculture, mining, and manufacturing employ less of the rural
population than before, they continue to anchor the economies of more
than half the U.S. counties (USDA, 2017).

2237
 FIGURE 27-4 Percentage of people in poverty for the United
States and Puerto Rico: 2017. (From the U.S. Census Bureau.
(2018). Poverty: 2016 and 2017. Geography of poverty. Retrieved
from
https://www.census.gov/content/dam/Census/library/publications/2
018/acs/acsbr17-02.pdf)

FIGURE 27-5 A farm in rural Utah.

Demographics

2238
Migrant farmworkers constitute a mobile population with shifting
composition, and it is difficult to precisely determine their number or origins.
These estimates also vary because of the influx of illegal and undocumented
workers. A large number of seasonal and migrant farmworkers reside in the
United States, 33% are U.S. citizens, and others have permanent resident
status. Most of the estimated 3 million migrant (42%) and seasonal (58%)
farmworkers tend to be either newly arrived immigrants, with few
connections, or established legal residents, with limited opportunities and
skills, who rely on farm labor for survival (NCFH, 2018a). In addition to
male workers, who make up the majority, you may also see mothers bring
infants and young children to work with them, and the children spend their
days strapped to their mother's back or playing among the pesticide-laden
fields.

Seasonal farmworkers generally live in one geographic location and

are temporarily employed in agriculture, whereas migrant farmworkers
meet that classification while moving to find agricultural work
throughout the year, usually from state to state, and establishing
temporary residences (Migrant Clinicians Network, 2017a).
Some live apart from their families, forming groups of single men;
others travel with their entire families. The average migrant farmworker
spends from June to September doing seasonal harvesting, with about 8
weeks on the road traveling from farm to farm for work, and is then
unemployed unless other work, such as hauling or canning, is found.
Work days begin before dawn and often last 12 hours or longer.
Farmworkers cannot be paid for overtime, as federal laws exclude this
category of work. Seventeen states do not require workers'
compensation insurance for agricultural workers, 14 states require
workers' compensation for all agricultural workers and the remainder
requires it but provide exceptions for small employers (NCFH, 2018a).

Migrant farmworkers represent some of the most economically

disadvantaged people in the United States. According to the 2013 to 2014
National Agricultural Workers Survey (NAWS) survey results, 30% of
migrant worker families had total family income levels below the national
poverty guidelines. The same survey found that 83% of these workers said
that they were paid by the hour, 9% were paid by the piece, and 8% were
salaried or had other payment methods. Using piece rate as a basis for
payment is common in agricultural work when the crop being picked is
easily weighed and measured, motivating workers work faster during such a
short window of seasonal crop harvesting (NCFH, 2018a). Farmworkers paid
at a per piece rate may earn as little as 40 cents for a bucket of tomatoes or
sweet potatoes, therefore needing to pick approximately 2 tons of produce
(125 buckets) to earn 50 dollars (Student Action Farmworkers [SAF], 2011–

2239
2019). In addition to low wages, agricultural workers rarely have access to
worker's compensation, occupational rehabilitation, or disability
compensation benefits.

Migrant Streams and Patterns

Migrant farmworkers usually have their permanent residence, or home base,
in states with a traditionally high number of immigrants, like California,
Texas, Florida, Washington, Oregon, and North Carolina (SAF, 2011–2019).
From their home base, migrant farmworkers move to locations where new
crops are ready for harvest, following the harvest seasons as they move from
place to place along predetermined routes called migrant streams (Fig. 27-
6). Some migrant farmworkers are multigenerational; their families have
been farmworkers for several generations, traveling the same streams for
many years. It is common for migrant farmworkers to send money back
home to family members in other countries, like Mexico, China, India, and
the Philippines. In fact, an estimated $625 billion dollars was sent by
migrants to individuals in their home countries in 2017, a 7% increase from
2016. More specifically, more than 30 billion dollars was sent from the
United States to Mexico by migrant workers (Pew Research Center, 2020).
Of farmworkers in the United States, 75% were born in Mexico and 60% live
apart from their immediate family members. Immigrant farmworkers often
leave their home country to seek a better life for their families (SAF, 2011–
2019).

2240
 FIGURE 27-6 Migrant streams. (Source: Migrant Head Start
Program, USHDHUD.)

Three principal streams formulate the agricultural routes that migrant

laborers follow.

The eastern stream originates in Florida, where most of their time is

spent, and extends up the East Coast through North Carolina,
Tennessee, Kentucky, Virginia, and other states east of the Mississippi,
as far as north as Ohio, New Jersey, New York, Connecticut,
Massachusetts, New Hampshire, Vermont, and Maine.
The midwestern stream begins in southern Texas or northern Mexico
and fans out across the United States, ending in the Northwestern and
Midwestern states bordering Canada, both east and west of the
Mississippi.
The western stream originates in California and moves up the West
Coast to all Western states and from central California into Oregon and
Washington (NCFH, 2018a).
California, Florida, and Texas are regarded as sending states, as they are
often home states with long growing seasons where migrant streams
begin and end (Fig. 27-7). Male workers may travel with the crops and
leave their families in these home states (USDHUD, 2016). Workers
move from areas with cotton, tree fruits and nuts, and vegetable crops to
other areas where they harvest cherries, watermelons, cantaloupes, or
potatoes.

FIGURE 27-7 Migrant farm workers pick and package crops

(strawberries) directly into boxes in the Salinas Valley of central
California.

2241
 Nomadic migrant workers travel away from home for several years,
working from farm to farm and crop to crop and relying on word of mouth
about job opportunities. Some of these workers eventually settle in the areas
to which they have migrated, whereas others return to their home base. A
given ethnic group usually follows its own particular stream and pattern of
migration. New growth states, like Utah, Minnesota, Wisconsin, Nebraska,
Kansas, Tennessee, and Arkansas, have seen immigrant population's
increase. Some migrant workers find work in service sector jobs and others
labor in construction or landscaping, thus ending their need to constantly
move with the crops. Married men, not living with their families, are more
likely to migrate than those living with their families, often because of the
need to send money back home.

2242
RURAL HEALTH
Rural areas have historically had less racial diversity than urban areas.
However, that is rapidly changing. More recently, rapid Hispanic growth
areas are found in the South and Metropolitan areas (Fig. 27-8; Pew
Research Center, 2018). California, Texas, and Florida are home to 55% of
the U.S. Hispanic population, with 14.4 million living in California. In rural
counties, the white population has decreased, and other ethnic groups have
increased in size, but still only 11% of rural counties are majority nonwhite
(Pew Research Center, 2020).

FIGURE 27-8 The fastest-growing Latino counties between 2007

and 2014 were largely located in the South and metropolitan areas.
(Reprinted with permission from Stepler, R., and Lopez, M. H.
(2016). U.S. Latino population growth and dispersion has slowed
since onset of the Great Recession. Pew Research Center: Hispanic
Trends. Retrieved from
http://www.pewhispanic.org/2016/09/08/latino-population-growth-
and-dispersion-has-slowed-since-the-onset-of-the-great-
recession/ph_2016-09-08_geography-06/)

Urban and rural disparities have changed over time. The National Rural
Health Association (2019) identifies life expectancy to have shifted with
those in rural areas living slightly longer than those in urban areas (Table 27-

2243
1). Health concerns of populations in rural areas are related to the
environment, occupations, injuries, and distance from health care providers.
Population trends have a direct relationship to the kinds of health services
that are needed in rural communities. Growing families with young children
need maternity, pediatric, and family health medical services, along with
dental care and mental health services. They also can benefit from health
promotion and disease prevention activities. The elderly, on the other hand,
need health care to manage increased number of chronic health conditions.
Rural communities need to provide access to nursing homes and
rehabilitative services, as well as to hospitals, clinics, and health promotion
programs that serve the elderly and the entire community.

BOX 27-1 Locating a Rural Home

Health Client It can be difficult to locate
a patient in the rural community.
Directions may include structures such
as barns, fences, and trees, or
identification of stores that are familiar
to the patient and their family but not
the nurse. In addition, living quarters
may be on long unmarked dirt roads or
be an additional structure to an already
existing address. Once I received
directions from a patient who told me to
“…take the second dirt road on the right
after you get off the highway (after the
Dairy Queen), you'll see a big oak tree
with a swing. Continue down that road
for about 5 maybe 6 minutes and turn
right again at the red one-story house.
Drive to you see the green barn, don't

2244
turn there, but turn left at the next barn.
You'll see our house over the hill.”
Additional time may be needed to
navigate rural residents because GPS
systems may not be of assistance in these
rural areas.

2245
The Built Environment in Rural Areas:
Relationship to Health
Even with the advances of medicine and genomics, and the staggering
percentage of our gross domestic product (GDP) spent on health care,
scientists feel that we will not be able to significantly improve our overall
health and quality of life without addressing how we plan our living spaces.
As discussed in Chapter 9, the built environment consists of the
development of housing, highways, shopping areas, and other man-made
features added to the natural environment.
As populated areas expand, stresses are placed on natural habitats, water
supplies, and air quality. The built environment is inextricably related to
health. Substantial scientific evidence gained in the past decade has shown
that various aspects of the built environment can have profound, directly
measurable effects on both physical and mental health outcomes, particularly
adding to the burden of illness among ethnic minority populations and low-
income communities (Hansen, Umstattd Meyer, Lenardson, & Hartley,
2015).
Urban sprawl is a concern in some rural areas, as people move from
urban centers to more suburban environments. Urban encroachment into
agricultural areas creates problems with air and water pollution, access to
health care, and heat islands. Heat islands occur when green areas are
exchanged for asphalt, resulting in temperature and ecosystem changes that
can extend to more rural areas (Trivedi et al., 2015). Ozone levels are often
highest just outside the city, because “ozone is formed relatively slowly by
the action of sunlight on oxides of nitrogen and hydrocarbons” (p. 72). Urban
sprawl also causes problems with water pollution and the availability of
water. Encroachment of housing areas into natural habitats or farmlands can
lead to wider human exposure to pesticides, herbicides, and other hazards
such as mosquito-borne illnesses. Mass transit is not often available in
suburban areas and almost never found in rural areas. Opportunities for
healthpromoting behaviors are often more limited in rural areas.
Deteriorating (or no) sidewalks can be a barrier to walking in rural areas.
Exercise or fitness facilities, bike paths, jogging trails, and other incentives
for physical activity are also often lacking in rural communities.

Trivedi and colleagues (2015) examined data from a large national

survey and found that rural adults were 1.19 times more likely to be
obese when compared to urban adults. The prevalence was 35.6% in
rural residents versus 30.4% for urban residents, and that difference was
also found for both males and females (37.7% vs. 32.5%; 33.4% vs.
28.2%).

2246
 Exercise levels were lower among rural adults than for those in urban
areas (Trivedi et al., 2015). Obesity is prevalent in rural areas, and the
physical environment, along with diet, plays a role in this epidemic
(Lenardson, Hansen, & Hartley, 2015).
Eating out, especially at buffets, fast-food restaurants, and cafeterias,
instead of cooking at home, as well as not participating in physical
activity have been associated with higher rates of obesity (Lenardson et
al., 2015). In fact, Bhutani, Schoeller, Walsh, and McWilliams (2018)
found that for every 1-meal/week increase in fast-food and sit-down
restaurant consumption was associated with an increase in BMI by 0.8
and 0.6 kg/m2, respectively.

Rural roads are another concern because they are often narrow, without
streetlights, and poorly maintained. More fatalities occur on rural roads and
highways. While 19% of the country's population lived in rural areas in
2012, 54% of all road fatalities occurred there (National Highway & Traffic
Safety Administration, 2018). Speeding, failure to use safety restraints, and
alcohol are common causes of fatal crashes in rural areas. Over half of fatal
crashes occurred during daylight hours in rural areas; the opposite is true in
urban areas. Fifty-five percent of all fatal alcohol-related crashes occurred in
rural areas, and 65% of rural occupant deaths in pickup trucks were not using
restraints. Slow-moving farm equipment traveling on rural roads, along with
speeding and failure to use safety restraints, are often fatal conditions for
drivers in rural areas.

2247
Self, Home, and Community Care in Rural Areas
Historically, self-management of health care problems has been the most
common way for rural people to cope with illness (Fig. 27-9). This can be
viewed as a type of strength, or it may be seen as a limitation.

FIGURE 27-9 Life in a rural area may seem idyllic, but there are
some significant risks of a rural lifestyle.

Rural residents are often viewed as hardworking, traditional, hardy, self-

reliant, and resistant to accepting help or services from outside agencies
regarded by them as welfare-type programs.
Many rural clients are considered individualistic, independent, and
resourceful. They often take care of illnesses or injuries on their own or
have a supportive network to help them get their health needs met.
Small communities commonly have strong social networks, but this
type of familiarity may lead to problems with privacy and
confidentiality, as well as stigma regarding mental health or substance
abuse treatment.
Because cost, travel, weather, and distance are barriers to obtaining
health services from formal health care providers, rural clients may
employ a variety of folk treatments and home remedies before
consulting a nurse or a physician; such clients tend to visit providers at a
much later stage than do people in urban areas.
Rural residents may utilize physicians who are more likely to provide
care that is outside their specialty areas.
Compared with hospitals that are less rural, CAHs have been found to
have significantly higher patient mortality rates.

2248
Patients living in rural areas are known to have higher risk for poor
health outcomes, more likely to smoke and consume less healthy diets.
These factors may contribute to higher mortality rates.
Social determinants of health for rural dwellers, such as living
environment, community health supports, distance to providers, and
local economic prospects, can contribute to the mortality disparity
(Heath, 2017).
The low population density in rural areas makes service delivery more
difficult, especially for those with special health needs. The greater
treatment barriers when living in an isolated area are geography and
lack of adequate transportation.
Home health care (HHC) is particularly difficult in sparsely populated
areas, for both patients and nurses. Locating addresses in very rural
areas often takes additional skills. (See Box 27-1 for the story of a home
health nurse trying to locate a client's home.) The benefits of HHC are
worthwhile; it allows people to stay at home, supports their hardiness,
and compensates for the long distance between home and formal health
care.

2249
Major Health Problems in Rural Communities
Among major health problems affecting individuals in rural areas are
cardiovascular disease (CVD), diabetes, and COPD. Geography, economics,
and rural lifestyle factors may account for the higher rate of these major
health problems.

Cardiovascular Disease
CVD is a leading cause of death in the United States (42%), and the total
direct and indirect costs of CVD and stroke were estimated at over $351.3
billion in 2015 (American Heart Association, 2020). Research demonstrates
that geography may play a role.

Mortality because of heart disease is highest in the South, especially

following the path of the Mississippi River (Bolin et al., 2015).
Regional variations have been noted in prevalence of CVD and stroke.
Studies have found increased stroke mortality in the South (stroke belt),
and many researchers are focusing on the possible underlying risk
factors related to geographical variations. One group of researchers
wanted to better understand the effect of length of time living in the
stroke belt and age at first exposure.
Rural areas usually have less high-tech health care equipment available,
which may affect outcomes for patients with cardiovascular
emergencies. Being within 60 minutes of a Primary Stroke Center
(PSC) can determine outcome for many patients. C/PHNs can advocate
for better access to care and promote healthy lifestyle choices as well as
population-targeted interventions to reduce stroke and CVD.
Rural residents may ignore early cardiovascular symptoms and give
little heed to preventive interventions such as exercise and low-fat diets.
Several models of care are being implemented to address rural CVD. In
Maine, community-based education is targeting the specific needs of
low-income residents with CVD with attention given to socioeconomic
status, and residents' local culture and education level. In Montana,
pharmacists are working with rural clients to discuss medication
management, nutrition, and other risk factors such as smoking with
good success. In rural east Colorado, community health workers meet
clients in local community facilities such as libraries and schools to
provide screenings, referrals, services, and education (Rural Health
Information Hub, 2019a).

Diabetes

2250
Rural populations are disproportionately affected by diabetes and CVD
(8.6% and 38.8%, respectively); the prevalence is generally greater in rural
areas, and this is even more pronounced among Hispanics and Blacks.
Mortality rates for diabetes were higher in the rural regions within the south
and Midwest with 21% of deaths per 100,000 compared to 15.1% per
100,000 in the northwest and west (HRSA, 2018). Overall, the prevalence of
diabetes is 15% to 17% higher in rural areas than in urban (HRSA, 2018).

Rural areas have been cited as promoting obesity on a population level

because of fewer opportunities for walking, as residents spend a great
deal of time commuting to work or driving to essential services, and
rural residence was positively correlated with BMI, distance to retail
food, and commute times, among other things (Calancie et al., 2015).
Lower physical activity rates and greater barriers to physical activity are
commonly found in rural populations, as opposed to populations living
in urban settings (Bolin et al., 2015).
Rural populations also face greater barriers in diagnosis, treatment, and
follow-up care. Some compliance issues with prescribed medication
regimens may relate to the lack of health insurance and low-income
levels in rural areas but could also be due to lower health literacy and
education levels.
Other problems with accessing care may involve transportation and
weather. A lack of access to quality health care services has been a long-
standing problem for rural Americans because of the significant
difference in access to health care (HRSA, 2020).

Anderson, Saman, Lipsky, and Lutfiyya (2015), in a comparison study of

people living in rural counties versus nonrural counties, found that rural
residents had statistically lower scores in areas such as clinical care,
morbidity factors, and general health behavior. For instance, a classic study
by Krishna, Gillespie, and McBride (2010) highlighted the extreme
complications encountered by rural residents who often have to travel great
distances to access services for diabetes care, such as basic follow-up with
podiatrists for diabetic foot care, ophthalmologists for retinal health, and
nutritionists and health educators, as well as routine laboratory blood tests, to
guide lifestyle choices. C/PHNs, especially in rural and frontier areas, often
provide follow-up for diabetic clients who may be unable to regularly access
their health care providers because of problems with distance or
transportation. Home visits to check on their diet/exercise, blood glucose
monitoring, and foot care are important safeguards for this population. Also,
interventions targeted to behavior change can be helpful.

Chronic Obstructive Pulmonary Disease

2251
Prevalence of COPD in rural counties is twice that of urban areas (8.2% vs.
4.7%) with high concentrations occurring in the Appalachia and the southern
geographic regions (DHHS, 2018). Medicare beneficiaries aged 65 years and
over in rural regions had higher COPD-related hospitalization than urban
(13.8 to 11.4 per 100,000). Lack of access to care, limited transportation,
decreased specialty services, and treatment options increase the disparity of
COPD in rural versus urban areas. Environmental exposures can also affect
COPD patients in rural communities (DHHS, 2018). Typical rural
occupations expose people to very dusty or dirty air, chemicals,
environmental pollutants, and occupational activities such as farming and
coal mining. Even nonagricultural rural workers are much more likely to be
exposed on the job to high levels of gases, dust, and fumes (27%) than urban
workers (15%). In addition, a higher percentage of rural than urban people
smoke, including exposure to secondhand smoke. Smoking among teen-agers
is decreasing but remains considerably higher among rural young people.
Other causative factors for high mortality rates from COPD include
difficulties for rural people getting to basic and specialized medical care.
Rural individuals may have to travel longer distances to received care and
treatment (DHHS, 2018). Small rural hospitals may not have the equipment
to measure and track changes in a person's breathing over time and may not
have respiratory therapists to teach patients better ways to live with their
damaged lungs (Myers, 2018). Environment issues particularly relate to
agriculture and the health risks that accompany farming and other rural
lifestyles.

2252
Agriculture and Health
Although farming is not characteristic of all rural areas where agricultural
production occurs, both direct and indirect effects on health can exist.

In a classic summary sponsored by the Institute of Medicine (Merchant,

Coussens, & Gilbert, 2006), it is noted that pesticides and fertilizers can
affect water, air, and soil, and dust created from plowing for crops can
affect the air quality. For instance, an “estimated 70% of antibiotics are
used for nontherapeutic purposes in intensive livestock production,”
placing workers at risk for developing antibiotic-resistant infections (p.
4).
Donham and Thelin (2016) focused their research on diseases
commonly seen in agricultural workers, mainly arthritis (rheumatoid
and osteoarthritis), injuries of the musculoskeletal system, skin cancer,
burns, rural roadway crashes, and zoonotic diseases. Neurotoxicity can
develop due to exposure to industrial chemicals and pharmaceuticals,
leading to report of neuropsychiatric disorders, such as attention deficit
hyperactivity disorder (ADHD) and autism.
Exposure to these substances during early development may lead to
adverse behavior effects manifested at a later time of life. Pesticides are
a wide group of chemicals that are still actively used, and residues are
found in the environment and in food products (Lee, Eriksson,
Fredriksson, Buratovic, & Viberg, 2015).
Pesticides are linked to disease and environmental risks through various
routes (e.g., residues in food and drinking water). These hazards range
from short term (e.g., skin and eye irritation, headaches, dizziness, and
nausea) to chronic problems (e.g., cancer, asthma, and diabetes).
Further, their risks are difficult to explain due to the involvement of
various factors (e.g., period and level of exposure, type of pesticide)
(Kim, Kabir, & Jahan, 2017).
Lawsuits have been filed in California, Delaware, Florida, Hawaii, and
Missouri against Monsanto over its popular herbicide, Roundup, with its
active ingredient now thought to be a “probable human carcinogen”
(Gillam, 2016, para. 8). The World Health Organization's International
Agency for Research on Cancer has called glyphosate a “probable
human carcinogen,” and in 2017, the state of California added this weed
killer to its list of cancer-causing chemicals (Cone, 2019).

Many rural residents depend on their own well water for drinking, and
water quality is monitored only sporadically by well owners and then usually
only for nitrates and coliform bacteria (Lee et al., 2015). About 30% of rural
residents obtain drinking water from very small water systems, without the

2253
monitoring and regulations associated with large urban water suppliers.
Testing of small water systems should be done at regular intervals in order to
get a true picture of water quality (Wedgworth et al., 2015). In addition,
agricultural-related morbidity and mortality are relatively high. Agriculture,
forestry, and underground mining are ranked high in the rate of occupational
injuries (U.S. Department of Labor, 2017).
It is estimated that 33,000 injuries to children are farm related, and
approximately 100 of them are fatal. Of the fatal injuries to youth, 23% were
machinery related (often tractors), 19% were vehicle related (including
ATVs), and drowning was to blame in 16% of fatalities. Most fatalities
(34%) were in the 16-to 19-year age group (Occupational Health & Safety
Administration [OSHA], n.d.). Farming injuries can result from tractor
rollovers, suffocations in grain bins, exposure to harmful substances, falls,
fires or explosions, accidents with other farm equipment, and on-or off-road
collisions. Some injuries result in permanent disability, and worker training
programs to recognize hazards and prevent injuries are rare in rural areas.
See Box 27-2 for farming accidents.

BOX 27-2 Agricultural Accidents

Farm Tractor Accidents In the old days before
mechanical equipment, a farmer might be
injured by one of his horses or mules, or
accidently stabbed with a pitchfork. Today,
tractors are involved in the majority of injuries
and deaths. ROPS, or a roll cage over the
tractor seat, can save lives; they were standard
on every tractor manufactured in the country
since 1985 (1959 in Sweden). If a farmer uses
the seat belt and the tractor equipped with
ROPS turns over, there is a good chance that he
will survive the accident. Sadly, many farmers
don't use seat belts, and many use older
tractors without ROPS protection. There are
many potential hazards on farms (e.g., falling
bales of hay, heat stroke, dangerous equipment

2254
like hay balers, choppers, combines), but
tractor rollovers and children falling from
tractors are much too common and can often be
prevented.

Death on the Farm Agricultural deaths are not

uncommon, elderly men, youths, and hired
hands are the most affected. Agriculture
industry has the highest fatal occupational
injuries with 23.2 per 100,000 and nonfatal
injuries 58,300 in 2016. Tractor rollovers are
preventable; ROPS along with seatbelt use can
eliminate these injures. Engineering controls
along with policies, practices, and protective
equipment can control agricultural workplace
accidents. Currently, there are 4.2 million
tractors in use with all new equipment
manufactured with ROPS. As of 2006, 59% of
tractors were equipped with ROPS. Due to
longevity of equipment, retrofitting of
equipment is an option, but cost, special

2255
clearance, tractor housings, and personal
preferences are barriers for many farmers.
Source: Forst (2018).
(Photo source: USDA Agricultural Research Service.)

2256
Access to Health Care in Rural Areas

Insurance, Managed Care, and Health Care Services

Health insurance in today's market is costly, especially for individual
purchasers. Some people, therefore, forego health insurance for themselves
and their families. Depending on their income, people may or may not be
eligible for Medicaid or State Children's Health Insurance Programs (S-
CHIPs). Even people who are eligible for government health assistance may
not apply because of their belief that it is a sign of weakness to accept a
handout. Historically, a traditional fee-for-service model delivered health
care in rural and urban communities (see Chapter 6). However, that is
changing, and it is challenging for rural providers to deliver the cost-
effective, complex health care that rural persons need in small practices.

Rural patients often utilize family practice clinics.

The managed care model, which attempts to control costs and improve
health care delivery, has slowly diffused into rural communities. In
addition, rural practitioners are reluctant to become part of organizations
that negotiate to reduce their payments, as many of them already see a
disproportionate number of Medicaid and uninsured patients that impact
their bottom line.
Low population density makes this type of health care insurance less
profitable.
More states are moving to Medicaid managed care models, and
Medicare offers this option to beneficiaries. This puts rural residents at a
disadvantage, as they may have poor access to services because of
distance and travel time.

Building provider networks in rural communities is both time-and effort-

intensive because rural providers are often inexperienced with managed care
organizations (MCOs). The federal government provides support for rural
health clinics in areas designated as underserved and nonurban; differences
in effectiveness and efficiency have been noted in larger clinics versus
smaller clinics (RHIH, 2020a). These clinics have served rural clients for
more than 30 years, and they are an important source of health care.

Rural areas are characterized by a lack of core health care services (e.g.,
primary care, hospital care, emergency medical services, long-term care,
mental health and substance abuse counseling services, dental care, and
public health services).
Shortages were noted for physicians, with urban areas having 263
specialists for every 100,000 residents and rural areas having 30

2257
 specialists for every 100,000 residents (Lahr, Neprash, Henning-Smith,
Tuttle, Hernandez, 2019).
In the United States, 56% of all rural counties do not have a pediatrician
affecting the health status of children (Rural Health Information Hub,
2019a).
Population health services in rural areas may be covered by a
combination of public health departments, physicians in private
practice, local hospitals, as well as various community agencies.
In some rural or frontier areas, state health departments may offer
services, as no local infrastructure may be present. Many rural residents
depend heavily on public health department services. Seventeen percent
of local health departments (LHDs) serve small towns (populations
under 10,000), and 44% serve communities with populations between
10,000 and 49,999.
These LHDs are less likely than larger health departments to provide
environmental health services, but they often provide many of the other
services (e.g., primary prevention, health services,
epidemiology/surveillance) found in larger health departments (National
Association of County and City Health Officials, 2016).
Numerous states have sizable rural areas; this geographic isolation may
restrict access to health care for vulnerable groups, especially minorities
and those with disabilities. To adequately address health disparities,
rural areas need to be better incorporated into discussions of geographic
and racial inequality (Caldwell, Ford, Wallace, Wang, & Takahashi,
2016). See Box 27-3 for a hard lesson learned by one C/PHN student.

BOX 27-3 PERSPECTIVES

A Nursing Student Viewpoint On Rural

Transportation I live in a relatively large city of
450,000 people. When I started my community
health nursing rotation, I was assigned to a rural
county public health department in an adjoining
county over 50 miles from my house. When I
arrived for my first clinical day, my professor told

2258
me that I was assigned to see clients in an isolated
community another hour away from the health
department! There was nothing but farmland
between the county seat and this small town.
After I got over my frustration about traveling such long distances, I
began to visit some of my families and started to actually enjoy my time
with them. They were so appreciative and open to my suggested
interventions. I really seemed to be making a difference. One older
gentleman, Armando, was a diabetic who spoke very little English. He lived
with his wife of 50 years, who spoke almost no English. Their children had
moved away in order to go to school and get better jobs. His diabetes was
not well controlled, and the rural health clinic FNP suggested that he see a
specialist (actually an internist) in the largest city in the county. I helped
him make arrangements with the doctor for an early afternoon visit and
made sure that he could catch the county bus that ran between the smaller
communities and the county seat.
When I came back for a follow-up visit the next week, I was shocked to
learn that Armando's appointment had been pushed back to 4:30 PM because
of the doctor's involvement in hospital emergencies, and by the time
Armando was finished with his appointment, the county bus service had
ended. Armando, with no money and no one to call for a ride, began
walking back to his home—over 52 miles away! About halfway home, a
farm truck driver gave him a lift to the large cotton farm a few miles from
his home. I never realized how difficult it was for rural people to get to their
medical appointments. I thought that the bus would not be a problem, but I
learned my lesson. Now, I make sure that the physician's office understands
the patient's circumstances and the importance of getting them back to the
bus stop in time to make the last bus.

Andrea, senior nursing student

Unpredictable weather adds to potential barriers for rural clients. Snow,

ice, wind, flash floods, and rain can make travel dangerous, even over short
distances.

Parents may decide not to risk driving on poorly maintained roads to get
their children immunized or to have their own hypertension evaluated
(Fig. 27-10).
Elderly people may choose to delay health care when long travel times,
especially in isolated rural areas, are involved.

2259
 Rural populations have disproportionately high injury mortality rates,
much of which is due to motor vehicle accidents (APHA, 2018).
In a more recent study by Chaiyachati et al. (2018), offering
complimentary ridesharing services to Medicaid patients did not reduce
rates of missed primary health care appointments. The acceptance of
free rides was low, and rates of missed appointments remained
unchanged at 36%. Study results indicated that efforts to reduce missed
appointments due to transportation barriers may require more targeted
approaches.
Historically, rural communities have been somewhat overlooked in the
transportation planning process. In fact, because of the way in which
transportation dollars are allocated, rural states often receive less
funding than more densely populated states (APHA, 2018).
Inadequate phone service, dead zones in cell coverage, and the lack of
adequate contact information for emergency physicians on staff are all
problems frequently encountered in rural areas (Bolin et al., 2015).

FIGURE 27-10 A railroad crossing along a dirt road across

farmland on a winter day without snow in northern Illinois.

New Approaches to Improve Access

The Healthy People 2030 document mandates improvements in access,
health education, health screening, immunizations, environmental health, and
disease morbidity for the United States. Creative ways of delivering these
and other services to rural clients need to be explored. Access to care is a
social justice issue: clients who live in rural areas should receive quality
health care, regardless of where they choose to live. The Healthy People
2030 plan of action includes investment in health and well-being for all
individuals. The first three overarching goals of Healthy People 2030 focuses

2260
on the elimination of health disparities, improving health access, and creating
healthy environments.

Attain healthy, thriving lives and well-being, free of preventable

disease, disability, injury, and premature death
Create social, physical, and economic environments that promote
attaining full potential for health and well-being for all (USDHHS,
2020a).

Faith-based nursing has been a staple in rural areas, as well as with some
urban communities, but is gaining momentum as more formal interventions
are developed, for instance, mental health promotion for rural Latino
immigrants (Stacciarini et al., 2016). Even informal support from other
church members and friends may provide a compassionate environment for
needed behavioral changes such as healthy diet and increased physical
activity. See more on faith-based nursing in Chapter 29. Results indicate that
perceived improvements in church nutrition environments were most
strongly associated with decreases in unhealthy food consumption and
stronger intentions to use physical activity resources at church. Perceived
changes in the physical activity environment were unrelated to church or
general behavior (Jacob et al., 2016).
One approach that has been successful in numerous rural areas is the use
of mobile clinics. These clinics bring health care providers to remote places
for health screenings, immunizations, dental care, mental health visits, and
other services.

Mobile health clinics are frequently staffed by NPs and can improve
access to health care for low-income residents.
They often are available to residents on evenings and weekends and
offer culturally sensitive and bilingual outreach, as well as care for
uninsured clients.
Although the aim of the Affordable Care Act (ACA) includes increasing
the number of insured individuals in the United States and overcoming
health disparities, it has no provisions for mobile medical clinics, which
appear to serve as an important component of health care delivery,
especially to vulnerable populations.
In addition, mobile dental clinics provide an innovative solution to
providing dental to improve physical access to dental care for medically
underserved population in poor urban and remote rural communities.
Many mobile clinics provide existing dental clinics services at lower or
no cost to the user.

School-based clinics can improve access for schoolchildren (and

sometimes their families) but may be less prominent in rural areas (see more

2261
on school-based clinics in Chapter 28). These clinics provide available,
community-based, affordable, and culturally acceptable care to well and sick
children. Often, grant-supported, school-based clinics facilitate the receipt of
health education and primary care by children who are otherwise without
easy access to health services. More than 66% of school-based health centers
offer primary care and behavioral health services. In addition, school-based
health centers are associated with improved educational status, including
higher grade point averages and higher rates of high school completion
(National Conference of State Legislatures, 2020).
Telehealth, another approach to increasing access to care, provides
electronically transmitted clinician consultation between the client and the
health care provider. This option is especially useful for connecting home
health nurses with their patients who need close monitoring at home. It is
also useful for patient and professional health education, public health
applications, and health administration. Specialty health care also may be
accessed, with patients and providers connected via two-way audiovisual
transmission over telephone lines or the Internet, thus obviating the need for
patients to leave their residences. Streaming media, video conferencing, and
store-and-forward imaging are just some of the applications commonly
utilized (HRSA, 2020).

Telehealth interventions for speech–language services to rural children

were found by parents to be both feasible and acceptable. Parents found
the teletherapy to be more frequent and consistent services, which in
turn promoted their confidence and skill in assisting their children to
achieve their speech and language goals (Fairweather, Lincoln, &
Ramsdeb, 2016).
Online counseling and remote counseling link rural clients with urban
behavioral health services. Counseling services can also be provided
online in Spanish (Rural Health Information Hub, 2020b).
Telehealth is especially critical in rural and other remote areas that lack
sufficient health care services, including specialty care. The range and
use of telehealth services have expanded over the past decades, along
with the role of technology in improving and coordinating care. Grants
and other funding are available to promote the use of this technology
(HRSA, 2020; RHIH, 2019b). See Chapter 10.

Healthy People 2030 Goals

The five overarching goals of Healthy People 2030 are to:

Attain healthy, thriving lives and well-being, free of preventable

disease, disability, injury, and premature death

2262
 Eliminate health disparities, achieve health equity, and attain health
literacy to improve the health and well-being of all
Create social, physical, and economic environments that promote
attaining full potential for health and well-being for all
Promote healthy development, healthy behaviors, and well-being across
all life stages
Engage leadership, key constituents, and the public across multiple
sectors to take action and design policies that improve the health and
well-being of all (USDHHS, 2020a, para. 11)

Because of the unique health issues facing rural America, Healthy

People 2030 identifies broad areas of concern such as access to health
services, environmental health, and health communication/information
technology (Box 27-4). Using surveys, literature reviews, and other methods
of data collection and analysis, top priorities for rural health have been used,
allowing rural stakeholders to reflect on and measure progress in meeting
previous Healthy People rural goals (Bolin et al., 2015). In addition, there are
data to substantiate continued problems with access to health care and
insurance, as well as emergency services, in rural areas. And there is a higher
rate of CVD and diabetes, along with obesity and tobacco use among rural
populations (NRHA, 2019).

BOX 27-4 HEALTHY PEOPLE 2030

Health Issues in Rural America

2263
Reprinted from U.S. Department of Health and Human Services (USDHHS). (2020a). Healthy
People 2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

A large longitudinal study of maternal and infant health in Maine

revealed that access to prenatal care, along with pregnancy care and
outcomes, was similar for rural and urban women over an 11-year
period (Harris, Aboueissa, Baugh, & Sarton, 2015). Rural mothers had
higher BMIs prior to pregnancy and were generally younger, less well
educated, unmarried, and living in low-income households. They were
also more likely to smoke, but less likely to drink alcohol, and were not
often sure of their pregnancies until later than urban mothers, but they
still accessed prenatal care at similar times (Harris et al., 2015).
Access to quality care is linked to availability of health insurance. Rural
residents, when compared to urban counterparts, have higher rates of
uninsured, higher out-of-pocket costs, and higher proportions of
emergency room visit costs; they are also less likely to be covered
through group health insurance or managed care plans and less likely to
have prescription drug coverage (Bolin et al., 2015).
Also, insurance instability (gaps in coverage) is correlated with
increased use of emergency rooms, and this is particularly significant
for rural residents who often have less access (Fields, Bell, Moyce, &
Bigbee, 2015). Because of lower rates of insured rural residents, their
preventive health care is often lacking (e.g., lower rates of
mammograms, colonoscopies, vision examinations).
Approximately 65% of primary care professional shortages occur in
rural counties. Rural residents are also less likely than urban residents to
have a usual source of primary care (Rural Health Information Hub,
2019a).
Problems more commonly seen in rural areas include oral health and
cigarette and smokeless tobacco use. Sixty percent of rural counties are
considered professional shortage areas for dental health, and more
dentists are over age 55 in rural areas (42% vs. 38% in urban) (Rural
Health Information Hub, 2019a). Rural populations are less likely to
have annual dental examinations. They are also more likely to have
tooth or gum disease, often because of higher rates of cigarette and
smokeless tobacco use, and they are more likely to use the emergency
room because of dental caries than urban residents (Bolin et al., 2015).
Rural teens have a higher rate of tobacco and alcohol use than their
urban counterparts (Rural Health Information Hub, 2019a).
Unintentional overdose deaths due to nonmedical use of prescription
drugs disproportionately impact rural over urban settings in the United
States. Specific geographic areas, such as Appalachia, parts of the West
and the Midwest, and New England, have seen higher prevalence than

2264
 other areas (United States Department of Health and Human Services,
2018).
Drug overdose rates in the Central United States have grown
dramatically over the last decade. Missouri, Oklahoma, and Wyoming
have rates of overdose nearly double the rates of New York, California,
Texas, or Virginia and nearly double the rates of Eastern rural states.
Unfortunately, some central states still do not make naloxone available
to the public, nor have they passed “Good Samaritan” laws protecting
bystanders who report overdose incidents to emergency services, or who
administer naloxone to someone who has overdosed. Some Central U.S.
states with high levels of overdose have taken action to make overdose
deaths less likely by making naloxone more available and its use in an
emergency more protected (Dombrowski, Crawford, Khan, & Tyler,
2016).
Prescription opioid use and abuse is increasingly becoming a public
health crisis across the United States. Over the last two decades, opioid-
related deaths have increased dramatically to become a serious public
health concern. Opioid-related mortality rates have reached epidemic
levels in rural areas of the United States, such as Appalachia, New
England, and the Mountain West with rural counties having an 87%
higher chance of receiving an opioid prescription compared to persons
living in large metropolitan areas (Mundell, 2019; Rigg, Monnat, &
Chavez, 2018).
Rates of opioid-related inpatient hospital stays, emergency room visits,
and mortality are high in predominantly rural states like Maine,
Kentucky, and West Virginia, but rates are lowest in other largely rural
states such as Iowa and Nebraska (Weiss et al., 2017).
Newer and less addictive types of pain control are needed (Dryden,
2016).

Cancer disparities are found in rural populations. Rural women are less
likely to receive screening mammograms and Pap smears than urban women.
In one study, cancer incidence was 447 cases per 100,000 in metropolitan
counties and 460 per 100,000 in nonmetropolitan counties. Cancer mortality
rates were 166 per 100,000 in metropolitan counties and 182 per 100,000 in
nonmetropolitan counties. Higher incidence and mortality in rural areas were
observed for cervical, colorectal, kidney, lung, melanoma, and oropharyngeal
cancers (Blake, Moss, Gaysynsky, Srinivasan, & Groyle, 2017). Rural
populations also have a lower proportion of colonoscopies to screen for
colorectal cancer. Further, most rural physicians are trained as generalists,
therefore not trained to perform colonoscopies (Evans et al., 2015).
Mental health is another concern in rural settings as 19.1% of rural
residents 18 years and older had any mental health issue and 4.9%
experienced serious thoughts of suicide (RHIH, 2020b). The prevalence of

2265
mental health is similar between rural and urban, yet there are limited
services available to address this issue in rural communities. Accessibility of
services, availability of services, and acceptability are all barriers for those
residing in rural areas (RHIH, 2020b).
Rural C/PHNs need to consider the Healthy People 2030 objectives
priority areas as guides for improving the health status of clients in rural
communities.

2266
Community Health Nursing in Rural Settings
Most rural nurses working in the community are thought to have little
education in public health, as the associate degree in nursing is often
accepted by health departments in rural areas (Harris et al., 2015). However,
rural areas promote a broad scope of C/PHN practice, as these nurses deal
with a wide variety of issues—immunizations, home health, school nursing,
maternal–child health, emergency preparedness, as well as communicable
disease/epidemiology. Rural health departments are often lacking in
technological and communication systems, but there is an even greater need
for reliable communication capability and training opportunities for rural
C/PHNs who provide the majority of care in rural and frontier communities
(Knudsen & Meit, n.d.).
Rural community health nurses most often grew up in rural areas or lived
for a time in small communities. They frequently have extended family, are
active members of their community, and are highly respected professionals.
The rural community health nurse plays many roles:

1. Advocate: Assists rural clients, families, and populations in obtaining

the best possible care 2. Coordinator/case manager: Connects rural
clients with needed health and social services, often assisting with
information on transportation 3. Health teacher: Provides education
to individuals, families, or groups on health promotion or other
health-related topics (e.g., prepared childbirth, parenting, diabetes
maintenance, home safety) 4. Referral agent: Makes appropriate
connections between rural clients and urban service providers 5.
Mentor: Guides new community health nurses, nursing students, and
other nurses new to the rural community 6. Change agent/researcher:
Suggests new approaches to solving patient care or community health
problems based on research, professional literature, and community
assessment 7. Collaborator: Seeks ways to work with other health
and social service professionals to maximize outcomes for individual
clients and the community at large 8. Activist: With a deep
understanding of the community and its population, takes appropriate
risks to improve the community's health

Rural C/PHNs have the opportunity to use autonomy in daily practice.

Nurses must rapidly assume independent and interdependent decision-
making roles because of the small workforce and large workload. For nurses
who live and work in rural areas, resources are limited and demands are
many. Rural C/PHNs learn to prioritize tasks quickly and work efficiently
with others to get the job done. Referrals to other rural providers are
facilitated because providers frequently know one another. Rural C/PHNs

2267
may experience the challenge of physical isolation from personal and
professional opportunities associated with urban areas. Rural nurses may also
feel isolated in their clinical practices because of the scarcity of professional
colleagues (Box 27-5).

BOX 27-5 STORIES FROM THE

FIELD
Frontier Nursing: Then and Now As described
in Chapter 2, Mary Breckinridge founded the
Frontier Nursing Service in 1925, with nurse–
midwives providing care to clients in their own
homes. Nurses traveled by horseback and on
foot into the sparsely populated hollows of
Kentucky (American Association for the
History of Nursing, 2018). Today, NPs working
in nurse-managed clinics in rural Appalachian
communities in Virginia were interviewed
about their practices, in a classic study by
Caldwell (2007), and spoke about their
connections to the people and communities they
serve. One said, “Here you get to know the
whole family and that is rewarding…you know
what is important to them…what their worries
and concerns are….so you probably get closer
to your patient in this area than you might
outside here. It becomes an extended family,
which is very rewarding” (p. 76).
Another NP described a man with severe COPD who visited her
clinic. He was also a patient of another area provider, but when the NP
examined the man, she noticed the gauze 4× 4 he had on the back of his
neck and enquired about it. The man said he “cut himself shaving.” The
NP pressed the man to see the wound and found that he had “cancer
with the bone exposed,” describing it as “the most awful thing that I had

2268
 ever seen in my life. I could put my fist in there. And you could see his
carotids pulsating.” She told the patient how serious this was and
arranged for a plastic surgeon to see him right away. He had a total neck
resection and recovered completely. She reflected, “What if I had
accepted his story about the sore and it being all right? It was not what
he was coming to see me for…I look at more than just the chief
complaint” (p. 77).

1. What factors are important to consider when caring for clients in

a rural setting?
2. What situations have you seen in rural settings?
3. Knowing more about rural health, would you do anything
differently in this scenario?

The rural community health nurse often receives a salary that is lower
than that of urban nurses in comparable positions (Harris et al., 2015).
However, there are benefits to rural nursing. Housing costs are usually lower
than in larger cities and long commutes to and from work on congested
highways are often avoided, although rural driving can be hazardous. As a
place to live and raise a family, rural communities offer a slower pace of life,
open spaces, and friendly atmosphere. The smaller system of health care in a
rural community can be advantageous to the C/PHN. It may be easier to
understand the system and initiate planned change.
However, many rural areas find it difficult to recruit nurses and need to
more effectively advertise their benefits. When RN to population ratios are
high in both rural and urban areas, years of potential life lost and rates of
poor health are significantly improved, as well as rates of teen births and
mammography; however, this association was shown to improve even more
as the level of rurality increased demonstrating the importance of adequate
nurse staffing in all areas (Fields, Bigbee, & Bell, 2016).

2269
MIGRANT HEALTH
Have you ever thought about the people who harvest the fruits and
vegetables that you eat? Have you ever thought about who they are, where
they come from, where they live, or what their health is like? What would
happen to the complex system of agricultural production and distribution if
workers were not available to pick crops at peak harvest times? Whatever
your political, social, or ethical views on this subject, migrant workers and
their families often cross paths with C/PHNs, and we need to understand
them in order to effectively provide care (Box 27-6).

BOX 27-6 What Do You Think?

Undocumented Migrant Workers There are
many critics of undocumented migrant workers.
Some feel that their willingness to work for low
wages keeps overall wages lower for everyone
working in agriculture, while others feel that
migrants are taking jobs away from Americans.
The United Farmworkers, an agricultural
worker union, introduced the Take Our Jobs
program in 2010 to address these issues.
Unemployed Americans were invited to work in
the fields along with migrant farmworkers, but
very few accepted this invitation; those that did
attempt it had a difficult time keeping up with
the grueling pace of work. Stephen Colbert, a
television show host and comedian, picked beans
and packed corn as part of the challenge, and
filmed some of his workday experiences for his
late-night show. He also gave testimony to

2270
 Congress on the need for better wages, living
conditions, and visa programs for these workers.
What do you think about the issue? You can view
this testimony first-hand in the following video
(https://www.youtube.com/watch?
v=0TYyeNU8Wvc). You can also view Charlie
LeDuff taking this migrant challenge in the San
Joaquin, California fields
(https://www.youtube.com/watch?
v=J7TGWaHaUeU).
In addition, a government project was trialed in 1965, when the
Bracero Agreement between the United States and Mexico, providing
Mexican agricultural workers in the U.S. fields, expired. Farmers
complained, stating that crops would rot in their fields. Therefore, project
A-TEAM was created—Athletes in Temporary Employment as
Agricultural Manpower. A nationwide call was placed to recruit high
school boys, providing field labor as their summer job. Although initially
18,000 were registered, only 3,300 actually worked in the fields.
Ironically, even though the initial intent was to recruit “jocks,” many of the
recruits were not athletes but just boys looking for summer jobs. The boys
were paid minimum wage—$1.40 per hour at that time—plus a small
stipend for filling crates with fruits or vegetables (i.e., 0.05 cents for every
crate filled with 30 to 36 cantaloupe). Work was hard, days were long,
temperatures were hot, and the boys were not allowed to return home until
summer's end. Many of the boys did not last the entire stint. A university
history professor, Lori Flores, was quoted as saying “The A-TEAM
reveals a very important reality: It's not about work ethic for
undocumented workers. It's about the fact that this labor is not meant to be
done under such bad conditions and bad wages” (Arellano, 2018, p. 7).
The A-TEAM was considered a giant failure and was never tried again!

Migrant farmworkers are an integral part of the farming community in

the United States and across the world. In fact:

The agricultural industry relies heavily on migrant workers to harvest

the almost endless array of fresh produce that appears year-round in
supermarkets across the United States as fresh, frozen, and canned fruits
and vegetables.

2271
Opponents of immigration restrictions predict that imposing them would
jeopardize the supply of labor available to farmers during critical plant
and harvest seasons. They contend that more restrictive immigration
policies could lead to reduced profits for some farms and threaten the
sustainability of agricultural sectors that are heavily dependent on farm
labor, especially fruit, tree nuts, vegetables, and horticulture (USDA,
2020).
More than 3 million seasonal and migrant farmworkers provide labor
for the $28 billion vegetable and fruit crops of the United States
(National Center for Farmworker Health [NCFH], 2018a).
Many of these workers are unauthorized or illegal immigrants to the
United States, often from Mexico. The vast majority entered this
country in an unauthorized manner.

2272
AGRICULTURAL LABOR AND
IMMIGRATION POLICIES
CHANGING
Despite their importance to American agriculture, migrant workers often go
unnoticed beyond the fringes of the camps and farms to which they travel in
order to pursue their livelihood. The number of migrant agricultural workers
there are in a particular region, state, or even in the nation is difficult to
estimate due to high mobility, language and cultural differences, and varying
levels of citizenship status (NCFH, 2018a). California, Texas, Washington,
Florida, Oregon, and North Carolina currently have the highest number of
migrant farmworkers (NCFH, 2018a). They come with the hope of bettering
their impoverished lives. Some are legal residents, but most are
undocumented aliens and live in fear of deportation. All endure
backbreaking, menial labor for low wages and are often deprived of basic
rights to safe working conditions, adequate sanitation/housing, health care,
and a quality education for their children (see Boxes 27-7 and 27-8).

BOX 27-7 U.S. Migrant Worker

Demographics
Origin and Nationality
Most are foreign-born (73%), with about 69% from Mexico.
Forty percent have been in the United States 20 or more years,
while 35% for 10 to 19 years.
Forty-seven percent of the crop workers are unauthorized, 31% are
citizens, and 22% have work visas.

Age
The age of agricultural workers in the United States has been
increasing since 2000.
Seventeen percent are between the ages of 14 and 24, compared to
35% in 1999 to 2000.
Twenty-seven percent are between 25 and 34 years.
Twenty-four percent are between 35 and 44 years.
Eighteen percent are between 45 and 54 years.

2273
 Fourteen percent are 55 years or more, compared to 5% in 1999 to
2000.

Sex/Marital Status/Offspring
Seventy-two percent of agricultural workers are male, and 28% are
female.
Sixty-three percent are married, 29% are single, and 8% are
divorced.
Fifty-seven percent are parents, 29% have one to two children, and
14% have three or more children in the household.

Education
Thirty-six percent have completed grades 1 to 6.
Twenty-one percent have completed grades 7 to 9.
Twenty-eight percent have completed grades 10 to 12.
Eleven percent have completed education beyond grade 12.

English Language
Twenty-seven percent cannot speak English “at all.”
Forty-three percent speak English “a little” or “somewhat.”
Thirty-one percent speak English “well.”

Migrant Status and Seasonality

Approximately 16% of farmworkers are considered migrant
(traveling 75 miles to obtain farm jobs).
Many travel to multiple farm sites within a year.
About 84% are considered seasonal agricultural workers.
Most (41%) work in fruit and nut crops.
Others (22%) work in horticulture (22%) and vegetables
(21%) (NCFH, 2018a).

Compensation
Only 8% of U.S. migrant farmworkers are salaried.
The majority are paid low hourly wages (83%) or by the piece
(9%).
Source: National Center for Farmworker Health (NCFH) (2018a).

2274
BOX 27-8 STORIES FROM THE
FIELD
A Case of Active Tuberculosis in a Rural
Community As the C/PHN in a rural
community, I received many types of referrals
for families including maternal child, older
adults, child abuse, or communicable disease
cases. The small public health district office was
located in a small agricultural town of
approximately 20,000 people, with a large
Spanish-speaking population. One day, I
responded to a new, active tuberculosis (TB)
case. A 20-year-old Hispanic male had been in
the county hospital and was on respiratory
isolation, I would need to examine his living
conditions and his contacts.
Gregorio explained that he and his brothers had traveled from his
home country of Chiapas, Mexico, to the United States. There were 20
names in total that were close contacts and needed follow-up. They
lived in a two-bedroom home, without furniture, and each man took a
spot on the floor to sleep at night. One by one, each was interviewed for
TB risk assessment and a TB skin test was placed. On return to the
home in 2 days, skin tests were read, and those who had positive tests
were referred to the community health center for chest x-rays.
Gregorio was hospitalized until he was no longer communicable.
The county health department instituted daily directly observed therapy
(DOT) and assisted with transportation to medical appointments.

1. What do you see as the role of the community health nurse in this
situation?
2. Discuss how communicable disease control and surveillance
looks different in a rural setting.

—Judy H. Pedro, MSN, RN, APHN-BC

2275
 The United States has passed legislation affecting agricultural workers.
States across the nation have implemented policies to address growing
numbers of unauthorized workers, whether they work on farms or elsewhere.
In over 20 states, legislatures have passed laws that penalize employers who
knowingly hire unauthorized workers. At least 100 municipalities around the
nation have proposed or enacted ordinances that penalize businesses for
hiring and landlords for renting to unauthorized workers (USDA, 2018).
The H-2A Temporary Agricultural Program provides a legal means to
bring foreign-born workers to the United States to perform seasonal farm
labor on a temporary basis; these consist of crop farmers and producers of
livestock. Employers must demonstrate, and the U.S. Department of Labor
must certify, that efforts to recruit U.S. workers were unsuccessful.
Employers must also pay a state-specific minimum wage, provide housing,
and pay for transportation. One of the most significant indicators of the
scarcity of farm labor is the fact that H-2A employment applications and
certifications have quadrupled in the past 12 years, increasing from just over
48,000 positions certified in 2005 to 200,000 in 2017 (USDA, 2018). With
the H-2A visa, there are restrictions against farmworkers changing
employers, and this could affect their work safety climate (Arcury et al.,
2015).

2276
Migrant Farmworkers: Profile of a Nomadic
Population
Maintaining a low public profile, migrant workers are often marginalized
from mainstream society. They remain unseen, unheard, poorly understood,
and excluded from many programs that provide health care assistance for
low-income people.

The migrant worker is a kind of disenfranchised person, for whom many

do not want to take responsibility. Yet the needs of these workers are
great. They are plagued with different, more complex, and more
frequent health problems than the general population (Migrant
Clinicians Network, 2017a).
Common ailments include infectious diseases (e.g., TB, parasites),
gastrointestinal disorders, dermatitis, pesticide exposure, emotional
distress and depression, vision and eye problems, cancer, and chronic
illnesses, such as asthma, bronchitis, diabetes, and hypertension.
They are often afflicted by poverty, poor nutrition, substandard housing
conditions, extended working hours, and grueling, often unsafe,
working conditions.
Their demographics, socioeconomic conditions, and lifestyle resemble
those of a low-income country, despite the fact that they live and work
in one of the most prosperous nations in the world.
Although migrant families are in dire need of health resources, various
economic, cultural, and language barriers prevent this aggregate from
accessing available health services. Poverty, frequent mobility, low
literacy, and language and cultural barriers impede farmworkers access
to cost-effective health care and social services.
Approximately 30% of all agricultural worker households had total
family incomes below the U.S. government's poverty guidelines. The
average wage earned by a migrant worker was $10.19 per hour. Further,
only 51% of agricultural workers reported being covered by workers'
compensation insurance (NCFH, 2018a).

Migrant workers often live and work in areas where health care
practitioners are in short supply. Among Latino immigrants, common
barriers to utilizing the health care system include access to insurance,
limitations in the type of health care utilized, discrimination in health care
services, immigration fears, stigmas, lack of social and financial capital,
communication problems, and long waiting periods for access to health care
(Migrant Clinicians Network, 2017a). Additional barriers include limited
transportation, prejudice because of immigrant status, mistreatment because
they are “undocumented,” lack of time-efficient health care delivery

2277
methods, increasing cost of health care, and needing services not being
offered (NCFH, 2018a). Migrant workers may use traditional cultural
remedies and folk healers, if available, but often also use low-cost, over-the-
counter medications, and professional health care systems, blending both
traditional and U.S. health care practices (McCullagh, Sanon, & Foley,
2015).

Historical Background
Both historically and internationally, farmers have rarely been able to
permanently employ the large workforces needed to harvest their crops.

Throughout the 19th century, however, the small, family-owned farms

typical in the United States got through the harvest by using
schoolchildren, neighbors, and local day laborers. As time went by, this
became more difficult to accomplish.
During the 1920s, over half a million Mexicans migrated to the United
States, many drawn to work in seasonal agriculture. With the Great
Depression, many of the small, independently run farms went bankrupt,
and citizens were concerned about limited employment opportunities.
The United States has experienced farm labor shortages for the past
century, becoming more severe during World War II. To meet the
demand for farm laborers, the Bracero Program was created in 1942,
which allowed over 4 million guest workers to come in from rural, poor
areas in Mexico due to agricultural worker shortages in the United
States.
In 1964, the program was replaced by the H2 Temporary Guest Worker
program, with H-2A being agricultural workers and H-2B being guest
workers who perform nonagricultural work.
In 2016, the U.S. Department of State certified 165,741 H-2A visas out
of 172,654 that were requested (NCFH, 2018a).
In 2016, the states with the highest numbers of H-2A workers were
Florida, North Carolina, Georgia, and Washington (Figueroa, Moberg,
& Hennen, 2017).
Some studies have noted an increase in the agricultural worker
population over the last decade, and the presence of agricultural workers
has been shown to increase the overall economic output of the regions
in which they work. In fact, research conducted about the agricultural
economy of Michigan found that agricultural workers contributed over
$23.3 million dollars to the state's economy annually by enabling
farmers to produce higher-value crops, after wages and housing were
deducted. Stringent immigration laws passed in Arizona and Georgia
demonstrated the devastating impact of farm labor shortages (NCFH,
2018a).

2278
 Living apart from society, the plight of migrant farmworkers was largely
ignored until exposure on a 1960 television documentary—Edward R.
Murrow's Harvest of Shame—created a national outcry. This led to the
passage of the Migrant Health Act of 1962, which addressed the specific
health needs of migrant workers for the first time in U.S. history. This act
authorized delivery of primary and supplementary health services to migrant
farmworkers (NCFH, 2018a). Federally funded migrant health clinics serve
areas in the United States where significant number of migrant farmworkers
gather. In 2010, 165 migrant clinics served more than 863,000 seasonal and
migrant farmworkers and members of their families, a number far below the
estimated 3+ million farmworkers thought to be in this country. Eligibility
for services at the clinics includes being principally employed in agricultural
labor for the prior 24 months (Farmworker Justice, 2020). Services may be
provided seasonally, on a temporary basis, or year-round. Staffing usually
includes doctors, nurses, NPs, PAs, outreach workers, social workers, and
dental and pharmacy workers, along with health educators.
Transportation may also be a component in some areas. Primary and
preventive health care services are provided to migrant workers and their
families throughout more than 500 clinic sites. However, funding is often
inadequate, and many clinics are not sufficiently staffed or operated to meet
the health needs of migrant farmworkers and their dependents. Most migrant
health centers receive funding from a variety of sources, including Medicaid
in some instances. Additionally, although these clinics exist throughout the
United States, large geographic regions are not served well or at all. Other
services, such as promotora programs that employ Hispanic lay health
workers or nursing voucher programs providing health care services at
participating clinics and nurse referrals to specialists, are available in some
areas. Encouraging recruitment of these health workers targeting Latino
communities, especially underserved ones, could potentially increase Latinas'
interest in serving as promotoras, improve the quality of promotora work,
and more fully engage Latinos in community health programs to address
their health issues (Molokwu, Penaranda, Flores, & Shokar, 2016; Schwingel
et al., 2017).

Migrant Lifestyle
To understand the health needs of migrant farmworkers and their families, it
is important to realize their lifestyle. Migrant workers and their families
endure a transient and uncertain life, with long hours, stressful working
conditions, low wages, and poor health care. Substandard housing, unsafe
working conditions, and language barriers make life even more difficult
(USDHUD, 2016). In addition, about 25% of migrant farmworkers have
been in the United States for under 1 year; therefore, American customs and

2279
behaviors may be foreign to them (Rao, Hancy, Velez, Freeman, & Davis,
n.d.).

Migrant workers are exposed to environmental hazards such as

pesticides, extreme temperatures, and chemicals.
Up to 20,000 pesticide injuries are reported yearly of the 2 million
agricultural workers in the United States.
Those in agriculture and farming are at risk for musculoskeletal injury.
In addition, limited or no PPE may be provided.
Workplace demands such as pressure to work without breaks coupled
with fear of job insecurity and deportation affects workplace stress
(Moyce & Schenker, 2018).

Depending on the economy and the crop, a migrant farmworker's income

varies widely. Migrant farmworkers' average annual income is $11,000; for a
family, it is approximately $16,000. This makes farm work the second lowest
paid job in the nation (after domestic labor). Even so, despite their poverty,
most farmworkers are not eligible for social services. Less than 1% of all
farmworkers use general assistance welfare, 2% use social security, and
fewer than 15% are Medicaid recipients (NCFH, 2018a).

Migrant Hero
César Chavez founded the National Farm Workers Association (NFWA; later
changed to United Farm Workers [UFW]), the first union in agricultural
labor history to successfully organize migrant farmworkers.

As a child, he traveled with his family to harvest crops, but they rarely
had enough food to eat and often lived in shacks.
Work was frequently scarce, wages were low, and labor contractors
cheated the family out of the money they earned.
Moving to California during the Great Depression, the family became
part of the migrant community.
Chavez attended as many as 65 different schools and dropped out of
school upon completing eighth grade, to help support his family by
working full time in the fields (Biography, 2019).
Chavez organized many successful strikes and boycotts, the most
famous one being the boycott of California grapes as a protest against
the indiscriminate use of spraying by growers in 1968. This boycott
lasted for longer than 5 years, and on two occasions, he fasted as a
protest against the use of agricultural pesticides. His efforts united
people who, as individuals, had no significance in the power structure.
His legacy is an example of how people can unite to build power
together. He achieved great recognition, although he never had the
financial trappings of success.

2280
Throughout his life, he ignored personal hardships to continue the
struggle with union victories and losses. Chavez and his union won
several victories for migrant farmworkers when many growers signed
contracts with the union.
As a labor leader, Chavez employed nonviolent means to bring attention
to the plight of farmworkers. He led marches, organized boycotts, and
went on several hunger strikes (Biography, 2019).

2281
Health Risks of Migrant Workers and Their
Families
Poverty, transient lifestyle, low literacy, language barriers, and cultural
barriers impede migrant workers' access to social services and cost-effective
health care (MCN, 2017a). In addition, migrant workers who use health
services must overcome other issues: limited means of transportation, lack of
time-efficient health care delivery methods, and the medical referral system.
In some areas, federally funded health centers are available to provide serves
to populations with limited access to health care. These include low-income
populations, the uninsured, those with limited English proficiency,
agricultural workers, individuals and families experiencing homelessness,
and those living in public housing (NCFH, 2018a). In 2015, the Health and
Resources Services Administration (HRSA) of the U.S. Department of
Health and Human Services reported that the health center program provided
health care to 910,172 agricultural workers and their families, with 92%
covered by specific funds to provide services to this population. According to
National Center for Farmworker Health (NCFH) (2018a) data, the most
common diagnoses reported by these Health Centers for migrant workers
included the following:

Overweight/obesity
Hypertension
Diabetes mellitus
Otitis media and eustachian tube disorders
Depression and other mood disorders

Migrant workers who are lawfully in the United States (including H-2A
workers) may receive coverage under the ACA. Legal farmworkers whose
income is below 138% of the federal poverty line may receive health care
through Medicaid. Workers unauthorized cannot receive health insurance
(MCN, 2017a).
Undocumented migrant farmworkers are “10.7 and 3% less likely to use
U.S. and foreign health care, respectively, compared to documented
farmworkers” (Luo & Escalante, 2018, p. 923). Health insurance has been
found to significantly increase hired migrant farmworkers' use of U.S. health
care by 22.3%. Notably, compared to their documented working peers,
undocumented migrant farmworkers are less likely to utilize private health
clinics and are even less likely to rely on migrant health centers, even when
these providers are their most viable sources of health services (Luo &
Escalante, 2018). National statistics on migrant seasonal workers are sparse,
with much of the data regional and only sporadically collected. Some of the
statistics include the following:

2282
 Migrant workers are a vulnerable and underserved population, with an
average life expectancy of 49 years, compared to 77.2 years for most
Americans. They have a greater disease burden than other populations
and work in occupations with high hazard levels.
TB rates tend to be 6 times higher for migrant workers and are at
increased risk for contracting a viral, fungal, bacterial, and parasitic
infections (La Cooperativa, 2020).
Migrant children are often delayed for immunizations and have an
increased incidence of TB; intestinal parasites and infections; nutritional
deficiencies and malnutrition; skin, respiratory tract, and ear infections;
dental problems; and pesticide and lead exposure (SAF, 2011–2019).
Migrant workers have high rates of work-related conditions, such as
musculoskeletal injuries, lacerations, falls, heat stress, eye injuries,
hearing loss, and skin diseases, because of equipment use and exposure
to pesticides and other chemicals, dust, exposure to hot and cold
extremes, and sun exposure (MCN, 2017a).
Migrant children are often exposed to heat and sun, musculoskeletal
injuries, pesticides, and hazardous tools and machinery (NCFH, 2018b).
The data indicate that HIV/AIDS is escalating among migrant
farmworkers and that steps need to be taken to prevent the impact
among the population and their families. Recommendations are
provided for improving health outcomes among migrant workers,
preventing HIV transmission, and providing continuous comprehensive
care and support for HIV-infected migrant farmworkers (CDC, 2020).
Poverty, migration patterns, lower educational level, and language
barriers may make it harder for some Hispanics/Latinos to get HIV
testing and care. Undocumented Hispanics/Latinos may be less likely to
use HIV prevention services, get an HIV test, or get treatment for HIV
because of concerns about being arrested and deported (CDC, 2020).
Migrants disproportionately suffer from the effects of COVID19 due to
economic hardships brought on by shutdowns and social distancing;
contagion risk due to overcrowding, predisposed health issues, lack of
access to health care, and uninsured status; and as targets for hate and
discrimination (Migrant Policy Institute, 2020).

Occupational Hazard
The hazards of agricultural employment, coupled with limited legal
protection, jeopardize the health of the migrant farmworker. Migrant workers
have higher rates of adverse job-related exposures and working conditions,
which lead to poor health outcomes, injuries, and occupational fatalities.
Health disparities of migrant workers are related to environmental and
occupational exposures, as a result of language/cultural barriers, access to
health care, documentation status, as well as the political climate of the host

2283
country (Moyce & Schenker, 2018). In a Canadian study with migrant
workers, participants reported that they did not speak up when they saw
unsafe workplace practices and even did not report their injuries for fear of
losing employment and fear of retaliation (Yanar, Kosny, & Smith, 2018).
Falls, cuts, muscle strains and sprains, and repetitive motion injuries (e.g.,
carpal tunnel syndrome) commonly afflict migrant laborers. Migrant and
seasonal farm work typically requires stooping, long hours working in wet
clothes, working with sometimes contaminated soil and water, climbing,
carrying heavy loads, and exposure to the sun and the elements. Failure to
perform these activities on a rigid timetable dictated by seasons and weather
can result in crop loss. This urgency compels farmworkers to labor in all
weather conditions, including extreme heat or cold, rain, bright sun, and high
humidity.

Migrant workers are among the most vulnerable members of society.

They are often engaged in what are known as “3-D jobs—dirty,
dangerous, and demanding (sometimes degrading or demeaning)”—and
these workers are often hidden from the public eye and from public
policy.
They work for less pay, for longer hours, and in worse conditions than
do nonmigrants and are often subject to human rights violations, abuse,
human trafficking, as well as violence.
Migrant workers are more likely to take greater risks on the job, do
work without adequate training or protective equipment, and do not
complain about unsafe working conditions (Moyce & Schenker, 2018).

Pesticide Exposure
Migrant farmworkers may be at higher risk of exposure to cancer-causing
chemicals than the general population (Fig. 27-11). They are exposed to
pesticides used routinely in the fields: picking produce that has been sprayed;
walking behind farm equipment that is mobilizing dirt that has been treated;
contact with pesticide spray from a neighboring field; bringing home
pesticide residue on their clothes and shoes; or exposure to chemical residues
in the soil, air, food, and well water (MCN, 2017a).

2284
 FIGURE 27-11 A crop duster applies chemicals to a field of
vegetation.

A large body of evidence exists on the role of pesticide exposures in the

increased incidence of human diseases such as cancers, Alzheimer's
disease, Parkinson's disease, amyotrophic lateral sclerosis, asthma,
bronchitis, infertility, birth defects, ADHD, autism, diabetes, and
obesity (Mostafalou & Abdollahi, 2017).
A study by Butler-Dawson, Galvin, Thorne, & Rohlman (2016)
indicated that children in farming communities are at increased risk
from pesticides due to a parent working in agricultural. Further,
organophosphate exposure may be associated with deficits in learning
on neurobehavioral performance, especially in tests of motor function.
Even though this pesticide is being phased out in the United States, we
still see elevated levels in agricultural households.
While research shows pesticide-associated cancers are higher in
farmworkers, data strongly suggest that cancer is even higher in
farmworker children. This is due to “a number of predisposing events
occurring prior to conception, in utero, and/or after birth” likely
resulting in a greater incidence of pesticide-related cancer in
farmworker children (National Center for Farmworker Health, 2018b).

Pesticide exposure levels in reproductive-age farmworkers consistently

exceed levels in the general population. It is estimated that thousands of
farmworkers suffer pesticide poisoning each year, but exact counts are not
possible because of inadequate surveillance systems and reluctance of
farmworkers to report injuries (Farmworker Justice, 2020). Surveillance
systems are only in place in 11 states; the Sentinel Event Notification System
or Occupational Risk (SENSOR) is a means of reporting pesticide-related
injuries as well as other occupational illnesses and injuries (CDC/National
Institute for Occupational Safety & Health, 2017). Some farmworkers,

2285
primarily those without H-2A visas, were less likely to be provided pesticide
safety equipment and often were not notified when pesticides were applied.
Reporting of pesticide-induced morbidity and mortality is not required in
every state. California has the oldest and most thorough pesticide
surveillance system in the United States, beginning in 1971 that requires
health care providers to contact their LHD whenever they suspect an illness
or injury is related to pesticide exposure. The health department then alerts
the county agricultural commissioner and also completes a Pesticide Illness
Report (California Department of Pesticide Exposure, 2020).
But, even with reporting laws, many cases are never recognized because
workers do not seek medical care. Pesticide burns and rashes often go
untreated because of lack of education about the dangers of pesticides and
lack of available services. Migrant workers are often unaware of the hazards
of pesticides.

Arcury et al. (2018) found that migrant farmworkers and

nonfarmworkers had detections for pesticide and herbicide urinary
metabolites.
Griffith et al. (2018) compared children's pesticide exposures by
expressing the child's pesticide metabolite concentration as a fraction of
the adult's concentration living in the same household. Exposures in
their community were consistently higher, often above the 95th
percentile of the exposures reported by the National Health and
Nutrition Examination Survey (NHANES).
Plascak et al. (2018) determined that dimethyl OP house dust
concentrations were 400% higher within homes where at least two
residents were agriculture workers.
Pesticide drift has been shown to result in elevated levels of active
compounds in both indoor air and house dust in homes near agricultural
application areas. Houses closer to agricultural herbicide applications
had significantly elevated levels of herbicides in house dust than in
homes that were further away (Shelton & Hertz-Picciotto, 2015).
Orchard air-blast applications of pesticides, along with wind direction,
can influence pesticide drift from crops into agricultural residences;
potential exposures can be analyzed through screening tests (U.S.
Environmental Protection Agency, 2018).

Even though it may be required of health care providers to report

pesticide poisoning, it is often misdiagnosed because the symptoms can
mimic those of viral infections or heat-related illness. Symptoms of pesticide
exposure include sore throat, runny nose, headache, fatigue,
red/swollen/watery eyes, drowsiness, itchy skin, abdominal pain, and nausea
or vomiting. More severe symptoms may include sweating, salivation,
blurred vision or pinpoint pupils, fever, severe thirst, muscle twitching, or

2286
weakness and incontinence (especially with organophosphate or carbamate
exposures). Finally, with the most severe exposures, seizures, respiratory
depression, and unconsciousness or coma can occur. There are over 19,000
pesticide products registered with the EPA and more than one thousand
active ingredients (U.S. Environmental Protection Agency, 2018). Only a
few categories of pesticides account for more than half of the cases of acute
illness; these include inorganic compounds, carbamates, pyrethroids, and
organophosphates. Although the impact of acute pesticide poisoning is
widely recognized, little is understood about the long-term effects of the
repeated low-level exposures to which migrant farmworkers are constantly
subjected. The Florida Department of Health lists the chronic effects of long-
term pesticide exposure as birth defects, cancers, blood disorders,
neurological problems, and reproductive issues. Extreme exposure can lead
to loss of consciousness, coma, or death (NCFH, 2018a). Numerous studies
have examined the link between exposure to pesticides and various
neurologic problems and cancer—most often with organophosphate-based
pesticides. Some evidence of an association between pesticide exposure and
the incidence of diabetes has been found (Grice et al., 2017). Prenatal
exposure to organophosphate pesticides has been significantly associated
with slightly decreased intellectual development (Hertz-Picciotto & Sass,
2018). Today, it is more common for farmworkers to be exposed to
“nonpersistent” pesticides that are metabolized in the body within days
(NCFH, 2018a).
The Environmental Exposure History, I PREPARE in Chapter 9, is a
helpful assessment tool for community health nurses working with migrant
and seasonal workers to use to determine pesticide exposure. When a client
presents with symptoms that may be suggestive of pesticide exposure,
mnemonic prompts may help to clarify common symptoms (Box 27-9).

BOX 27-9 Mnemonic Prompts to

Determine Cholinergic Symptoms of
Organophosphate Exposure
Sludge
Salivation
Lacrimation
Urination
Defecation
Gastric secretions
Emesis

2287
 Dumbbels
Defecation
Urination
Miosis
Bronchorrhea
Bradycardia
Emesis
Lacrimation
Salivation/seizures/sweating (the four most acute symptoms:
bradyarrhythmias, bronchospasm, muscle weakness, and
bronchorrhea)
Source: Open Anesthesia (2020); Rajan (2016).

Pesticide exposure can be a single event, may occur multiple times, or

can even be continuous. Health effects are thought to be a function of the
frequency of exposure and the dose. Most migrant workers come into contact
with pesticides through their work. However, exposure to pesticides does not
affect only those working in the fields.

Organophosphates decrease the levels of acetylcholinesterase, found in

nerve endings, and can be absorbed through the skin, inhaled, or
ingested. Most workers have metabolites present, and farm work and
housing close to agricultural fields are common factors associated with
exposure (Chem-Tox.com, 2019).
Drifts from sprayed fields and residues on farmworker clothing, shoes,
tools, and skin, as well as food brought from the fields, are all potential
sources of exposure. Vehicles can also become contaminated, as can
carpets and furniture. Contaminated clothing should be kept in separate
hampers and laundered separately; workers need to be encouraged to
leave boots and shoes outside their homes and to change clothing and
shower before eating and playing with their children. Substandard
housing is also a factor.

Agricultural fields are usually located in isolated areas on the outskirts of

rural communities (Fig. 27-12). While in these isolated fields, migrant
workers often are not provided with sanitation facilities or fresh drinking
water. Farmworkers experience more heat fatalities than any other group of
outdoor laborers. Migrant farmworkers are often paid by the piece instead of
the hour, which incentivizes the workers to not stop for breaks. This is a ploy
that employers use to get the workers to work faster and harder (Moyce &
Schenker, 2018). Migrant farmworkers also face many cultural barriers that
leave them “marginalized and unempowered” (Kearney, Hu, Xu, Hall, &

2288
Balanay, 2016). These cultural barriers are often the reason that many
employers do not offer sufficient safety education, shade, hydration, and
cooldown rest to prevent heat-related illnesses. Employers must show the
employees how important their safety and well-being is to them, while also
take proactive measures to conduct risk assessments and health education to
reduce unnecessary deaths and prevent heat-related injuries for agricultural
workers (Kearney et al., 2016). In fact, it is the employer's responsibility to
encourage workers to drink sufficiently to maintain hydration; to ensure
water availability; to facilitate worker access to water, shade, and other
resources; to provide regular rest breaks of appropriate duration for the work
conditions; and to monitor workers for signs of illness (Kearney et al., 2016).
California and Oregon have implemented such standards.

FIGURE 27-12 Fields in Eastern Oregon. (Source: USDA,

Agricultural Research Service.)

U.S. Laws Enacted to Protect the Migrant

Farmworker

2289
Below are some of the laws that have been enacted to protect migrant
farmworkers and their families. Even so, despite difficult working
conditions, farmworkers in the United States are excluded from many
federal-level labor protections (Rodman et al., 2016).

The Migrant and Seasonal Agricultural Worker Protection Act (MSPA)

(1992/revised in 2015): protects migrant and seasonal agricultural
workers through the establishment of standards relating to wages,
housing, transportation, disclosures, and record-keeping. This act also
mandates that farm labor contractors register with the U.S. Department
of Labor (NCFH, 2018a).
Occupational Safety and Health Act (1970): specifies that agricultural
employers with 11 or more employees who conduct hand labor
operations in a field must provide drinking water at a suitable drinking
temperature, toilet and handwashing facilities within a reasonable,
accessible distance, and the employee must be notified by the employer
of the location of such facilities (NCFH, 2018a).
Agricultural Worker Protection Standard (1992/revised in 2015):
Enforced by the Environmental Protection Agency (EPA), this standard
is primarily focused on the safe handling of pesticides. It now prohibits
children under the age of 18 from handling pesticides, requires that
workers do not enter areas recently sprayed with pesticides, and
improves protection for workers from retaliation if they make
complaints about standard violations (NCFH, 2018a).
Immigration and Nationality Act: The H-2A portion of this act offers
protections for H-2A workers concerning: pay rate; written notification
of a work contract with beginning and end dates; the three-fourths
guarantee (employee must guarantee employment for at least 75% of the
contract period); housing will be provided at no cost to the employee;
and the employer will be responsible for transportation to and from
work as well as to and from their country of origin (NCFH, 2018a).
Title VII of The Civil Rights Act of 1964: This act initially involved the
prohibition of employment discrimination based on race, sex, color,
national origin, and religion. Multiple amendments of this act are
especially significant for female migrant farmworkers. Title VII protects
employees of both sexes against sexual harassment such as: Quid pro
quo (offering a professional benefit in exchange for sexual acts); hostile
environments (sexual comments, suggestive physical contact, or
showing sexual materials); and retaliation (punishment from the
employer for reporting or formalizing a complaint on sexual
harassment) (NCFH, 2018a).

Substandard Housing and Poor Sanitation

2290
Quality of housing affects farmworker health (Wiltz, 2016). Formal
demographic data on farmworker housing are often lacking. Migrant worker
housing is often substandard or nonexistent.

In 1989, the North Carolina Legislature passed the Migrant Housing Act
of North Carolina, establishing minimum standards for agricultural
worker housing. The Migrant Housing Act requires that any person
owning or operating a housing unit for migrant workers and their
dependents register with the North Carolina Department of Labor and
have the housing inspected prior to the migrants moving in so that
corrections needed can be made (Langley et al., 2017).
Investigative reporting on migrant housing found that in seven states
along the midwest and southern territories found mold, sewage, faulty
electrical wiring, and pest infestation. To improve living conditions for
workers some states have offered tax credit for investors who build
farmworker housing (Wiltz, 2016). There is much room for sustained
advocacy and action for migrant farmworker housing as access to
adequate and safe employer-provided housing for migrant farmworkers
is needed.
Over the last decade, governmental agencies and nonprofit groups have
become more interested in the improvement of agricultural worker
housing conditions. The U.S. Department of Agriculture's Rural
Housing Service, the U.S. Department of Labor, and the U.S.
Department of Housing and Urban Development all provide housing
services to agricultural workers and can be contacted with agricultural
worker housing questions. Some of these programs include the Farm
Labor Housing Loans and Grants Program, the National Farmworker
Jobs Housing Assistance Program, and the Family Self-Sufficiency
Program (NCFH, 2018a).
In a classic article by Cole and Crawford (1991), a vivid example of one
migrant camp in Alabama highlighted workers living in a converted
chicken house. An upper portion of the wall had been removed for
ventilation, creating easy access for insects and birds. A dirt floor, a
single light bulb, and two portable toilets located a distance away were
some of the other features. Two sinks in a common living area provided
the only water for the almost 60 people who lived in the chicken house.
Many did not have mattresses, and because the workers were harvesting
potatoes, potato baskets often served as the only furniture.
Such living situations still exist today. Living with 13 other workers in a
three-bedroom home in Watsonville, California, a female farmworker
remarked, “We have to put up with this because we can't afford anything
else” (Holden, n.d., p. 40).

2291
 Migrant farmworkers move frequently, and often have great difficulty
securing adequate housing. Farmers who hire workers on H-2A visas are
required to provide free housing, but this accounts for only 2% to 5% of the
workers. For farmworkers who don't live in state-licensed or inspected
facilities, they may live in unregistered labor camps or rely on the private
housing market (Wiltz, 2016).
Although data on migrant housing are scant, surveys have uncovered the
following:

Over 50% of all housing units surveyed were overcrowded (compared

to only 3% of U.S. households), and 44% of mobile homes were
substandard.
Approximately 25% of the units surveyed had at least one broken
appliance or fixture, and 11% had no working stove.
Between 13% and 39% of housing is owned by employers, and for
those lucky enough to find employer-owned housing, over half of those
units were offered without charge.
Agricultural employers most commonly own single-family homes
(39%), apartments (14%), dorms/barracks (4%), motels (2%), and some
even reported living conditions not meant for human habitation such as
in cars, tents, and outdoors (2%).
Over 25% of housing units were located adjacent to agricultural fields,
and more than half of these had no working shower/tub.
Families with children occupied 65% of moderately or severely
substandard units (HAC, n.d.).

Substandard housing is not the only concern. Crowding is also a

problem, as many farmworkers, unable to find sufficient numbers of rental
units, share housing—sometimes paying per person costs. One of the few
studies on migrant housing found that Minnesota seasonal vegetable workers'
construction trailer barracks, housing 15 to 20 single migrant workers, rented
for $90 per month per person (Migrant Housing, n.d.). When housing cannot
be found, workers and families may have to resort to paying rent to live in
garages, barns, sheds, chicken coops, or they may be forced to stay in their
cars.

Poor Nutrition, Overweight, and Obesity

Migrant and seasonal farmworkers and their families have higher rates of
obesity and are more likely to be obese and overweight (Lim, Song, & Song,
2017). Despite often working among fruit and vegetable crops, migrant
families often have difficulty procuring food and maintaining a sufficient
supply. Farmworkers constitute a vulnerable population with several
characteristics that put them at risk for poor dietary quality: low income,

2292
food insecurity, rural isolation, poor housing, and lack of access to food
subsidy programs. In addition, parental feeding styles may underlie poor
dietary quality for children in farmworker families, where dietary quality is
poor. Because of the connections of diet quality to obesity and the negative
health outcomes of obesity, interventions to improve dietary quality for
migrant farmworker families are necessary (Quandt et al., 2016). Quandt et
al. (2018) also found that less than one in five migrant families supplement
meals with garden produce and food from food pantries, farmers markets,
and hunting, and fishing. Approximately one half of lunches and 25% of
dinners are purchased from vendors or other commercial sources, while 20%
report issues with food security. Food-related practices of migrant
farmworkers require change to improve the inclusion of fresh produce and
other nutrient-dense foods. Common health problems of migrant children are
similar to their parents and include general poor nutrition, anemia, vitamin A
deficiency.

Risks to Social, Emotional, and Behavioral Health

Migrant children are often called upon by their families to stay home
from school to care for younger children, attend to other household
chores, or even to work alongside their parents in the fields. Many
children of farmworkers report beginning as early as age 10 (MCN,
2017b).
They may feel socially estranged, be constantly moving, have difficulty
finding healthpromoting recreational activities, and have difficulty
assimilating (MCN, 2017b). This causes stressors related to
immigration status.
Migratory patterns for farm worker's children make it difficult to
complete credits and stay in school. The transient nature of farm
working means children may leave the school year early or receive
partial instruction for an academic year (Granados, 2018).

Migrant children are less likely to graduate from high school, because
educational interruption and difficulty “catching up.” Globally, children
between the ages of 7 and 14 who live in a rural setting are less likely to
attend school but more likely to work. The average level of education
completed was the eighth grade (NCFH, 2018b).
Research on children whose parents have been arrested, detained, and/or
deported has led to parental depression and poor cognitive and behavioral
outcomes for children (Migration Policy Institute, 2015). According to the
AAP policy Detention of Immigrant Children, children seeking refuge in the
United States endure emotional and physical stress and should not be
separated from families but instead should be treated with dignity and

2293
respect, according to the recently released. Separation from parents, siblings,
and other relatives and caregivers could exacerbate the children's health
problems and could also overwhelm the system and cause a crisis in care.
The situation becomes even more complicated when one parent of legal
children is born in the United States and is a legal citizen and the other is not.
Mixed-status families are extremely vulnerable in terms of access to health
care and increased chances of being impacted by family disruption through
deportation removal (Vargas & Pirog, 2016).
Ramos, Carlo, Grant, Trinidad, & Correa (2016) study results indicated
that stress and depression were positively associated with occupational
injury. Further, occupational injury was a significant factor for depression.
Participants who had been injured on the job were more than seven times
more likely to be depressed. These results highlight the interconnection
between the work environment and mental health.

Intimate Partner Violence

Intimate partner violence (IPV) is a serious public health problem with
substantial consequences for women's physical, sexual, and mental health.
Migrant farmworking women are particularly at risk in an intimate
relationship because of cultural beliefs and environmental factors, which
include challenges with the migratory lifestyle, limited finances, as well as
poor working and living conditions. In addition, the migrant women are often
less aware of resources to advocate for themselves within the health care
system, making interventions difficult (MCN, 2017a). While health care
provider screening for IPV increases the rates of identification, many
providers do not effectively screen (Wilson et al., 2015). Research on
domestic violence among this vulnerable population is scant, but more than
1,000 battered farmworker women in a multicenter study were interviewed
and researchers identified the typical profile as:

Childbearing age (15 to 40)

Hispanic
Afraid of their partner
Married or living with partner
Drug or alcohol use by partner

The overall incidence was 24.5%. Fifty percent of abused women were
pregnant at the time of the abuse (MCN, 2017c). What makes farmworker
domestic violence so significant is the fact that these women often
experience language barriers, do not have adequate access to health care, live
isolated lives with little social support, and fear deportation if they report the
abuse—all factors that lead them to endure their violent situation in silence.
One example is a migrant woman, who shared a one-room dwelling with her

2294
husband, infant, and five single men. Her husband became increasingly
violent and unpredictable. He began to beat her and the baby, and she was
unable to predict what would initiate a violent attack. She finally fled when
one of the men living with them also began beating her. She attributed the
aggressive behavior to the powerlessness felt by the men. The Violence
Against Women Act of 1994 affords protection for undocumented battered
women and children by allowing them to seek legal immigration status
without the help of their abusers (MCN, 2017c). C/PHNs must be aware of
these issues and what resources are available in the community (Box 27-10).

BOX 27-10 Levels Of Prevention Pyramid

Domestic Violence in the Migrant Population
SITUATION: Although the migrant lifestyle can
be difficult for the entire family, women and
children suffer most from family violence that the
migrant way of life promotes. Research is scant;
however, informal discussions occur among
women and health care providers. Outreach
workers sometimes possess lists of men who are
abusive and their victims. Isolation and
subjugation to a patriarchal system usually
prohibit migrant women from seeking help if
they are abused. Fear of consequences and
difficulty expressing negative views about their
husbands prevent women from speaking out
(MCN, 2017c).
GOAL: Prevent intimate partner violence.

2295
 *Secondary prevention is difficult because of limited financial resources, lack of transportation, no
nearby friends or relatives for support, language barriers (e.g., non–English speaking), and limited
safe shelters for battered women in rural areas.

Infectious Diseases
TB is a common infectious disease among farmworkers.
The number of agricultural worker patients diagnosed with TB at
Migrant Health Centers in 2016 was 261, equating to a prevalence rate
of 30.3 cases per 100,000 patients.
Research conducted with migratory workers near the U.S.–Mexico
border found that 55% of the 109 workers tested positive for a latent TB
infection (NCFH, 2018a). Because of their migrant patterns, it is
difficult to be accurately diagnosed and to complete treatment regimens;
they endure poor access to health care and social isolation.
Many factors may prevent them from successfully completing a
treatment regimen, and language barriers, along with cultural
differences, may preclude them from fully understanding the impact of
their disease on themselves and others. For instance, a Mexican migrant
worker may be diagnosed with TB in California and begin treatment
there but may move to Washington state to pick cherries and run out of
medication before completing treatment. Moving back to California for
summer work, he may again start treatment but may travel home to
Mexico during the winter, only to be reinfected by an older, untreated
member of his extended family.
Migrant children are at increased risk for respiratory and ear infections,
intestinal parasites, skin infections, TB, and delayed development
(MCN, 2017b). Lack of awareness that minor symptoms, such as
diarrhea, fever, or ear aches, may indicate a more serious underlying
issue can be problematic. An earache is minor, but it can lead to a major

2296
 problem, such as deafness, if left untreated. Delays in seeking medical
attention, due to poverty and a lack of health insurance, can create long-
standing health issues.

Migrant workers are at greater risk of HIV infection due to inconsistent

condom use; heterosexual contact with an infected male; use of commercial
sex workers due to the shortage of women in the rural communities; and use
of lay injections, where untrained peers will inject a migrant with vitamins
and antibiotics and reuse needles (Rural Health Information Hub, 2018b).
They also note that there is now a higher prevalence of HIV found in rural
areas of Mexico, as workers bring the infection back to their homes. HIV-
positive status may be misunderstood and, because of stigmatization and
fears of deportation, may be purposely hidden from health officials.
Estimated HIV rates are reported to be between 0.47% and 13%, depending
on geographic area and personal risk factors like drug abuse; however,
accurate national prevalence rates are almost impossible to attain (MCN,
2017a). Other infectious diseases (e.g., hepatitis, enteric diseases, and
parasites) may commonly afflict migrant workers, often because of
inadequate sanitation and hygiene facilities.
Whatever your viewpoint on this issue, it is important to the public's
health that basic health care services be available to vulnerable populations.
Continued efforts must be made to conduct research assessing risks and
hazards, especially those of pesticide exposure. Many government
publications document the despair and isolation of migrant workers, yet very
little has been done to address the living and working environments that
contribute to diminished health. Although migrant workers are a mobile
population and difficult to study, they represent an important, integral part of
our economy; infectious disease among this population increases health risks
for all (NCFH, 2018a).

2297
Unique Methods of Health Care Delivery and
Primary Prevention
Because migrant health centers do not adequately meet the health needs of
the entire migrant community, several innovative methods of health care
delivery have been developed and implemented by community health nurses.

Several programs are using promising models to intervene to address

some of the social determinants of child health by utilizing existing
programs and also linking community partners to better serve the
community. An example is the partnership between Farmworker Justice
and the Migrant Clinician's Network working together to monitor
initiatives to improve children's health (MCN, 2017b). Migrant
education programs, especially with Mexican American resource
teachers as role models, have also been helpful.
Mobile health vans staffed with bilingual community health nurses and
lay workers can travel to migrant camps; this provides an effective
strategy for outreach health screening and education. By going to
migrant camps and delivering care during nonwork hours such as
evenings and weekends, community health nurses increase health access
and overcome barriers. Although migrant families receive only
fragmented acute care, a nurses' outreach team can succeed in
encouraging migrant farmworkers to prevent illness with
immunizations, good nutrition, and healthy lifestyles. A viable
alternative to traditional medical clinics, the mobile nursing clinic
provides primary care to an underserved population through health
promotion, disease prevention, and early treatment (Williams, 2017).
Mobile dental vans can provide services to migrant worker's children,
often with arrangements made through school nurses and dental care
provided by dental schools or through partnerships. Barriers to good
oral health include lack of insurance, high cost of services, language,
immigration status, socioeconomic status, and fear/trust (Ponce-
Gonzalez, Cheadle, Aisenberg, & Cantrell, 2019). Children of migrants
are suffering from poor oral health; this disparity can be reduced by
improving their parents' literacy in their primary language and educating
parents regarding good oral health practices. An appropriate oral health
policy remains crucial for marginalized populations (Reza et al., 2016).
Migrant farmworkers were reported to have low levels of knowledge
about oral cancer risk factors and signs/symptoms and to be less likely
to seek preventive care (Dodd, Schenck, Chaney, & Padhya, 2016).
Migrant preschoolers were found to have overall low-quality diets, with
fewer than recommended levels of vegetables, fruits, and whole grains
in one study (Quandt et al., 2016).

2298
 Hispanic women have greater incidence and mortality rates of cervical
cancer when compared with non-Hispanic Whites in the United States
Fleming et al. (2018). Peer-led health instruction and coaching via
Charles (talking circles) may improve cervical cancer screening and
improve detection rates among farmworker communities.

Mobility impedes continuity of care, and the inadequate system of

medical record keeping for the migrant population is frustrating and
challenging. Data information systems are vital components for monitoring
the health status of individual farmworkers as they migrate, as well as
essential for generating research and follow-up care for long-range health
planning. Data also help justify appropriation of monies to migrant health
agencies. The Health Center Resource Clearinghouse (n.d.) is a 501c3
nonprofit organization that creates practical solutions intersecting poverty,
migration, and health. They have instituted tracking systems and clinical
tools for diabetes, CVD, cancer, and prenatal networks, to name a few.
Another system, TBNet promotes the completion of TB treatment among
migrant populations.
The medical histories of migrant children are often unknown to current
providers. The U.S. Department of Education (n.d.) now offers the Migrant
Student Information Exchange (MSIX) that permits states to transfer health
and educational information on migrant students. The MSIX system was a
part of the amended No Child Left Behind Act that was enacted by Congress
to assist states in developing an effective method of tracking educational and
health information as well as the number of migratory children in each state.
However, the ability to track these children in the migratory lifestyle from
one work location to another is often inconsistent. Early intervention for
migrating children is not always feasible, but it can greatly improve
outcomes.
MiVIA (“my way” in Spanish) is putting health records online and
making them available to migrant workers and their health care providers.
Workers get a photo identification card, and their records can be accessed
only by the use of a personal password. They can access their medical files,
medications, a medical reference guide (bilingual), and other resources, such
as local clinics and doctors, public transportation, and housing online, no
matter their location (MiVIA, 2016). The program began in California's wine
country in 2002 but is spreading to more distant locations.

2299
Community Health Nursing in Migrant Settings
Beyond barriers to health care, such as lack of health services, language, and
cultural impediments, inadequate transportation, financial strains,
underinsurance, and questionable residency status, which are by themselves
formidable obstacles, the migrant lifestyle is troubled with challenges.
Because of the insecurity and instability inherent in a mobile lifestyle, long-
term health goals are difficult to establish and long-term follow-up of any
chronic illness is problematic. Nonetheless, C/PHNs provide much-needed
services using community resources, innovative thinking, tenacity, and
sensitivity.
Strategies for improving the health status and resource use of migrant
workers and their families include the following:

Improving existing services

Advocating and networking
Practicing cultural sensitivity
Using lay personnel for community outreach
Utilizing unique methods of health care delivery
Employing information tracking systems

Community health nurses are the major providers of migrant health

services and have a crucial role in the development and management of
interventions. In response to the growing need for available, accessible, and
affordable health care for farmworker families, nurses are called on not only
to understand the migrant lifestyle but also to help migrant families
overcome the barriers to health care (Box 27-11).

BOX 27-11 PERSPECTIVES

Nurse And Nursing Instructor Viewpoints On

Migrant Health “I spoke with one of my students
after clinical last week, and she told me about her
work this semester with a 35-year-old single
mother of two who had been discharged from the

2300
hospital following a lupus flare-up. The student
felt that her client was a devoted mother, but she
let her 8-and 12-year-old children stay home from
school to help with family farm tasks in order to
make ends meet. After weekly visits with her
client for almost 2 months, she told me—‘I was
finally able to get her to trust me enough to help
her trust others.’ She has reached out to her
neighbors and asked for help and they are more
than willing to lend a hand. Now, her children can
return to school and go back to being children
instead of day laborers! I told her that sometimes,
it takes a strong person to reach out for help and
that she is a strong woman!”
Kevin, nursing faculty member, faith-based college, western Massachusetts
“I was having a conversation with students about how to “break the ice”
when making home visits to families who have never had home health
services. One student mentioned that at the beginning of the semester, she
was afraid that her shyness would be her downfall. But in the week that
followed, it occurred to her that the best way to establish trust with anyone
is to express an interest in answering questions they have before you pose
your own. The student now makes it a habit to ask every patient the three
things they would like her to know about them that will help her to
personalize their care. During week 8 of the clinical semester, the student
stated—This was a real “icebreaker” and my patients have been much more
open to listening and learning from me once I listen and learn about them!”
Betsy, community health nursing instructor in a northern California school
of nursing “First of all, a nurse should expect the unexpected. Because of
the migratory way of life…clients do not always know where they will be
next week or next month. Therefore, we must understand that they do not
always have their medical records, immunization records, or income
records. Hours are very irregular, depending on what time the workers get
in from the fields and what time the shifts are. Because of the distances we
travel, we work anywhere from 8 to 12 hours a day. The most rewarding
part of the job is bringing health services to the underserved and uninsured.
The people are so gracious and appreciative of whatever services we
provide.”

2301
 J. S., RN, Michigan
“Since farmworkers come to our area for only 4 months of the year, it is
rare that I care for a migrant woman through her entire pregnancy. I may
diagnose her pregnancy, I may see her for three or four prenatal visits, or I
may meet her only once before she goes into labor and delivers her baby. I
struggle with the desire to make a difference in a short period of time and
with the disappointment of not being able to follow through.”
C. K., CNM, RN, Pennsylvania
“I worked as a Head Start nurse for many years in an agricultural area
of California. One of my assignments was a state/county migrant farm labor
housing project. I was asked to make a home visit to check on a 4-year-old
who hadn't come to preschool in a few days. When I arrived at the family's
duplex, I found the sixth grader there, caring for all five of her younger
siblings, including the 4-year-old and an 8-month-old baby. When I asked
why she was home with all of the children, she guardedly informed me
(after some coaxing) that her parents had been picked up in an immigration
raid at the tree farm where they worked and had been taken back to Mexico.
The children were now alone, with no family nearby. I worked with a nun at
Catholic Social Services to provide care for the children until the parents
returned to the United States so that the children, who were all U.S.
citizens, would not be placed in foster care. The parents had not been
allowed to contact their children before being placed on the bus to Mexico,
but other workers, who were not undocumented, had seen them go and told
the children about their plight. It was heartbreaking to see the fear in their
eyes. I quickly went to work looking for resources for them.”
Holly, Head Start nurse, California

In the past, male migrant workers traveled primarily in organized crews;

now, they may travel in family units with women and children. Added
attention must be given to family members exposed to the hazards of the
migrant lifestyle. Even as many migrant workers settle into communities, the
cycle of poverty continues as other workers arrive from impoverished
countries. With a paucity of health resources, the C/PHN is sometimes the
only health provider who provides care for this population.
Providing care for migrant workers presents a challenge, requiring nurses
to be innovative and to go beyond the boundaries of traditional health
services (Box 27-12). Although many resources and programs exist to help
migrant families, the needs are still overwhelming. By aligning with the
goals of Healthy People 2030 to improve the health of one of the most
underserved populations, the community health nurse will also be improving
the health of the nation as a whole.

2302
BOX 27-12 C/PHN USE OF THE
NURSING PROCESS
Working With Migrant Families
Background Data and Assessment Tom Reynolds
is a community health nurse in central Montana.
He has three migrant camps in his service area
that are homes for primarily Mexican residents.
The men primarily work in strenuous
construction jobs–masonry, landscaping, and in
agriculture (cherry orchards, dairy farm, and
ranches). The women work as housekeeping staff
in private homes, motels, and hotels in the area. In
the evenings, he would stop by the camps to catch
up with residents and assess any current health
concerns. At the end of a 3-week period, Tom had
met with the residents in each of the three camps.
The feedback from these informal conversations
assisted Tom in the formulation and
implementation of a nursing plan of care targeting
the health promotion needs of this unique
population of residents.
Problem Statements
1. Changes in the family health status secondary to language,
transportation barriers, and health literacy barriers 2. Fear as it relates
to deportation and separation from family members 3. Occupational
and situational injury, illness, and stress because of extended work
hours and poverty-level living conditions

Plan and Implementation Tom researched funding

options for a demonstration project that was
sponsored by the local health department. The

2303
director of the health department agreed to
support the project for 6 months if Tom could find
matching funds for the project from a local
foundation, recruit the needed personnel, and the
results were positive.
Tom was able to recruit three other community health nurses, one of
whom was bilingual and familiar with the cultural values and practices of the
migrant workers. In addition, Tom reached out to the university's
undergraduate nursing program and the community health instructor agreed
to utilize the three camps as clinical sites for the upcoming semester. The
nurses, students, and staff social worker from the health department
coordinated weekly evening and weekend visits to each of the three camps.
The teams completed a family assessment for each family: established health
records, completed a community-based assessment for each of the three
camps, administered immunizations, assisted with arranging transportation to
and from medical appointments, and enrolled families in the Women, Infants,
and Children Supplemental Food Program (WIC). In addition, the teams
completed short teaching sessions on topics such as oral care, hand hygiene,
family planning, and infant safety.
The students were inspired by Tom's energy and asked to utilize this
experience to develop their Capstone Projects that centered on meeting an
unmet need of the unique group of residents. The local farmworkers heard
about all of the activities at the camp and they began to organize food and
clothing drives to assist the residents in meeting the challenges of the warm
Montana summers and snowy winters.

Evaluation
The evaluation of the interventions was so positive that the program became
a permanent service of the health department. In the months that followed, a
nurse practitioner and volunteer dentist were added to the team to provide
on-site care and evaluations. With optimal health and a decrease in issues
related to health disparities, several families were able to leave the camps
and establish permanent homes in the local community.

2304
URBAN HEALTH
Urban health is influenced by the interactions of citizens in three areas:

Where they reside

Where they work
Where they gather for daily life events

According to the World Health Organization (WHO) (2020a) the

following facts influence the social determinants of health in urbanized area
settings:

Poverty: Often, poor urban households may be hidden in urban areas of

higher wealth. Many people are also likely to be pushed into poverty
due to higher prices of essential commodities in urban areas.
Slums: Approximately 33% of the developing world's urban population
lives in slums, accounting for close to one quarter of the total global
urban population. Slums are characterized by overcrowding, lack of
access to safe water and sanitation, and safety concerns. Poor housing
conditions, overcrowding, lack of access to safe water and sanitation,
and a lack of secure tenure characterize slums. Lack of access to and use
of safe, sustainable water and sanitation is globally one of the biggest
contributors to ill-health and preventable mortality.
Poor air quality: Data from >1,600 cities, 88% of the urban population
are exposed to particulate matter levels in the air that exceed WHO Air
Quality Guideline values.
Child labor: Globally, 168 million children worldwide are child
laborers. Child laborers comprise 11% of the child population as a
whole. In urban settings, child domestic labor is a principal
phenomenon.
Health concerns: A range of acute and chronic health concerns and risk
factors has emerged in urban settings, and these realities offset earlier
gains. Noncommunicable diseases (NCDs) are pervasive to urban
living.
Transportation: Cities and towns within residential urban areas were
designed for the convenience of private automobiles, which makes it
extremely difficult today to provide efficient access to public services
for older people, especially once they are no longer able to drive.
Substance use and abuse (including alcohol, prescription, and illegal
substances).

2305
 There is a direct relationship between the health of urban residents and
the physical environment, the social influences within the environment, and
access to services that support physical health and social well-being. Urban
health considers those characteristics of the environment as they relate to the
health of the population living within large cities. Characteristics that define
urban areas such as size, density, and complexity come with advantages and
disadvantages; large size in cities may mean that the public health system can
efficiently reach large numbers of people for interventions but may also lead
to incomplete coverage for services due to larger populations.
During recent decades, public health crises, such as the flooding from
Texas to Arkansas due to excess rain (2019), the Flint, Michigan water crisis
(2014) and wildfires in California (2018) powerfully demonstrate the
convergence of race, place, and poverty in determining health outcomes.
Tung, Cagney, Peek, and Chin (2017) described the Flint water crisis, as an
urban nightmare marked by concentrated poverty, deteriorating housing
conditions, infrastructure decay, and organizational failure in a city inhabited
by predominately poor, black residents. See Chapter 9 for more on this.
Deaton (2018) documented the link between poverty, human rights, and
the inequities of the U.S. health system. According to Deaton, 40 million
people (12.7%) of the population live in poverty within the United States and
that number is growing exponentially because of the inequities in our nation's
health system. The following are some of the most astounding findings from
his analysis:

U.S. infant mortality rates are one of the highest in the developed world
(ranking 33 out of 36) (America's Health Ranking, 2018).
The United States has the highest prevalence of obesity in the developed
world.
In access to clean water and safe sanitation, the United States ranked
36th in the world.
The United States has the highest income inequality rate of all Western
nations.
Eight million more Whites are poor in America than are African
Americans living in poverty. Thirty-one percent of poor children are
White, 24% are Black, and 36% are Hispanic.
Seven million Americans making more than 150% of the poverty line
($31,000 for a family of three) dropped below the poverty line after
paying medical costs between 2010 and 2014. Over half of them ended
up below 50% of the poverty level.

How can the poorest of the poor Americans overcome the health
disparities that surround their daily lives? The solution posed by Deaton and
other health care advocates is to support the implementation of nationwide
universal health coverage.

2306
 In 2000, the Johns Hopkins University founded the Urban Health
Institute (JHI) as a means to bolster support among an inner-city population.
The goals of the Institute (2018) include the following:

Facilitate collaborations between JHI and the Baltimore community

around research, community projects, program
planning/implementation, and evaluation.
Improve the understandings of JHI as they relate to the health needs and
goals of the community and, concurrently, to improve the
understandings of the community as to the work that JHI does that has
the promise of improving the health and welfare of the community.
Strengthen the capacity of the Baltimore community by bringing the
knowledge and skills available through JHI to community-identified
needs and issues.
Strengthen educational offerings and opportunities within JHI as they
relate to urban health and development.
Initiate long-term, cooperative interventions that will improve the
health and well-being of Baltimore and the East Baltimore community.

The New York Academy of Medicine (2020) has organized the Institute
of Urban Health to the academy sponsors the Journal of Urban Health, a
publication that focuses on population-based research with low-income and
at-risk populations living in urban areas. But how did the health of these
urban communities regress to such conditions that focused efforts are now
required? The routes of these conditions trace their origins to the 1800s.

2307
History of Urban Health Care Issues
An examination of urban health care issues requires an in-depth analysis of
the vulnerabilities of urban dwellers that has existed for centuries. The
following list provides a historical summary of these unique issues:

Housing: During the mid-1800s and early 1900s, U.S. population

increased dramatically due to the influx of millions of immigrants from
large European and Eastern European countries. Groups of individuals
and families began to congregate in urban tenements and ghetto housing
buildings. The 1893 World's Columbian Exposition in Chicago
introduced the “city beautiful” concept of replacing crumbling urban
cities and tenements with more classical buildings and parks/lakes to
address the crime and social problems of the day (Pain, 2016).
Poverty: Today, Haitian and Middle Eastern families inhabit some of the
same neighborhoods that were inhabited by the Eastern European
immigrants during the early 1900s. However, many of the same
buildings continue to provide less than optimal shelter for this new
group of immigrants. Although ghetto living provides a sense of
belonging, for many, it is temporary because it engenders more
negatives than positives. Children and grandchildren of the original
immigrants seek different lives for themselves, away from the urban
areas that are often riddled with crime, unsafe housing, and disease.
Others, because of poverty, drugs, or fear of being homeless, remain in
urban slum areas.
Access to health care: Access to care remains inequitable due to
cultural, economic, and health literacy barriers that were not adequately
addressed by many health care organizations.

Two connected disciplines, urban planning and public health, have

addressed housing and health care issues from the 19th century to the
present. Urban planning worked to improve the welfare of individuals and
communities by supporting the growth of healthy, effective, appealing, and
accessible places. Urban planners often address the community's needs
related to diversification of the transportation system, housing, reducing air
pollution and greenhouse gases, street network design, and built environment
site design; in some large cities, these tasks are handled by separate
departments that do not often interface with environmental or public health
(Nieuwenhuijsen, 2016).

The American Public Health Association (APHA, 2020) describes the

mission of public health to “promote and protect the health of people
and the communities where they live, learn, work, and play.”

2308
 Public health leaders promote wellness by encouraging healthy
behaviors. Together, these disciplines addressed the needs of the
identified vulnerable populations. Initially, during the late 19th and
early 20th centuries, these two systems were linked in promoting health
by facilitating physical activity through the creation of green space.
They also designed cities to be less vulnerable to contagions. They
joined together in preventing infectious diseases by ensuring healthful
drinking water and sewage systems (Owens, 2016).
The target of public health agencies shifted from investigating ways to
improve the infrastructure to a focus on germ theories and
immunizations, challenges that were easier for physicians to address
than changing environments.

Objectives of specialists in urban planning and public health are to

support sustainable urban development in developed nations are to mitigate
climate change, minimize energy consumption, reduce pollution, protect
natural areas, and provide a safe and healthy environment for the citizens,
particularly those who comprise the most vulnerable populations. Leaders at
the CDC are concerned with factors that affect people and their environments
and support efforts that address the improvement of both physical and social
environments as related to places to live, work, and play. The CDC's Healthy
Places describes the components involved: interaction between environment
and health, poorly planned growth leading to sprawl, and increased used of
vehicles, and healthy community design that promotes health and well-being
(2017).
The WHO provides education and information regarding strategies that
will optimize the health of cities and their citizens (WHO, 2020b). WHO
recognizes the opportunities that exist for urban residents regarding health,
education, and safety while acknowledging the unique risks that face urban
residents (WHO, 2020a). By 2050, 70% of the global population will live in
cities (WHO, 2020a). Issues of overcrowding and lack of available sanitation
facilities and clean water increase the risks of communicable diseases for
urban residents who reside in urban slums and tenement housing projects.
Additionally, there is an increased likelihood of substance use disorders,
urban crime, violence, and mental illness due to global poverty issues and
barriers posed by the limited health literacy of urban residents. WHO
advocates for education and program initiatives that support the physical,
emotional, and social health of all urban residents.
The Healthy People 2030 document addresses societal determinants of
health and the environments in which we live, work, and play.
Notwithstanding the complexity of urban areas, particularly in large
metropolitan cities, health promotion efforts and a focus on healthier
environments are key components of this national health effort. Topical areas

2309
of concentration include global health, adolescent and older health, and the
social determinants of health. These foci allow governmental policy leaders
to assess, implement, and evaluate health programs regarding information
and resources to optimize health in urban communities.

2310
Emerging Issues in Access to Health Services
Access to health care in the United States is regarded as “unreliable” because
many people do not receive the appropriate and timely care they need. The
U.S. health care system, which was already overwhelmed, has faced an even
greater influx of patients because health care reform was fully implemented
in 2014; 20 million Americans have gained health insurance coverage yet
millions still lack (U.S. Department of Health & Human Services
[USDHHS], 2020b). Health care issues that should be monitored over the
next decade include the following:

Increasing and measuring insurance coverage and access to the entire

care continuum (from clinical preventive services to oral health care to
long-term and palliative care)
Addressing disparities that affect access to health care (e.g., race,
ethnicity, socioeconomic status, age, sex, disability status, sexual
orientation, gender identity, and residential location)
Assessing the capacity of the health care system to provide services for
newly insured individuals
Determining changes in health care workforce needs as new models for
the delivery of primary care become more prevalent, such as the patient-
centered medical home and team-based care
Monitoring the increasing use of telehealth as an emerging method of
delivering health care (USDHHS, 2020b, para. 10)

2311
Urban Populations and Health Disparities
The majority of the world's populace now lives in cities, which is a change
from long-held rural dominance (Fig. 27-13). An analysis of the mortality
rate differences between high-poverty urban and high-poverty rural areas
suggest that place characteristics influence health and health outcomes above
and beyond the impact of the social determinants of health for those
populations. However, it is important to note that these populations are not
static in their residence and the dynamic nature of urban living directly
influences the health of populations over time.

FIGURE 27-13 An example of urban housing: Colorful Victorian

homes in San Francisco, California.

Along with urban living, other global challenges include health inequity,
NCD, infectious disease, and the social determinants of health (Lee et al.,
2018; Winchester et al., 2016). The greatest growth of large cities around the
world is among less-wealthy nations, where urban slums are developing at a
rapid rate, but leave many still impoverished and without piped water and
sanitation (Ritchie & Roser, 2018). Depending upon the classification used,
more than one third of the U.S. population lives in central cities.
In the United States, in 2018, 83.7% of the population is urban
(273,368,693 people), which is expected to increase to 86.1% (305,356,412)
by 2030 (Worldometers, 2017). According to the Pew Research Center
(2020), in the United States, 14% of the population lives in rural areas (46
million), 31% are urban residents (98 million), and 55% live in the suburbs
(175 million). Rural county populations have lagged in recent years, with one
half having fewer residents now than in 2000 (Table 27-2).

2312
TABLE 27-2 Urban Versus Rural Trends

One example of how changes in population can adversely affect large

cities can be found in Baltimore. Between 2017 and 2018, the city lost 7,436
or 1.2% of its population and marks the 4th year for a population decline.
Domestic migration, where the population moves out of the city to other
cities and counties than those that move into the county, accounts for the
decline (The Washington Post, 2019). Population loss leads to a smaller tax
base and a greater proportion of poor residents, yet the city had the same
maintenance expenses for sewers, water lines, and streets.

Historically, movement to the suburbs began with the housing boom and
highway expansion occurring after WWII.
People moved from large cities to more suburban areas, and shopping
malls and schools followed.
Cars became even more essential, because public transportation did not
always extend into suburban areas thereby leading to long commute
times and traffic congestion.

Although not all suburban areas have remained attractive and vital, an
income gap persists between city and suburban residents. Poverty is two
times greater in large central cities than in corresponding suburban areas
(19.6% vs. 11.2%); the suburban poor, or those living below the poverty line,
grew by 57% between 2000 and 2015. By 2012, 59 of the top 95
metropolitan areas in the United States found the majority of their region's
poor located in the suburbs. In 2015, 16 million poor people lived in
suburban areas (Kneebone, 2017). This is indicative of a “suburbanization of
poverty” (p. 12). Poverty rates were highest in metropolitan areas in the
Midwest and South, and almost half of all large cities had significant
increases in poverty rates. Only about one third of suburban areas recorded
poverty rate increases.

2313
 Today, the declining urban situation is not confined to a few large cities.
To achieve the vision of creating “social, physical, and economic
environments that promote full potential for health and well-being for all” as
an overarching goal of Healthy People 2030, more must be done to promote
health and prevent disease in urban areas (USDHHS, 2020a, para. 11). The
primary reason for health disparities, as mentioned in Chapter 23, is the
disproportionate burden of certain health and social problems among
different populations—in this instance, urban areas. Environmental exposure
to air pollution contributes to illness and mortality including heart disease,
cancer, and respiratory diseases. Consumer products (e.g., fast-food, alcohol,
tobacco) are more readily available in urban and low-income areas and have
been shown to be significant health risks that contribute to health disparities
(Holleran, 2017).
Other environmental issues, such as extreme heat events where
temperatures rise and lead to climate-related deaths, may amplify public
health stressors and profoundly affect vulnerable populations. When
examining urban form and its relationship to this weather phenomenon,
exposures to dangerously high temperatures are a public health threat
expected to increase with global climate change (CDC, n.d.).

Heat waves can exacerbate the risks associated with heat exposure, and
urban residents are more vulnerable to these threats due to the urban
heat island effect. Urban planners are urged to consider construction
limits in order to help with thermal regulation (Eagleview, 2016).
Urban cities are often heat islands because of fewer green spaces and a
larger proportion of asphalt. Extreme heat events not only lead to
increased ED visits for heat-related illness, they can lead to increased
hospitalizations for those with asthma and other chronic conditions, as
well as death for elderly and other vulnerable populations (Matte et al.,
2016; Soneja et al., 2016; Winquist, Grundstein, Chang, Hess, & Sarnat,
2016).
Cities provide interventions such as extreme heat warnings and cooling
centers but not all residents avail themselves of these services.
Canadian researchers (Bélanger et al., 2016) interviewed almost 3,500
people in 1,647 buildings in disadvantaged areas across nine of the
largest cities to determine their perception of adverse health effects of
urban heat. Those with negative health impacts relied more on
adaptation methods (e.g., eating iced foods, visiting air-conditioned
places, taking showers to cooldown, turning off appliances). As with
rural areas, the built environment greatly impacts urban neighborhoods.

Urban health equity depends on political empowerment of the people to

strongly represent their interests and needs in order to challenge unfair
distribution of resources. Further, with most of the world living within the

2314
built environment, this poses a major opportunity to improve urban health
and equity (APHA, 2018). Poor social conditions and health inequalities
have been recognized in urban areas around the world. Urban slums in low-
and some middle-income countries provide social exclusion for many living
in poverty and threaten development. For example:

The Zika virus was, and continues to be, a disease of the urban poor.
Slum-defining characteristics, such as poor water and sanitation,
crowding, and poor structural quality of housing, offer ample
opportunities for mosquitoes to breed and spread the Zika virus (Snyder
et al., 2017).
People in cities are also at risk for COVID19 infections based on risk
factors such as household overcrowding, race, ethnicity, low income,
and underlying health conditions such as diabetes and obesity (NYU
Langone Health, 2020).
Inadequate urban housing and neighborhood disorder are related to
poor-quality sleep among Latino adults (Chambers, Pichardo, &
Rosenbaum, 2016).
Prenatal exposure to particulate matter (diesel fuel, perchloroethylene)
has been shown to affect math scores when the children reach third
grade; researchers suggest “individual pollutants may additively impact
health” (Stingone, McVeigh, & Claudio, 2016, p. 144).
Indoor environmental exposures are contributors to childhood asthma
morbidity. Indoor area pollutants have been associated with asthma
symptoms in children, and reduction of indoor allergens and pollutants
has shown improvements in asthma symptoms (Matsui, Abramson &
Sandel, 2016).
Urban indoor environments in multifamily housing units pose
challenges as pollutants may be seen in many of the units and residents
have limited ability to make changes (EPA, 2018).

In addition to concerns about housing, hazardous waste landfill sites are

often located in or near urban areas. Noise exposure, often associated with
large inner cities, has been linked to cardiovascular death, hypertension, and
ischemic heart disease (Munzel et al., 2018). In Flint, Michigan, following
pollution of their water system, soil lead data show higher lead values in the
metropolitan city center, and seasonal blood lead variations indicate that
resuspension of lead dust may be to blame (Laidlaw et al., 2016). See
Chapter 9 for more on environmental health.

Continued exposure to higher sound levels found in large cities can lead
to noise-induced hearing loss as well as decreased levels of work
performance, among other things (Recio, Linares, Banegas, & Diaz,
2016).

2315
 Significantly lower psychomotor speed and reduced working memory
were found in a sample of healthy adults when subjected to urban noise
levels (Wright, Peters, Ettinger, Kuipers, & Kumari, 2016).
Lead poisoning has been more often reported in older homes and
apartments in large cities (Childers, 2017).
A national study found that traffic-related air pollution (measured by
nitrogen dioxide levels) was significantly associated with small for
gestational age births and lower birth weights and may be a source of air
pollution related to poor pregnancy outcomes in Canada (Fig. 27-14;
Stieb et al., 2016).
Another study examined the effects of long-term air pollution exposure
on survival rates for acute myocardial infarctions (Chen et al., 2016).
Researchers concluded 12.4% of deaths could have been prevented if
the lowest measured concentration of ambient fine particulate matter in
urban areas had been consistently achieved over the study period.
The risk for major depressive disorder has also been shown to increase
as exposure to particulate matter increased; this was true in the general
population but was even more highly significant in people with chronic
diseases (Kim et al., 2016).

FIGURE 27-14 Air pollution is a common problem in

metropolitan areas, as seen in this view of the Los Angeles skyline.

While global data have often suggested that urban residents have better
health on average than their rural counterparts, this benefit is truly only
greater for those at the high end of the income scale. This only magnifies the
disparities in urban areas between rich and poor or the social gradient. A
more current view is that those living in urban slums, often in megacities
outside the United States, have health outcomes that are either similar to or
worse than those of their rural neighbors (Kneebone, 2017).

2316
 Violence is often associated with large metropolitan cities. After many
years of a decline, the national rates for violent crimes increased from 2014
to 2016 or 361.6 per 100,000 in 2014 to 386.3 per 100,000 in 2016. Crimes
increased by 4% in cities >1 million, decreased by 4% in cities from 500,000
to 999,000, and increased by 5% in smaller cities <50,000 (Congressional
Research Service, 2018).

In 2015, victimizations of people from urban areas accounted for 40%

of all rapes and sexual assaults, 48% of robberies, and 40% of
aggravated assaults.
In contrast, victimizations of those living in rural areas accounted for
5% of rapes and sexual assaults, 5% of robberies, and 14% of
aggravated assaults.
Over a four-decade period, Parker and Stansfield (2015) found that
increased population diversity in U.S. cities contributed to declining
homicide rates; racial differences were noted with growing Hispanic
presence in Black areas leading to lower Black homicide rates, but no
differences were found in White homicide rates.

Among youth, Latinos/Hispanics are disproportionately represented

among youth gangs, and substance use and sales are gang-related activities.
Individuals who are exposed to urban violence may develop PTSD, and a
study examining health-related quality of life among those with PTSD who
were exposed to urban violence found that they had higher levels of anxiety
and depression, more childhood traumas, and more new trauma experiences
(Pupo, Serafim, & deMello, 2015). Supportive family members were shown
to be associated with decreased levels of involvement with violence during
adolescence. While those living in low-resource urban areas may be unable
to avoid witnessing violence, having one supportive parent was a predictor
for significantly less violence involvement (Culyba et al., 2016).
Inner cities are often thought to be places with low-income residents
living in large, poorly maintained government housing projects. Dilapidated
housing in central cities exposes residents to cracks in walls and ceilings,
peeling paint, broken windows, leaking pipes, and pests such as cockroaches
and rats. There is often limited access to adequate rental properties, and rent
is often higher in large cities, making it difficult for low-income residents to
find adequate housing.

Nationwide, about one third of households live in rentals, but 43% of

rental properties are in central cities. Median rents in 90 cities were over
30% of the gross median income; no more than 30% of one's household
income is considered to be affordable rent (Pew Charitable Trusts,
2018).

2317
 In Chicago, the average rental percentage increased from 21% to 31%,
and New Orleans reported 35%. Miami rent is now 43% of the typical
household income, despite efforts to increase the number of apartment
buildings.
Apartment rental growth has seen an increase nationally of 1.6% with
some areas such as Phoenix and Las Vegas seeing additional growth.
Rental rates have increased by 1.3% nationally with rent hikes of over
30% in Colorado and California (Salviati, 2020). Low-income housing,
when available, is often plagued with construction and maintenance
problems and is characterized by crowding, poor quality, high
population density, and attendant health problems. Over 1.3 million U.S.
households are located in public housing. Over one third of rental
housing was built before 1960, and owners of multifamily rental
properties that have lost tenants and income may scrimp on maintenance
that decreases property values even more (Pew Charitable Trusts, 2018).
Urban poor are often forced to live in neighborhoods that do not
facilitate outdoor activity or have markets that provide healthy foods,
such as fresh fruits and vegetables.
A walk through most urban corner markets reveals that they do not
always offer low-fat dairy products or fresh produce but generally do
their best business selling lottery tickets, liquor, sodas, and cigarettes.
In New York City, it is estimated that only half of residents consume
two or more servings of fruits and vegetables daily, and typical
interventions aimed at increasing consumption are not likely to be
effective in neighborhoods with low education levels (Li, Zhang, &
Pagán, 2016).

In a Philadelphia study of patients with high hospital utilization (≥3

inpatient admissions within 12 months; ≥6 chronic illnesses), 30% were
found to be food insecure, and 25% were marginally food insecure (Phipps,
Singletary, Cooblall, Hares, & Braitman, 2016). In the past 30 days, 40%
were concerned that their food would run out, 17.5% said that they did not
eat for a full day, and 10% reported being hungry and not eating some or all
of the time. Food insecurity can have negative impacts on health, especially
for those with chronic conditions. In a qualitative study of San Francisco area
individuals with HIV/AIDS, participants discussed living on insufficient
food supplies and being hungry, as well as having concerns about the
potential poor health effects of eating a “cheap diet” (Whittle et al., 2015, p.
154). Some reported having to use socially and personally unacceptable
means of getting food (e.g., trading sex for food, depending on
friends/family/charities). High rents related to gentrification of their
neighborhoods were cited as a cause of their food insecurity.
Sociologists Wilson and Kelling first proposed the broken window theory
in 1982, noting that if a broken window goes unrepaired, soon more windows

2318
are broken, and this sends a powerful message to residents that no one cares.
A classic research study by Keizer, Lindenberg, and Steg (2008) tested this
theory in six-field experiments where neighborhoods, characterized by
broken windows, litter, unreturned shopping carts, and graffiti, were studied.
They found that when residents see others violating social norms or rules
(e.g., disorderly or petty criminal behavior), they are then more likely to also
violate norms and rules and that this is a cause for the spread of disorder.
Population density, complexity, and racial/ethnic diversity are associated
with urban areas. Central cities are often home to a large proportion of poor
people and those from different racial and ethnic groups. In the 21st century,
America has evolved into a metropolitan nation with more than 8 out of 10
Americans living in metropolitan areas of varying sizes. Between 2010 and
2018, the fastest growing U.S. cities included The Villages, Florida; Myrtle
Beach, South Carolina; Austin, Texas; Midland, Texas; Greeley, Colorado;
St. George, Utah; Cape Coral/Fort Myers, FL; and Redmond, Oregon.
Conversely, the cities with the greatest rates of decline included Pine Bluffs,
Arkansas; Johnstown, Pennsylvania; Charleston, West Virginia; Douglas,
Arizona; and Beckley, West Virginia (Stebbins, 2018).
Urban poor have health problems characterized by accidental and violent
injuries, as well as NCDs and chronic stress (Maxmen, 2016). As noted in
Chapter 23, poverty makes a significant difference in health status.
Neighborhood disadvantage and disorder (drug activity, violent crime) have
been related to the rapid transition from no drug involvement to problem
drug use (Reboussin et al., 2015). Neighborhood poverty has been associated
with HIV diagnosis in a New York City study (Wiewel et al., 2016). Working
class urban residents no longer can find industrial jobs, and a concerted effort
to improve conditions in urban America is needed in the form of urban
policy development. Over the past 25 years, cities and their suburbs have
become more alike, and the demographic and health profiles that were
previously uniquely urban are now shared by “edge cities” and suburbs
populated by poor and minority families. Political power has shifted to more
affluent suburban areas, where the tax base and spending practices are
greater, at the expense of these cities.
Urban health disparities present a challenge that can be addressed only
by the joint effort of public health and urban planning bodies. Coalitions of
public health professionals, planners, builders, architects, along with
transportation engineers and government officials, are needed to promote
healthy, sustainable communities (Fig. 27-15).

2319
 FIGURE 27-15 This view of New York City shows Central Park,
a green area interspersed among densely populated areas—an
example of good urban planning.

There is a move to make cities and their suburbs sustainable

communities. These are seen as healthy places where both natural and
historic resources are protected, employment is available, urban sprawl
is contained, neighborhoods are safe, air pollution is minimized, lifelong
learning is promoted, health care and transportation are easily
accessible, and all citizens have the opportunity to improve their quality
of life.
A federal collaborative program, the Partnership for Sustainable
Communities (2018), is a nonprofit organization that helps American
cities become more socially, economically, and environmentally
sustainable while focusing on land use planning, affordable housing,
community development, energy use, and transportation.

As with all good plans, the sustainable development plan requires that
the recipient of the planning be involved. Democratizing the practice of
urban planning is vital to its success. Communities that have been victimized
through ineffective planning must be included in the decision-making
process. This process will require the inclusion of the practical experience
that residents bring to the table, alongside expert input. The health of
communities must be addressed from all levels of environmental impact
(individual, community, and systems), and population health in the urban
setting must be studied (Gottlieb et al., 2016). Data must be included from
the various environments, such as homes, workplaces, schools, and
community spaces. These approaches then bring such action in line with
what is often referred to as environmental justice or the marriage of
environmental health and civil rights (Agyeman, Schlosberg, Craven, &
Matthews, 2016). A framework to ensure such justice requires that all
individuals and communities have the right to work, play, and live in

2320
environments that are safe and healthy. It also requires that polluters are
punished and required to provide compensation for damages and/or
renovation.

2321
Community Health Nursing in Urban Settings
Urban public health nursing can be very rewarding, and many nurses are
drawn to urban areas where salaries are higher and opportunities for
advancement or additional education greater. In urban areas, there are a
larger number of nurses, more schools of nursing, and more intensive
recruitment efforts than in rural areas, although inner-city areas, much like
rural settings, can have problems filling C/PHN vacancies.

RN workforce studies reveal a higher rate of nurses (935 vs. 853 per
100,000 populations) and a greater proportion of nurses with a BSN
(65% vs. 48%) in urban areas when compared with rural areas (HRSA,
2020).
The current health care education system tends to be urban-centric, with
the exception of online education programs.
Urban areas sometimes draw people away from rural areas.

C/PHN practice is population-focused care that requires unique

knowledge, competencies, and skills. C/PHN roles have always extended
beyond sick care, also encompassing advocacy, health education, community
organization, collaboration with community agencies, as well as political and
social reform. Primary prevention (health promotion) is a major focus.
C/PHNs have a key role of working with populations to improve health and
social conditions of vulnerable populations. These nurses practice in diverse
settings such as community nursing centers, home health agencies, housing
developments, local and state health departments, neighborhood centers,
churches, schools, and worksites. C/PHNs can develop sustainable programs
and build community capacity for health promotion in collaboration with
community members. By utilizing a community-based participatory research
(CBPR) model, C/PHNs can collaborate with community members, leaders,
and stakeholders to identify resources and solutions to problems. Specific
public health roles include advocates, collaborators, educators, partners,
policy-makers, and researcher. An example is through the use of the “power
of the pulpit.” The Black Church is seen as an influential political and social
force in the Black community. Church leadership often supports a history of
promoting encouraging and facilitating community-based screening and
health care programs (Bishop-McDaniel, 2017). Community health nurses
collaborate with their clients to develop their facility for long-term health
promotion and improvement of their quality of life. Their ultimate goal is to
empower clients to be self-sufficient.
There are many points at which the community health nurse can make a
difference in people's lives. Nurses provide services in deteriorating urban
areas, with those living in poverty in all settings and among all vulnerable

2322
populations. Nurses first need to assess themselves for their attitudes and
preconceptions. Although access to care can be improved for many low-
income people in urban areas, many clients simply need an advocate. Our
ability to envision solutions and join together with clients aids us in helping
to create a healthier environment for all (Fullilove & Cantal-Dupart, 2016).
The urban communities, and the poor or vulnerable people living in them,
need strengthening and interventions that can be initiated by C/PHNs using
the nursing process as a guide. See Chapter 23.

Self-assessment
Confronting poverty and caring for vulnerable people from diverse
backgrounds, whether in rural or urban areas, necessitates reflective
assessment of one's own assumptions and beliefs. Because poverty may be
prevalent over a lifetime, nursing students may have personal or family
experience of living in poverty. However, because the stigma is so great and
faultfinding so pervasive in American society, acknowledging and reflecting
on this experience may be painful. In contrast, because poverty is so hidden
and frequently denied, some nursing students have lived apart from any
knowledge of the human experience of poverty. They may have come to
believe many of the negative stereotypes about poor people. Nursing students
and practicing nurses need to ask such questions as “How have my
judgments been shaped? How can I open myself to caring for those from
whom most of society turns away?”
We learn from one another's stories (Box 27-13). First, learn from your
classmates, friends, and neighbors who are courageous enough to tell you
their own experiences of living in poverty. Ask them and listen intently.
Then, let your clients teach you. One honor that nurses have is the
opportunity to work with people from all walks of life. During your clinical
experiences in community health, you are particularly likely to meet
impoverished, vulnerable individuals and families living outside the
mainstream. And you can join with them to empower them by helping to
build skills and confidence and connecting them to resources.

BOX 27-13 PERSPECTIVES

2323
C/PHN Instructors' Viewpoints on Urban Health
Nursing
Ann, a nursing faculty member at a small Roman Catholic college, had
a one-to-one postclinical conference with a student and relays this
conversation. The student had made many visits to an African
American teen mother of two thriving children. The young mother
lived in a dangerous housing project, and, although she locked him out
of her second-floor apartment, her abusive boyfriend had been known
to climb up the drainage pipe and over the porch roof. Sometimes, he
forced open a window and beat her. The mother worked every day at a
fast-food establishment; her grandmother took care of the children.
After a couple of months of weekly visits, the student exclaimed,
“When I read her chart, I saw her as an immoral girl— a slut—and I
expected her to be a loser. Now, I can't believe what I've learned about
how strong she is. She just keeps fighting for herself and for her kids
to survive! She's a great mom and I told her so!”
Another faculty member, Sharon, who taught community health
nursing in a Midwestern school of nursing, was having an informal
discussion with a student who related her experience of trying to get
comfortable making home visits with low-income young women. She
was making brave attempts at home visits to a pregnant woman, about
her age, living in the deteriorating outskirts of a major city. She
thought she had established rapport and was making headway
developing trust with the client. One day, the client asked the student,
with concern in her voice, if she had “broken off her engagement.” The
flustered student then had difficulty explaining the absence of her
engagement ring, which she had never mentioned, but the client had
obviously noticed. During the previous week, she had suddenly
realized she was wearing this special ring in marginal neighborhoods
and thought it best to leave it at home. Of course, she thought that she
had to fabricate another reason to tell the client but felt badly for being
so judgmental when the client was identifying with the student and
believed they had something in common.
Lynn, a new public health nursing faculty member from a large state
university in the West, was shocked and repulsed by the comment of
one of her students during lecture one day. When discussing vulnerable
populations in urban centers and rural areas, the point was made that
poverty can be a generational phenomenon and that many of our
clients may find it difficult to dig out of this circumstance. Social
justice was discussed, along with the need for C/PHNs to become
social activists in order to change political and socioeconomic factors
that keep the status quo. One student, a Hispanic female from a

2324
 middle-class family, spoke up stating “they should all get jobs at
McDonalds.” This spurred further discussion about population-focused
versus individual-focused interventions and approaches and the need
for all of us to be aware of our prejudices and stereotypical viewpoints.

Improving Access
Even with ACA and government-sponsored health insurance and services,
extensive barriers prevent many people from accessing services. The
community health nurse serves as an advocate and bridge for families who
need to gain access. Barriers to access associated with the clients themselves
include reluctance to seek coverage because of feelings of powerlessness;
being unaware that such services exist or are worthwhile; lacking resources
such as a telephone or transportation; being illiterate; and preoccupation with
meeting survival needs and competing life priorities instead of health needs.
Barriers associated with applying for health insurance include a system that
is unfriendly and complicated. The process may require a car, a phone, and
appointments at inconvenient times. Also, service interruptions are not
uncommon, as wages vary over time. The nurse can intervene as a coach and
guide, interpreting the system to the client and the client to the system.
Likewise, nurses can serve as change agents to improve the system whenever
possible.

Strengthening Communities
We are all connected. All of us as citizens have a stake in preventing the
adverse hardships of poverty and ill health. All of society pays to support
community members that do not contribute, to house those who are
incarcerated, and to ignore the vulnerable. Many of us fear crime in our
homes, schools, businesses, and communities. Society, as a whole, is
impacted when adults are incapable of providing nurturing environments for
their children. In addition, the alienation of many groups in society erodes
our sense of community as a nation. Community health planning should
seriously consider an organizing process that builds community and that
focuses on developing neighborhood competence to solve problems and
create solutions for itself (see the discussion of community development in
Chapter 15).

2325
SUMMARY
Rural clients are a unique aggregate, and community health nurses are
key to ensuring the delivery of appropriate health services to this
population. There are numerous definitions of the term rural. In this
chapter, some characteristics of rural communities include the
following:
Communities with fewer than 10,000 residents.
A county population density of fewer than 1,000 people per square
mile.
Rural areas often have less diversity than urban cities but that is
changing in many areas.
Rural clients generally have lower educational levels than urban
clients, due in part to less access to higher education and lower-
paying jobs.
Income levels and housing costs are frequently lower in rural areas
than in larger cities.
Many at-risk populations live in these communities, where there
are often fewer employment opportunities, a lack of adequate
housing, and limited access to health and social services.
Rural elders may have more limited alternatives for housing if they
can no longer live alone.
Mental health services are inadequate, even though the need may
be great. Numerous risks are associated with agriculture.
Between the 2000 and 2010 censuses, urban population growth was
about twice than in rural areas. The elderly are a rapidly growing
population in rural communities.
Urban health issues have existed for hundreds of years in the United
States, and they continue today. Many disenfranchised and minority
groups call inner cities home. Air pollution, poverty, discrimination,
substandard housing, crime, substance use disorder, and social
inequities often characterize life in urban settings.
The built environment is an important consideration in urban as well as
rural settings and can contribute to greater health risks. Some large
cities have had marked decreases in population and significant problems
with unemployment, although more people around the world live in
urban areas now than in rural areas.
Migrant farmworkers are an integral part of the agricultural community
in the United States and the world but are often barely visible in society.
As members of the community with varied and significant health needs,
these are complicated by social isolation, occupational hazards such as

2326
pesticide exposure, poor working conditions, and working with
dangerous farm equipment.
Migrant workers and their families often endure substandard housing
and poor sanitation, while living in high-risk environments. Migrant
children are often educationally, socially, and physically disadvantaged.
Migrant health care centers often do not adequately meet the health
needs of the migrant community; therefore, innovative methods of
health care delivery have been developed and implemented by
community health nurses, including mobile health vans and information
tracking systems.

2327
ACTIVE LEARNING EXERCISES
1. Search for two recent journal articles relating to access to health care
or quality of care for rural, urban, or migrant population. After
summarizing the content, identify barriers to access that are common
to both and those that are different. What are the main themes relating
to health and access to care?
2. Discuss the common characteristics of rural, migrant, and urban
clients. How can the C/PHN be better prepared to meet their unique
needs? What are some specific challenges facing the C/PHN working
in a rural area? In an urban area? Or with the migrant farmworker
population?
3. Describe some of the benefits of rural public health nursing. Describe
some of the benefits of urban public health nursing.
4. Discuss health, living, and working concerns of migrant workers.
How does a nomadic lifestyle affect the needs of migrant workers?
5. Using “Create, Champion, and Implement Policies, Plans, and Laws”
(1 of the 10 essential public health services; see Box 2-2 ), examine
new or existing policies or laws and determine how they might affect
today's migrant population.

thePoint: Everything You Need to Make the

Grade!
Visit http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, study aids for
all learning styles, and more!

2328
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2345
 UNIT 7
Settings for Community/Public
Health Nursing

2346
2347
CHAPTER 28
Public Settings
“Public health nursing is the practice of promoting and protecting the health of populations using
knowledge from nursing, social, and public health sciences.”

—The Definition and Practice of Public Health Nursing: A Statement of the

APHA Public Health Nursing Section, 2013

KEY TERMS
Correctional nurses Indian Health Service (IHS) Individualized education
plans (IEPs) Individualized health plans (IHPs) Local health departments
(LHDs) School-based health centers (SBHCs) School nurse
Section 504 plans Student study teams (SSTs) U.S. Public Health Service
(USPHS) Commissioned Corps

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Explain the focus of the nursing process and how community/public
health nurses (C/PHNs) and other nurses working in the publicly funded
sector use the tool to provide care in their communities.
2. Describe how federal, state, and local public health infrastructures
influence the population's health.
3. Evaluate the potential benefits of school-based health centers and
possible parental or community objections.
4. Compare and contrast common roles and functions of C/PHNs, school
nurses, and correctional nurses.

2348
INTRODUCTION
Many nursing students are not aware of the vast employment opportunities
available outside the hospital in publicly funded settings. This chapter
discusses several of these publicly funded health settings and the
opportunities nurses can garner, particularly in services such as public health
nursing, school nursing, and correctional nursing.
Although these nursing opportunities differ greatly from one another,
they have several characteristics in common. Community nurses who work
in a setting supported through public funds (e.g., taxpayer-funded):
1. Still use the nursing process, just with a population or group of people
rather than an individual.
2. Emphasize prevention of disease or disability.
3. Work with a variety of people, usually vulnerable populations.
4. Focus on population-based care and must be able to network and
collaborate with other agencies and disciplines (e.g., a nurse working in
a correctional facility collaborating with mental health workers and
correctional officers).
5. May advocate for individuals and the community and serve on regional
task forces or advisory boards.
6. Must be autonomous, flexible, creative thinkers who are self-directed
and able to prioritize and use the nursing process and evidence-based
practices to make decisions and plan efficient care for their respective
populations.

2349
PUBLIC HEALTH NURSING
A C/PHN is a nurse who works to promote and protect the health of an entire
population (American Nurses Association [ANA], 2013). An estimated
231,000 to 341,000 workers compose the U.S. public health workforce
(University of Michigan Center of Excellence in Public Health Workforce
Studies, 2018). This workforce consists of epidemiologists, nurses,
environmentalists, laboratory professionals, nutritionists, dental workers,
social workers, and other health care providers.
Approximately 18% of all registered nurses (RNs) are employed in
public or community health settings (Beck & Boulton, 2016). The trends of
inadequate access to health care and rising costs of health care have
contributed to more nurses working in these settings. Unfortunately, many
are unaware of the employment opportunities available in the public sector.
This section describes the roles and opportunities for RNs at the local, state,
and federal levels of government, with particular focus on governmental
agencies, as these facilities employ the majority of C/PHNs.

2350
Education
The ANA (2013) recommends that an entry-level C/PHN should have a
bachelor's degree in nursing. This is important because baccalaureate
programs provide additional training in public health and leadership. Some
states, such as California, require nurses to take additional classes and obtain
certification beyond a bachelor's degree if the Bachelor of Science in Nursing
program does not offer specific content (e.g., child abuse, public health
didactic, and practicum). C/PHNs working with specific populations or in
administration should hold a master's degree.

2351
Key Functions of the C/PHN in the Public Setting
Public health nursing practice consists of many areas of expertise, including:

Focusing on the health of populations

Reflecting the needs and priorities of the community
Establishing caring relationships with individuals, families,
communities, and systems
Being grounded in cultural sensitivity, compassion, social justice, and a
belief in the worth of all people (e.g., vulnerable populations)
Having a basic understanding of all aspects of health (e.g., physical,
emotional, mental, social, spiritual, and environmental)
Using strategies to promote health that are motivated by epidemiologic
evidence
Using individual, as well as collaborative, strategies to achieve results

In brief, the role of the C/PHN is to focus on the health of the public.
C/PHNs combine their nursing and clinical knowledge of disease and the
human response to it, along with public health skills, to accomplish their
goals (ANA, 2015). They apply the nursing process, not only with
individuals but also with populations. C/PHNs are a critical link between
data tracking (e.g., epidemiology) and developing a clinical understanding of
a disease or condition and use the data to prioritize their interventions to stop
the spread of diseases, such as measles, and also to intercede with other
concerns (e.g., childhood obesity). For example, C/PHNs may develop a
campaign for children to wear bike helmets after an increase of fatal head
injuries is noted in their area. A key emphasis of the C/PHN is prevention,
and a key focus is educating and empowering the community.
The Council of Public Health Nursing Organizations (CPHNO)
(https://www.cphno.org), formerly the Quad Council, developed the first
Competencies for Public Health in 2010. The organization is composed of
these organizations: Association of Community Health Nursing Educators
(ACHNE), Association of Public Health Nurses (APHN), Rural Nurse
Organization, American Nurses Association (ANA), Alliance of Nurses for
Healthy Environment, American Public health Association—Public Health
Nursing Section (APHA). These competencies have been updated and are
used as a tool in education and for agencies in orienting new C/PHNs (Quad
Council Coalition, 2018). See Box 28-1 for community settings for C/PHNs.

BOX 28-1 Community Settings for

Public Health Nurses Community/Public

2352
 health nurses (C/PHNs) can be found
working in communities advocating for
environmental, transportation, and
safety policies in collaboration with
community organizations.
C/PHNs may work in schools, public health clinics/departments, or
local government agencies advocating for elimination of health
disparities.
C/PHNs are increasingly seen working on global health issues as
the international borders are rapidly disappearing due to increased,
rapid international travel and enhanced electronic communication
technology (American Public Health Association, 2013).
Visiting nursing is an opportunity for family health education and
one-to-one educating for managing specific illness.
Geriatric nursing is a growing specialty as the care for older adults
in assisted living skilled care facilities or through home care is
increasing with the aging baby boomer population.
Correctional nursing provides an opportunity to impact community
health by promoting healthy lifestyle practices and effective
management of communicable diseases are implemented during
incarceration prior to release.

C/PHNs may focus on a population that is a geographic community (e.g.,

a state or municipality) or a focus group (e.g., adolescents or older persons)
spanning all socioeconomic levels. To accomplish this, C/PHNs often work
with individuals or families at highest risk, and their motive is to improve,
protect, and promote the health of the entire population. A distinctive goal of
C/PHNs relative to the goals of other nursing disciplines is achieving the
greatest good for the majority of people (ANA, 2015) (See Chapter 23 for an
in-depth discussion of social justice). This requires priority planning and a
basic knowledge of the community. It can also create ethical dilemmas for
C/PHNs when they have personal and passionate issues that they would like
to pursue but which are not the top priority for the majority of community
members.
For example, a child in a community may have been hit by a car while
riding his bike without a helmet, while at the same time, in the same
community, there may be 10 births to teen moms, 20 instances of drug
overdose, and an outbreak of pertussis. The C/PHNs in that community must
prioritize which issue to address first by deciding which issue impacts the

2353
most people and what interventions will help the population thrive (ANA,
2015). Because each community is different, once all factors are taken into
account, the priorities will vary among communities. Hence, assessment is a
critical component of public health and a key tool for the nurses who work in
the public sector (ANA, 2015; Turnock, 2016).
Another way Community/public health nursing differs from other areas
in nursing is that C/PHNs must actively seek out and identify potential
problems and situations (ANA, 2015). Nurses who work in a hospital setting
address the issues that come to them. A nurse in the intensive care unit of a
hospital works with an assigned patient load. C/PHNs, on the other hand, are
out in the community identifying the problems, not waiting for problems to
come to them. For example, C/PHNs may participate in visits to childcare
centers to note any safety hazards and ensure that rules and regulations are
being followed and that children are properly immunized. These visits are
part of the priority of assurance (Turnock, 2016).
C/PHNs cannot perform all these activities alone. They need to
collaborate with other partners and optimally use often limited resources.
C/PHNs are in a unique situation because they work with their populations
(i.e., clients) and with others to find the best solutions for a situation or
problem. For instance, C/PHNs may notice an increase in the number of
measles cases in their community. They may then work with families to
identify where and how the children were exposed to the disease and with
local health care providers to provide treatment and vaccinations for those at
highest risk of exposure to and damage from measles. C/PHNs also work
with school nurses and other school personnel to exclude from school
attendance those children who are not adequately immunized against
measles. This helps decrease the spread and potential harm because of
measles. C/PHNs educate a variety of groups, such as parent–teacher
associations and city or school officials, as to how measles spreads, what can
be done to treat the disease, and the importance of herd immunity in
protecting the public. Education thus empowers each group to be part of the
solution. Finally, C/PHNs can work with public health officials to develop a
policy for all new school entrants to receive a second booster of measles
vaccine. Policy development is the third critical component of public health
(Turnock, 2016).

2354
PUBLIC HEALTH FUNDING AND
GOVERNMENTAL STRUCTURES
Well-functioning public health departments are critical entities in the effort to
build a healthy nation. Accurate estimations of essential funding to support
public health adequately are difficult to determine. Because C/PHNs can
work at any and all levels of government, it is important to understand the
organizational structure, communication, and funding streams between the
federal, state, and local levels of government (see Chapter 6 for more on the
structure of the public health system).

2355
National Policy
The federal government oversees national policy and funding, provides
expertise, and sets a national agenda (World Health Organization, 2019).
Healthy People initiatives identify our nation's health improvement priorities
by setting 10-year goals and targets. Since 1990, “Healthy People has
established evidence-based national health objectives with clear targets that
allow us to monitor progress, motivate action, and guide efforts to improve
health across the country” (https://health.gov/our-work/healthypeople/). For
example, see Box 28-2 for content areas related to children and adolescents.

BOX 28-2 HEALTHY PEOPLE 2030

Content Areas for Children and Adolescents
Healthy People 2030 provides the direction and
goals for all community/public health nurses
(C/PHNs). Healthy People 2030 is used to guide
prioritizing activities for C/PHNs. Below are the
Healthy People 2030 content areas that pertain to
the health of children and adolescents.
Access to health
Blood disorders
Cancer
Child and adolescent development
Chronic kidney disease
Chronic pain
Drug and alcohol use
Economic stability
Education access and quality
Emergency preparedness
Environmental health
Family planning
Health care
Heath care access and quality
Health communication
Health insurance
Health IT
Health policy
Hospital and emergency services

2356
 Housing and homes
Injury prevention
LGBT
Neighborhood and built environment
Nutrition and healthy eating
Overweight and obesity
Parents or caregivers
People with disabilities
Pregnancy and childbirth
Preventative care
Physical activity
Respiratory disease
Schools
Sensory and communication disorders
Sleep
Sexually transmitted infections
Social and community context
Tobacco use
Transportation
Vaccination
Violence prevention
Reprinted from U.S. Department of Health & Human Services (USDHHS). (2020a). Healthy People
2030: Browse objectives. Retrieved from https://health.gov/healthypeople/objectives-and-
data/browse-objectives

2357
State Agencies
The U.S. Constitution bestows states with the responsibility to safeguard the
health of their citizens (Turnock, 2016). Much of public health is overseen at
the state level. However, the structure of where public health fits into the
executive branch of state government varies. The governor appoints a
commissioner, or leading health official, to oversee public health and serve
as a member of the governor's cabinet.
The purpose of state agencies is to carry forth regulations and policies
determined by the federal government (e.g., Medicaid, Medicare, and State
Children's Health Insurance Programs). Many of these programs have
specific federal requirements but also allow states the ability to personalize
the programs to fit each state's individual needs.

2358
Local Public Health
Local health departments (LHDs) carry out state laws and policies
(Turnock, 2016). They provide the most direct, immediate care to the
population while providing the essential public health services at the local
level (Moore, Berner, & Wall, 2020) and operate programs with funding
from federal and state agencies. LHDs often work with state health
departments to ensure that culturally appropriate and population-specific
services are delivered to the community.

2359
NURSING ROLES IN LOCAL,
STATE, AND FEDERAL PUBLIC
HEALTH POSITIONS
Public health nurses are employed at federal, state, and local levels of
government. Those working for LHDs are the eyes and ears of their
communities (Fig. 28-1).

FIGURE 28-1 C/PHNs are the eyes and ears of their community.

2360
Assess
An assessment of the situation is the key component to any nursing care.
C/PHNs use the nursing process in a variety of ways when they are in the
community and when they conduct home visits. Often, the C/PHNs work
with other public health personnel when assessing and tracking data. By
using data and conducting an assessment, C/PHNs are able to successfully
target interventions for populations at risk (Community Tool Box, 2020). See
Chapters 12 and 15.
Environmental risks are important to the public's health and are often
assessed by C/PHNs. A community positioned next to a factory that emits
fumes will have different issues than a rural community 90 miles away from
any industry. At the same time, a C/PHN may identify an outbreak of
Escherichia coli in one town as a risk to a neighboring town. See Chapter 9.

2361
Diagnose
Assessment is key to diagnosing a situation or problem (Box 28-3). For a
C/PHN, diagnosis includes identifying priorities for the many concurrent
issues which may be present.

BOX 28-3 STORIES FROM THE

FIELD
Tuberculosis Exposure (Compare Your Local
Response With That Outlined Here) As a
community/public health nurse (C/PHN), you
are alerted to a person who has an active TB
case. He presents into the health department for
a chest x-ray after he failed his tuberculin skin
test. The person has recently arrived by plane
from another state. He stayed for a few weeks
with family members in a small house but now
lives with friends in a small apartment. When
talking to the patient, you note that he coughs
often and does not cover his mouth.
1. As a C/PHN, what steps would you take to determine exposure?
How will you determine who was exposed and will need to be
tested? What questions can you ask to help determine when and
how the patient was exposed to TB?
2. What type of education will you provide to him?
3. How can you ensure that the patient is compliant with
medication treatment?
4. Imagine that you are the school nurse of the patient's 8-year-old
daughter, who has also tested positive. What steps would you
take?
5. What would you do differently if you were a correctional nurse
and the patient was an inmate?
6. What are the ethical and legal issues related to TB?

2362
 As nurses diagnose individual needs, they apply this information and
watch for increased or decreased rates (e.g., of disease or injury) among the
population. Nurses are in the perfect position to identify issues and trends
early (Community Tool Box, 2020).
Constant assessment and diagnosis are tools by which C/PHNs identify
critical situations and prioritize issues that must be addressed. Several
documents have helped C/PHNs prioritize issues, such as Healthy People
2030 a guide to identifying many of the nation's top priorities (U.S.
Department of Health and Human Services [USDHHS], 2020a). Public
health performance standards established by the Centers for Disease Control
and Prevention (CDC, 2018a) and the Institute of Medicine (2015) have
identified specific leading indicators for improving patient care and health
research. See Box 28-4.

BOX 28-4 HEALTHY PEOPLE 2030

Public Health Priorities
Leading Health Indicators Framework The
Healthy People leading health indicators are
selected to communicate high priority health
issues and challenges. The focus is on social
determinants of health that support quality of life,
healthy behaviors, and healthy development
across the life stages for all. The leading health
indicators are selected and organized using the
Health Determinants and Health Outcomes by
Life Stages conceptual framework. This approach
is intended to draw attention to both individual
and societal determinants that affect the public's
health and contribute to health disparities from
infancy through old age, thereby highlighting
strategic opportunities to promote health and
improve quality of life for all Americans.
Healthy People 2030

2363
Every decade, the Healthy People initiative develops a new set of science-
based, 10-year national objectives with the goal of improving the health of
all Americans. The development of Healthy People 2030 includes
establishing a framework for the initiative—the vision, mission,
foundational principles, plan of action, and overarching goals—and
identifying new objectives.
The Healthy People 2030 framework explains the central ideas and
functions of the Healthy People 2030 initiative. The purpose of the
framework is to:

Provide context and rationale for the initiative's approach

Communicate the principles that underlie decisions about Healthy
People 2030
Situate the initiative in the 5-decade history of Healthy People

Leading health indicators will address the lifespan and focus on:
Upstream measures such as risk factors and behaviors Address issues of
national importance
Address high-priority health issues that have an impact on community and
public health nursing outcomes Be modifiable through evidence-based
interventions and strategies Address social determinants of health, health
disparities, and health inequity

Source: Office of Disease Prevention and Health Promotion (ODPHP) (2020); U.S. Department of
Health & Human Services (USDHHS) (2020b).

2364
Plan and Implement
Once C/PHNs have diagnosed and prioritized the needs of their community,
they develop and carry out plans to address those needs. Many interventions
require collaborating and working with other agencies and professions.
C/PHNs provide preventive health education and serve as advocates to
influence those who can make essential policy and funding changes. The
interventions are endless, but here are a few examples:

A nurse conducts home visits to mothers at risk and concurrently

conducts family assessments to determine the level of psychological
issues and education needed by the family regarding specific needs.
A community nurse working in risk management develops and teaches
an education program about workplace safety and ergonomics and helps
to develop policies regarding shift hours and heavy lifting.
A school nurse serves as an advocate for a program that will help
children with special health care needs attend a clinic closer to home.
A C/PHN develops a campaign for social media sites (e.g., Twitter,
Facebook), television, radio, and local newspapers regarding the need to
receive a flu shot, including incentives that target older persons in the
community, who are at additional risk for developing complications
from this illness.
A C/PHN organizes a health clinic at local shelters that provides foot
care and screenings for blood pressure, diabetes, tuberculosis (TB), and
cholesterol, as appropriate.
A school nurse works with schools to educate teens regarding birth
control and the impact of teen pregnancy. The nurse includes counseling
regarding sexually transmitted diseases (STDs) and works with the
community to ensure that a variety of teen-focused activities are
available for this population.
A C/PHN helps identify resources for families without insurance to
ensure that well-child and adult screenings are performed regularly to
reduce health care costs associated with illness.
A C/PHN organizes a bicycle fair to educate the community regarding
the need for bicycle helmets in hopes of decreasing head injuries, works
to develop public policy related to child car seat/booster seat usage, and
collaborates with local businesses to provide vouchers for discounts on
child restraints for low-income parents.
A nurse, who is an elected member of the state legislature, sponsors a
bill to increase funding for school nurses.

The following interventions are examples of evidence-based practice (see

Chapter 4) in public health nursing:

2365
Media campaigns targeting specific populations to educate and promote
healthy lifestyle behavior (Atusingwize, Lewis, & Langley, 2015).
Improving work-based health literacy through educational programs to
improve musculoskeletal pain (Larsen et al., 2015).
Children with chronic conditions such as asthma are more likely to have
anxiety, leading to increased morbidity, including missed days of school
and caregiver work time. Asthma education programs along with
behavioral building programs may influence mental health, leading to
medication compliance and reduced anxiety (McGovern, Arcoleo, &
Melnyk, 2020).
Promoting the use of helmets in an attempt to reduce injuries among
motorcyclists in a rural area by adopting a community-based
participation approach (Babazadeh, Kouzekanani, Ghasemzadeh,
Matlabi, & Allahahverdipour, 2019).

2366
Evaluate
The world in which C/PHNs work is always changing. It is crucial to
constantly evaluate programs and interventions to determine whether
interventions are effective and desired goals are reached (Box 28-5). The
CPHNO supports research studies about the impact that C/PHNs have on
improving population health and societal outcomes (Quad Council Coalition,
2018).

BOX 28-5 Levels Of Prevention Pyramid

Cervical Cancer in The Community Setting
HEALTH ISSUE: Cervical cancer in the
community setting

2367
 BOX 28-6 PERSPECTIVES

A C/PHN Instructor Viewpoint on Community

Health Nursing As an instructor of undergraduate
nursing students, I want students to realize that
public health nursing is a wonderful and
rewarding employment opportunity. Many
students often enter the nursing program not
knowing much about public health nursing. They
may only get minimal exposure to public health
and thus do not often understand who or what is
involved in public health nursing. In so doing,
they miss out on a wonderful opportunity to work
with a variety of people. It may be helping new
moms, or working with children and adolescents,
or the elderly. They may help give vaccinations or
prepare for community disasters. They might
teach about breast-feeding or conduct cancer-
screening clinics. They are out working directly
with the people, ensuring the public's health.
Community/public health nurses (C/PHNs) are able to use the science of
nursing because they need to understand the pathophysiology, anatomy,
human development, and disease transmission. They may not do as many
hands-on procedures as hospital nurses, but they still must keep up-to-date
in knowledge, as they are often teaching. In addition, they must be quick
and receptive thinkers who can work independently and creatively. C/PHNs
also are the essence of the “art” of nursing. They must understand and relate
to people and grasp social systems and human behavior. They are the voice
for the most vulnerable and the champion of all.

2368
 Although C/PHNs may not see an immediate reward for their actions,
as a nurse who works in the hospital does, C/PHNs make a long and lasting
impact not just to an individual but also for an entire society. They have the
opportunity to really be a patient advocate. They do this by helping well
people stay well and by preventing illness. They also help those who are
sick obtain medical access. C/PHNs can also be involved in public policy
change that can help an entire community. Public health nursing
encompasses the entire art and science of nursing.

Erin M.

Among distinct opportunities at the federal level are those associated

with the Department of Veterans Affairs (2020) and the USDHHS (2020c).
See Box 28-7.

BOX 28-7 Federal Agencies Employing

U.S. Public Health Service Nurses
Administration for Children and Families (ACF)
Centers for Disease Control and Prevention (CDC)
Centers for Medicare and Medicaid Services (CMS)
Health Resources and Services Administration (HRSA)
Indian Health Service (IHS)
National Institutes of Health (NIH)
Substance Abuse and Mental Health Services Administration
(SAMHSA)
U.S. Department of Agriculture (USDA)
U.S. Department of Commerce
U.S. Department of Defense
U.S. Department of Homeland Security
U.S. Department of Justice
U.S. Department of Veterans Affairs (VA)
U.S. Food and Drug Administration (FDA)
U.S. Marshals Service

C/PHNs in these agencies oversee and carry out the initiatives of Healthy
People 2030, along with other program initiatives. Federally employed
C/PHNs at the Health Resources and Services Administration may review
state funding proposals for projects and ensure that guidelines are met. They
are a resource for state health departments and LHDs and often are called
upon as consultants. Nurses working at the National Institutes of Health
(NIH) may assist in conducting research or work with legal and bioethics

2369
staff in evaluating the impact of research on participants, monitoring patients
for adverse reactions, or coordinate care for specific groups of patients (NIH,
n.d.).

2370
Indian Health Service
C/PHNs working with the Indian Health Service (IHS) strive to ensure that
comprehensive, culturally acceptable personal and public health services are
available and accessible to the 573 federally recognized Tribes that consist of
2.56 million American Indians and Alaska Natives in 170 IHS and tribally
managed service units (IHS, 2020). Employment with the IHS allows a
C/PHN to live in a variety of rural and urban settings and to work
specifically with Native Americans, a vulnerable population. This type of
nursing, in remote areas with limited consistent electricity or telephone
access, is very challenging but can also be extremely rewarding.

2371
Uniformed Public Health Nursing
Established in 1798, as part of an act to treat sick seamen in Marine
hospitals, the U.S. Public Health Service (USPHS) Commissioned Corps
is a group of more than 6,500 specially trained public health professionals
committed to the mission of protecting, promoting, and advancing the health
and safety of our nation (Fig. 28-2). As an essential component of the largest
public health program in the world, these elite groups of officers are involved
in:

2372
 FIGURE 28-2 U.S. Public Health Service (USPHS)
Commissioned Corps infographic. (From the Commissioned Corps
of the USPHS. (2019). USPHS Commissioned Corps infographic.
Retrieved from https://usphs.gov/aboutus/)

Health care delivery to underserved and vulnerable populations,

including immigrants entering the country
Disease control and prevention, including communicable disease
outbreaks
Biomedical research
Food and drug regulation
Mental health and drug abuse services
Response efforts for natural and man-made disasters, often as first
responders, remaining involved until the situation is resolved

The U.S. Surgeon General oversees the Commissioned Corps and

supports the officers stationed in more than 20 federal agencies or
departments across the nation, filling essential public health leadership and
clinical service roles within the nation's federal government agencies
(USDHHS, n.d.).
The USPHS Chief Nurse Officer is integrally involved with global health
care, ensuring that PHS nurses are improving health for the entire community
by providing direct care, conducting research, or reviewing new medications.
These nurses work in a variety of federal agencies and provide nursing care
and health care leadership around the world. Commissioned Corps Officers
are on the front line of the COVID-19 response, deploying 400 officers to aid
in the response to the coronavirus health emergency (US Food and Drug
Administration, n.d.). During the height of the Ebola virus global epidemic,
the president of the United States called upon the USPHS Commissioned
Corps to deploy to West Africa to provide care to the health care workers
who had been exposed to or infected with the Ebola virus (Pierson et al.,
2017). Four teams of approximately 70 officers composed of clinicians
(physicians, nurses, and behavioral health specialists), pharmacists, infection
control and laboratory officers, and administrative management personnel
rotated to Liberia for 60 days at a time beginning in October 2014 (Pierson et
al., 2017). Upon the departure of these specially trained teams of PHS
officers in May 2015, Liberia was declared Ebola-free. Concurrently, smaller
teams of PHS officers served to combat the Ebola outbreak in Guinea and
Sierra Leone and remained on site educating the community on Ebola
treatment and prevention. The president presented the USPHS
Commissioned Corps with the Presidential Unit Citation, the highest award
for a uniformed service, for their contributions in the fight against Ebola.

2373
 More recently Commission Corps officers were sent to Louisiana
following catastrophic flooding and heavy rains in 2016 (Iskander et al.,
2018). Officers provided round-the-clock medical and behavioral health care
for special needs medical shelter residents. In addition, officers coordinated
with other shelters and local providers to ensure care for patients with critical
health care needs such as dialysis and placement in skilled care facilities
(Iskander et al., 2018). For more information on Commissioned Corps
deployment: https://www.usphs.gov/
For more information on the USPHS Commissioned Corps in general,
visit their Web site at https://dcp.psc.gov/ccmis/

2374
School Nursing
School nursing is a specialized practice of professional nursing that advances
the well-being, academic success, and lifelong achievement of students.
School nurses are a link between the school, families, community, and health
care stakeholders.

History of School Nursing

In 1902, the practice of school nursing began when the New York Board of
Education contracted with Lillian Wald's Henry Street Settlement to provide
a C/PHN to work with the families and schools to facilitate the return of
healthy children to school. The nurse, Lina Rogers, made home visits to
follow up on children excluded from school for illness or poor health and
was assisted by other Henry Street nurses in providing care, educating
families about diseases and the need for hygiene, and working with other
organizations to provide needed food, shoes, and clothing (Houlahan, 2018).
The board hired 12 more school nurses, and over the next few years, other
cities and states began hiring nurses to work in the schools. School nurses
have historically advocated for hot lunches, breakfast programs, better social
conditions, and the need for increased health education in schools and for
families (Houlahan, 2018). See Chapter 3.
School nurses are a professional nursing specialty that serves the school-
age population through the age of 21 years, working with students' families
and the school community in regular and special education schools, as well
as other educational settings (e.g., preschools, court, and other community
schools).

The nationally recommended ratio of one school nurse for every 750
students was adopted to provide accommodations to both disabled and
chronically ill students. Increasingly, school nurses are providing care to
students with complex social, physical, and emotional needs (Endsley,
2017).
The National Association of School Nurses (NASN) position statement
on safe staffing recommends a 1:225 ratio for populations requiring
daily professional nursing services, a 1:125 ratio for populations with
complex health care needs, and a 1:1 ratio for students requiring daily
professional nursing services (NASN, 2020b).

The role of the school nurse has expanded over the years, along with the
increase in chronic conditions and challenges in accessing health care
(Endsley, 2017). In addition, federal law requires school systems to provide
care for children with disabilities. The Individuals with Disabilities

2375
Education Act (IDEA, 1975), the Rehabilitation Act (1973), and Title II of
the Americans with Disabilities Act (ADA) all mandate equal educational
opportunities for all students, including children with complex medical
conditions. It is now commonplace for children to attend school
accompanied by feeding tubes, catheters, insulin pumps, glucose monitors,
and ventilators. There is a growing population of adolescent and
preadolescent children who are within 6 months of dying from chronic
disease and are routinely attending school (NASN, 2018a). ANA and NASN
(2017) defines the role of the school nurse as:
School nurses, grounded in the ethical and evidence-based practice, are the
leaders who bridge health care and education, provide care coordination,
advocate for quality student centered care, and collaborate to design systems
that allow individuals and communities to develop their full potential (p. 1).
The school nurse role has dramatically changed, as has the student
population, in this millennium. Children are affected by poverty, food
insecurity, lack of access to medical care, language and cultural barriers,
lower socioeconomic status, challenges to basic safety and security, chronic
health issues, and discrimination. School nurses play a critical role in
promoting the academic success of these and other children in school
(Darnell, Hager, & Loprinzi, 2019). School nurses may be “the only contact
a student has with a health care professional”; yet many schools across the
United States have one nurse for large populations or no nurse, relying solely
on office staff to care for complex medical conditions (Willgerodt, Brock, &
Maughan, 2018, p. 232). Today's school nurse performs multiple roles,
including care coordination, leadership, quality improvement, and
community/public health (NASN, 2018c). See Figure 28-3.

2376
 FIGURE 28-3 Framework for 21st century school nursing
practice. (Reprinted with permission from the National Association
for School Nurses. (2019). Framework for 21st century school
nursing practice. Retrieved from https://www.nasn.org/nasn/nasn-
resources/professional-topics/framework)

An integrative study looked at the relationship between school nurse

interventions and the impact on health and education outcomes of school
children. Using the NASN Framework for 21st Century School Nursing

2377
Practice, Best, Oppewal, and Travers (2018) categorized school nurse
interventions and health outcome measures through a systematic review and
meta-analysis of the literature with studies falling under one of the
Framework's four areas:

54% of the studies were in the area of care coordination, in which

nurses provided case management, chronic disease management,
collaborative communication with staff and parents, direct patient care,
support groups, counseling, and student care plans.
18% of school nurse work was in the area of leadership and lifelong
learning, in which nurses took classes to support their knowledge and
care in areas such as asthma, child protective services, food allergies,
and concussions.
25% of school nurses provided interventions in the area of health
education, screenings, referrals, follow-up on medical issues, and
surveillance.
Less than 3% of the school nurse's time is spent in the area of quality
improvement, including documentation and data collection.

School nurses, administrators, teachers, parents, and community

stakeholders are all vital in coordinated school health programs and in
developing health-promoting schools (Best et al., 2018). The NASN serves
as a resource for school nurses across the United States. Their position
papers and resources give guidance to nurses in the trenches who typically
serve in autonomous positions and may be the only nurse for their district,
traveling great distances between schools, especially in rural America. The
NASN position papers provide direction for school nurses and include such
categories as disaster preparedness, bullying and cyberbullying, chronic
absenteeism, individual health care plans, school violence, sexual health
education in schools, and telehealth. The full list of position papers can be
found at https://www.nasn.org/nasn/advocacy/professional-practice-
documents/position-statements (NASN, 2018b).
It is the position of NASN that school nurses play an essential role in
keeping children healthy, safe, and ready to learn. The school nurse is a
member of a unique discipline of professional nursing and is often the sole
health care provider in an academic setting. Twenty-first century school
nursing practice is student-centered, occurring within the context of the
student's family and school community (NASN, 2016). “It is essential that all
students have access to a full-time school nurse all day, every day”
(American Academy of Pediatrics [AAP], 2016; NASN, 2018c, p. 3).

Key Roles of the School Nurse

2378
The school nurse's main role is to provide both individual and population
health care and coordination for school-age children and adolescents. In
providing services, school nurses use their knowledge of:

Normal growth and development

Social determinants of health
Safety and health (including environmental health)
The educational system
The connection between health and learning

Other key roles of the school nurse are to (AAP, 2016):

Promote health among students, families, and staff.

Provide case management for children with chronic illnesses (e.g.,
diabetes, asthma, severe allergies).
Provide immunization monitoring/access.
Collaborate with parents, teachers, and psychologists in providing
appropriate educational plans for students requiring special education
services.
Work with school staff to ensure a healthy and safe environment (e.g.,
nutrition, physical activity, playground safety).
Collaborate with community agencies (e.g., public health departments,
other health agencies, charitable groups, and service clubs), physicians,
dentists, parent groups, and child protective services to meet students'
and families' needs.
Conduct screenings and work with school staff to promote their health
and wellness.
Work with school-based clinics to provide direct health care to children
and their families.
Assist in leading coordinated school health programs.

The NASN (2016) describes the broad role of the school nurse as a
“specialized practice of professional nursing that advances the well-being,
academic success, and lifelong achievement and health of students” (para. 8).
The school nurse (NASN, 2016):

Facilitates the normal development of students and promotes positive

intervention outcomes
Provides leadership in the areas of health promotion, safety, and a
healthy school environment
Provides high-quality health care and promotes early intervention for
actual and potential student health problems
Uses sound clinical judgment in the provision of case management for
students

2379
 Collaborates actively and professionally with others to promote student
and family capacity for self-management and adaptation, as well as
learning and self-advocacy

The partnership between school nurses and families is important for the
child's health outcomes, and the use of problem-based communication
strategies helps promote this collaboration (Roberts, Taylor, & Pyle, 2018).

Liaison With the Interdisciplinary School Health

Team.
School nursing services are part of a coordinated school health program that
provides school health services, health education, and health promotion
programs for faculty and staff (American School Health Association, n.d.).
Although the school nurse plays a central role, collaboration with many other
individuals is important. School nurses must be familiar with the education
setting and work closely with teachers and aides, special education teachers
and staff, principals, administrators, school office staff, health aides,
psychologists, and speech therapists, as well as parents and families. The
Whole School, Whole Community, Whole Child (WSCC) model focuses on
the child, emphasizes a school-wide approach, and acknowledges learning,
health, and the school as being a part and reflection of the local community
(CDC, 2020). The Virtual Healthy School
(https://www.cdc.gov/healthyschools/vhs/#!/scene/1) emphasizes the
relationship between health and school, highlighting the WSCC model
(CDC, 2018b). See Figure 28-4 for the WSCC model.

2380
FIGURE 28-4 Whole School, Whole Community, Whole Child
model. Reprinted from the Centers for Disease Control and
Prevention. (2016). Whole School, whole community, whole child.
Retrieved from http://www.cdc.gov/healthyyouth/wscc/

It includes 10 components:

Health education
Physical activity/education
Nutrition services/environment
Health services
Counseling/social/psychological services

2381
 Social/emotional climate
Physical environment
Employee wellness
Family engagement
Community involvement

Positive Working Relationship With School Team

Members
The school principal influences all phases of the school health program by
promoting good school health through active support of the school's health
services, participation in setting health-related policies, and tapping into
community resources. The principal can reinforce positive efforts within the
school, ranging from the health teaching in the classroom to the cleaning
activities of the custodian. Because of the principal's influential position, it is
absolutely essential for the nurse and principal to maintain a positive and
cooperative working relationship.
Teachers, whether they are involved in regular instruction, physical
education, or special education, play a major role in school health. Because
they spend the most time with students, their observations, health teaching,
and personal health habits have a profound effect on student health and the
quality of school health services.
The school nurse and teachers must collaborate constantly, as the school
nurse provides information and guidance to teachers regarding students in
their classrooms with specific health conditions and concerns and teachers
report on students' health concerns and behaviors. Mink (2019) found that
teachers had higher levels of satisfaction when nurses were available on
campus full time and appreciated nurses' help with students having chronic
conditions, managing medical emergencies, and providing first aid when
students were injured. They also found benefits when school nurses followed
up on hearing and vision problems, making necessary referrals and getting
services for students having problems.
Student study teams (SSTs), where teachers, administrators,
psychologists, school nurses (Fig. 28-5), and others meet to discuss students
identified as having learning or health problems, were also noted as an
important collaborative opportunity (Merced Union High School District,
n.d.).

2382
 FIGURE 28-5 The school nurse is part of a team providing a
coordinated school health program.

Other health team members, such as health educators, health

coordinators, psychologists, audiologists, speech therapists, occupational
therapists, physical therapists, counselors, health care providers, dentists,
dental hygienists, social workers, security and juvenile justice personnel,
health aides, and volunteers, may also be involved, depending on size and
financial resources of the school. All team members, including students,
parents, bus drivers, and custodians, have a specialized role complementary
to that of the school nurse.
School-based health centers (SBHCs) provide an access to health care
services for youth confronted with barriers to social determinants of health
and are often sponsored or funded by public health departments, community
health centers, or hospitals. They often provide care for children, and
sometimes their families, who otherwise do not have access to health care.
SBHCs provide “significant positive effects on youth health and
academic outcomes including high school completion and grade point
average, grade promotion, lower rates of hospitalizations, emergency room
visits, substance use, and higher rates of contraception use.” (Bersamin et al.,
2019, p. 11). SBHC are predominantly established in lower socioeconomic
neighborhood and urban settings. Over the last 3 years, there has been a 20%
increase or 2,315 new SBHC across the United States (Bersamin et al.,
2019).

Responsibilities of the School Nurse

School nurses address the social determinants of health such as environment,
access to health insurance, housing, and income as most health issues are
associated with social determinants of health (NASN, 2018c). They bridge

2383
health and education preventing illness and promoting and maintaining the
health of the school community. The school nurse serves not only
individuals, families, and groups within the context of school health but also
the school as an organization and its membership (students and staff) as
aggregates. The school nurse identifies health-related barriers to learning,
serves as a health advocate for children and families, and promotes health
while preventing illness and disability (NASN, 2018c).
School nursing activities are varied and is composed of nursing care of
children with special health needs, including nasogastric tube feedings,
catheterization, insulin pumps, and suctioning; general and emergency first
aid; vision, hearing, scoliosis, and TB screenings; height, weight, and blood
pressure monitoring; oral health and dental education; immunization
assessment and monitoring; medication administration; assessment of acute
health problems; health examinations (athletic participation or school entry);
and referrals (Best et al., 2018). School nurses also assess and are the
frontline providers for identifying communicable diseases, such as outbreaks
of influenza or meningitis. Medication administration is another common
school nurse duty and includes giving a wide range of medications for acute
and chronic issues, as well as delegation of medication tasks:

94.3% of school nurses reported giving ADHD medications

82.4% gave asthma-related medications
64% gave medication for either type 1 or 2 diabetes
45.2% gave psychiatric-related medication
31.5% of medications were for allergies, 19.6% of medications were for
seizures
11.2% were for bowel or bladder management (Maughan, McCarthy,
Hein, Perkhounkova, & Kelly, 2018).
Administration of medication can be delegated 77.9% of the time to
unlicensed assistive personnel (UAP), such as health aids or school
clerks (Maughan et al., 2018).
Administrators, teachers, and others may also give medications
depending upon state laws.

In addition, school nurses perform first aid, help students with inhalers
and nebulizer treatments, and some may do gastric tube feedings and
ventilator/tracheostomy care. They are responsible for documenting their
care, but this can be difficult because of time constraints, educational
regulations, and lack of a functional standardized data set or method of
collection. Other duties of a school nurse may include training school staff in
cardiopulmonary resuscitation (CPR), universal precautions and first aid, as
well as overseeing the health and wellness of school staff members. Each
school nurse must assess and prioritize how to address the specific needs in
each individual school and determine the order. As you can see, there are a

2384
wide variety of activities involved in school nursing. This largely
autonomous practice requires specific skills and training.

Education: Special Training and Skills of the School

Nurse
School nurses operate from one of two administrative bases: the school
system or the public health department (NASN, 2016). In most localities,
public or private school systems or districts hire school nurses, and they
maintain a specialized, school-based practice. Private schools and
universities also hire school nurses.
In this specialized role, the nurse can concentrate time and effort solely
on the school health program and develop specialized skills in school health
assessment and intervention. Today, with the emphasis on delivery of health
care at community sites where clients spend most of their time (e.g., schools
for children, the workplace for adults), the nurse whose specialty is school
health care seems better prepared to meet the complex needs of the school-
age population. In contrast, the school nurse who operates under the board of
health's jurisdiction provides services to schools as one part of generalized
public health nursing services to the community. The community health
nurse working through the health department usually devotes only a portion
of the workday to the school; she may have additional responsibilities, such
as clinic nursing and home visits.

Depending on the state of residence, a school nurse is usually an RN—

frequently with additional education beyond the bachelor's degree in
nursing, sometimes including a master's degree—that has primary
responsibility for the health care of school-age children and school
personnel in an educational setting.
In some areas of the country, licensed practical nurses (LPNs) or
licensed vocational nurses (LVNs) may be hired by school districts, but
they must generally work under the supervision of an RN. School
nursing: Scope and standards of practice (ANA & NASN, 2017)
indicates that school nurses should, at minimum, possess a bachelor's
degree.

As the needs of school-aged populations become increasingly complex,

some states require even more specialized training for school nurses. In
California, for instance, school nurses are expected to hold a school health
services credential. This credential is obtained through a post-baccalaureate
program that includes course work in audiology, guidance and counseling,
exceptional children, school health principles and practice, a practicum in
school nursing, child psychology, and health curriculum development, in

2385
addition to other courses. A national certification is available as well (NASN,
2018d).

Functions of School Nursing Practice

The three main functions of school nursing practice are health services,
health education, and promotion of a healthy school environment. Health
services include caring for individual students who have chronic conditions,
acute situations, and comprehensive care coordination needs while at the
same time thinking of the entire population and tracking trends (Willgerodt et
al., 2018). For example, the school nurse observes an increase in the number
of students diagnosed with asthma and investigates ways to help all students
with asthma. One way of doing this may be to organize an Open Airways
course (American Lung Association, 2018) to assist students in identifying
triggers and managing their own care. The goal of this course would be to
decrease student asthma attacks.

Health Services for Children With Chronic Conditions

Chronic health conditions are commonly acquired, incurable and conditions
lasting longer than 12 months with physical, emotional, functional,
developmental, and behavioral conditions (NASN, 2017a). The number of
children afflicted with chronic diseases is rising; it is estimated that 25% of
children and adolescents in the United States are affected by a chronic
condition (Miller, Coffield, Leroy, & Wallin, 2016).
Common chronic conditions include asthma, epilepsy, anaphylaxis,
hypertension, diabetes, and oral health (Leroy, Wallin, & Lee, 2017; Miller et
al., 2016). A systematic review (Leroy et al., 2017) noted a significant
reduction in absenteeism and positive trending in attendance with school-
based care and/or education. Overall, there was improvement in medication
adherence, improved symptoms, and health care use when plans of care in
the school were put in place. Although, reducing absenteeism is a common
function for school nurses, and chronic absences have often been linked with
chronic conditions like asthma and diabetes (Jacobsen, Meeder, & Voskuil,
2016). School nurses will need to maintain knowledge and training in
chronic issues (NASN, 2017a). Refer to content in Chapter 20 and see Box
28-8.

BOX 28-8 QSEN: Focus On Quality

Patient-Centered Care for Correctional Nurses Patient-
Centered Care: Recognize the patient or designee as the source
of control and full partner in providing compassionate and

2386
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.) Working in a correctional facility is
unlike working in any other setting. Prior to being incarcerated, inmates may
not have received health care. Custody is always with nurses when providing
health care. This may cause problems with patient confidentiality. Nurses
must remember not to self-disclose any part of their life outside of work.
Instead, develop therapeutic relations by following through with statements
made, ask questions, and practice active listening (Nursing @CSU Staff,
2019).
Common health issues with this population are many. Infectious disease
includes HIV, STDs, hepatitis B and C, and tuberculosis. Mental illnesses are
prevalent. When first arrested, inmates may experience drug or alcohol
withdrawal (American Academy of Family Physicians, 2019). Chronic
conditions such as hypertension, cancer, diabetes, asthma, and cirrhosis of
the liver are seen in the population (USDOJ, 2016). Nurses need to be
prepared to care for inmates experiencing a CVA, drug overdoses, or MI.
Depression is the most common mental illness seen in this population. Other
disorders include bipolar, anxiety, and PTSD (Reingle Gonzalez, & Connell,
2014).

1. As a new correctional nurse, what concerns/fears might you have

when providing patient-centered care to this population?
2. Do you think knowing the crime committed would affect the care you
provide? Why or why not?
Source: American Academy of Family Physicians (2019), Cronenwett et al. (2007), Nursing @CSU
Staff (2019), Reingle Gonzalez & Connell (2014), U.S. Department of Justice (2016).

For students in special education programs, school nurses can coordinate

individualized education plans (IEPs) with individualized health plans
(IHPs) to develop health management goals for students. Medically fragile
or technology-dependent students, who may require procedures such as
suctioning or tube feeding, would have IHPs developed for specialized
physical health care procedures (Orange County Department of Education,
n.d.). Because these students are often hospitalized, interrupting their
education, the school nurse needs to assist with transition planning.
Collaboration with school psychologists and school and health team
members is important to transition planning that is also needed as students
move from elementary to middle school, from middle school to high school,
and as they move out of public schools and on to other educational or job
training settings (NASN, 2018e).

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 School nurses develop IHPs to ensure that students with special needs
(e.g., chronic conditions) have these needs met. If these students attend the
regular classroom and do not fall under the IDEA, the plans may be known
as Section 504 plans, named after the section of the Rehabilitation Act and
the accompanying statute, the ADA, that specifically allows for school
accommodations with this population. Some examples might include severe
peanut allergies that lead to anaphylaxis, serious asthma complications,
diabetes, or heart disease.
Students are to be provided with a “free and appropriate public
education,” and some students may be covered under both IEPs and Section
504 plans (California Code of Regulations 5CCR 3030, n.d.). See Box 28-9
for a list of IEP-eligible disabilities.

BOX 28-9 Thirteen Disabilities Eligible

for Individualized Education Plans
Autism
Deaf-blindness
Deafness
Emotional disturbance
Hearing impairment
Intellectual disability
Multiple disabilities
Orthopedic impairment
Other health impairment
Specific learning disability
Speech or language impairment
Traumatic brain injury
Visual impairment, including blindness
Source: Galemore and Sheetz (2015).

Asthma
Asthma is often deemed the most common chronic disease of childhood.
Students loose over 13 million missed school days a year from this chronic
disease (Everhart, Miller, Leinach, Koinis-Mitchell, 2018). Student
symptoms include shortness of breath, tightness of chest, wheezing, and lack
of energy (Everhart et al., 2018). School environmental factors (e.g., mold,
allergens, indoor air quality) also exacerbate asthma symptoms in children
and youth.

2388
 Asthma management programs are useful in helping students manage
symptoms and reduce asthma triggers. School nurses work with students,
their families, and their doctors to develop an asthma action plan to control,
prevent, or minimize untoward effects of acute asthma episodes. Peak flow
meters can be used regularly to determine early signs of asthma problems.
Monitoring asthma medications and teaching proper methods of inhaler use
are also vital school nursing functions. It often falls to school nurses to
ensure that proper protocols and training are in place. It is imperative that
school nurses are well versed in the care and treatment of asthma.
In Colorado, a framework for asthma care curriculum was created to
guide the continuing education of school nurses and health care team
members in their state (Cicutto et al., 2017). A Healthy Homes program
headed by C/PHNs in Baltimore, Maryland, focused upon home assessments
for environmental health risks (lead, asthma triggers, carbon monoxide,
pesticide use, environmental tobacco smoke) as well as source of heating in
the home. They also included educational sessions to review home
environmental health risks and a targeted hazard reduction intervention (U.S.
Department of Housing and Urban Development, n.d.). Refer to content in
Chapter 20.

Diabetes
Diabetes is another common chronic illness in young people: approximately
208,000 or one in 433 children and adolescents have diabetes (National
Diabetes Education Program, 2016). Of these, 87% are diagnosed with type 1
and 11% are diagnosed with type 2 diabetes (NASN, 2017b). It is estimated
that there are 18,000 newly found youth under the age of 20 annually
diagnosed with type 2 diabetes and over 5,000 newly diagnosed with type 1
diabetes (NASN, 2017b). Both types of diabetes are on the rise in
adolescents, leading some scientists to frame it as a major public health crisis
caused largely by obesity, sedentary lifestyle, and the predisposition of
certain ethnic groups to diabetes (National Institute of Diabetes and
Digestive and Kidney Diseases, 2017). Refer to content in Chapter 20.
Working with families and health care providers, school nurses assess
and develop a care plan for students with diabetes. School nurses work
closely with the family to maintain confidentiality and at the same time
ensure that the school is a safe environment for the child:

A multidisciplinary team approach is needed, with family, school, and

physician collaboration.
Training for teachers and fellow classmates is also important.
Teachers are often called upon to assist students with their insulin or
food management.

2389
 Younger children with type 1 diabetes, especially those who use insulin
pumps, may need careful monitoring—something that is not always
possible for the school nurse, who may not be present where and when
problems arise.
A student experiencing a hypoglycemic reaction should never be left
alone. It is important for school nurses to alert teachers and school
personnel to the signs and symptoms (as well as the treatment) of
hypoglycemia.
A current position of NASN, NIH, and CDC is that a diabetes medical
management plan should be in place to assist in the care of children
with diabetes (NASN, 2017b; National Diabetes Education Program,
2016).
Care coordination, training, and delegation are the roles of the school
nurse (NASN, 2017b). However, many school nurses do not feel
comfortable delegating tasks such as administration of insulin or
glucagon.

Testing blood sugar and taking insulin at school can be frustrating and
can cause children to feel different from their peers. Students may be
required to administer medication or check blood sugar levels in health
offices as well as follow protocol for needle dispensing. Diabetes must be
managed 24 hours a day, seven day a week.
Type 2 diabetes cases have been rising, and school nurses can be
instrumental in prevention measures and early identification. It is often found
more frequently in Native American and Hispanic populations and less
frequently among non-Hispanic Whites. Also, obesity is an independent risk
factor, with close to a quarter of children and youth being obese. Visceral fat
is associated with insulin resistance and impaired glucose tolerance, a
pathology linked to type 2 diabetes. Culturally sensitive interventions that
include increased physical activity and education on good nutrition, as well
as behavior modification and ongoing methods of support (e.g., group
meetings, phone/e-mail reminders) were shown to be effective in a
systematic review (Brackney & Cutshall, 2015). School nurses should assess
their school population and promote interventions that benefit at-risk
students, as well as the general school population. Refer to content in
Chapter 20.

Seizure Disorders
Seizure disorders are not uncommon in the school-age population. Epilepsy
is a disorder of the brain in which neurons sometimes give abnormal signals.
For the majority of those diagnosed, seizures can usually be controlled with
medication (e.g., antiepileptic drugs specific to the pediatric population),
surgical treatment, or a special (e.g., ketogenic) diet (Epilepsy Foundation,

2390
2017; National Institute of Neurological Disorders and Stroke, 2018). It is
important for school nurses to develop care plans to address seizure concerns
during school hours.

Care plans include monitoring medication compliance and teaching

school staff about first aid measures for seizure victims.
Children and adolescents with seizure disorders may feel embarrassed
or be the victims of teasing or bullying.
They may exhibit signs of school avoidance. Nurses need to work with
these children and to teach all students about the disease process and the
need for empathy and understanding.
Similar to issues related to insulin administration for diabetic students,
children with seizure disorders may have an emergency medication
ordered by their physician (e.g., Diastat, midazolam, lorazepam,
clonazepam). Prescribing providers and school nurses should be aware
of the laws regarding the administration of seizure rescue medications,
particularly as they pertain to UAP (Hartman, Devore, & Section on
Neurology, Council on School Health, 2016).
The Epilepsy Foundation (n.d.) has advocated for its use in schools, and
school nurses are often caught between the rights of students and their
parents and their state's nursing practice act. Refer to content in Chapter
20.

Food Allergies and Anaphylaxis

Another leading chronic condition found in school settings is severe food
allergies that can lead to anaphylactic shock.

It is estimated that the 5.9 million school-aged children have food

allergies (Food allergy Research and Education [FARE], 2018).
Such severe allergies result in approximately 200,000 ED visits each
year (FARE, 2018).
Eight common foods account for 90% of severe food allergies. They are
fish, shellfish, soy, milk, egg, wheat, peanuts, and tree nuts (e.g.,
cashews, walnuts).
Many common foods and school supplies (e.g., play dough) can contain
hidden allergens, and care must be taken to prevent exposure.
School nurses coordinate and work with students and their families,
along with school personnel, to raise awareness and enlist caution.
School nurses also work with families, and health care providers, to
ensure that epinephrine via an auto injector (EpiPen) are available for
the child in case of emergencies. It is also used for bee sting and other
allergies, in addition to food allergies.
Although many factors are taken into consideration, most pediatric
allergists believe students between 12 and 14 years should carry and be

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 able to self-administer their own EpiPen (American Academy of
Allergy, Asthma & Immunology, n.d.).
School nurses should coordinate with teachers and lunchroom personnel
to ensure that proper protocol is followed for allergic reactions. School
personnel should be made aware of the food allergy, understand an
anaphylactic reaction, and be able to verbalize or demonstrate how to
use the EpiPen or other needed medication (CDC, 2018c). School
nurses need to ensure the Allergy and Anaphylaxis Emergency Plan is
completed by the parent and physician to ensure proper treatment for a
student with severe allergies while at school (AAP, 2018a). In addition,
a 504 or IHP should be completed. Refer to content in Chapter 20.

Behavioral Problems and Learning Disabilities

Other chronic childhood health problems are those of emotional, behavioral,
and intellectual development. These are not always easy to detect and
measure, and they can be debilitating. Although these problems are not new,
awareness and concern have increased as the rates of occurrence for other
life-threatening childhood diseases have diminished.

The National Institute of Mental Health (NIMH) reports that emotional

and behavioral disorders affect 10% to 15% of children globally (Kid's
Mental Health Portal, 2018).
Problems such as oppositional defiant disorder, bipolar disorder, and
early schizophrenia can affect the school-age population and is a
concern to school nurses and staff (Riley, Ahmed, & Locke, 2016).
The causes of emotional behavioral problems and learning disabilities
appear to have genetic, environmental, and cultural influences.
High-risk children often come from families with a high incidence of
child abuse (physical and sexual) and neglect.
The number of children affected by parental drug use has surpassed that
of children with disabilities caused by lead poisoning, another major
contributor to developmental problems in children.

Attention-deficit/hyperactivity disorder (ADHD) is a cluster of problems

related to hyperactivity, impulsivity, and inattention. Approximately 6.4
million school-age children have been diagnosed with ADHD (National
Center for Learning Disabilities, 2017). School nurses must be aware of the
signs and symptoms and serve as an advocate for these children and their
families. At each stage of development, those with ADHD are presented with
distinct challenges. For example, children in elementary school may often
have difficulty and conflict with peers, as well as problems organizing tasks.
They may be more accident prone and may have more school-related
problems, such as grade retention and suspension or expulsion. They often
have problems with grooming and with handwriting, and they exhibit

2392
difficulty sleeping. ADHD is sometimes found with associated disorders,
such as communication or language disorders and learning disabilities. It is
estimated that as many as one third of children with learning disabilities also
have ADHD (National Center for Learning Disabilities, 2017). Counseling
and behavior therapy are often used with these children with a 70% to 80%
success rate demonstrated by improved behavior (Substance Abuse Mental
Health Services Agency, 2020).
Behavioral and emotional problems of school-age children can stem
from many causes. School nurses can be alert to early symptoms and refer
families for counseling.

Collaboration is needed between the child's family, the school, and the
child's health care provider to diagnose ADHD and effectively plan
appropriate interventions and educational accommodations.
Numerous checklists and assessment tools are available, and school
psychologists typically serve as a source for additional information and
resources.
School nurses can assist parents in recognizing the symptoms of ADHD
and obtaining appropriate treatment and follow-up. A multimodal
treatment approach may include stimulant medication, usually
methylphenidate (Ritalin or Concerta), dextroamphetamine (Dexedrine),
and amphetamine (Adderall).
Family and individual counseling, parent support groups, and training in
behavior management techniques, as well as family education about the
condition, are also essential features of this method of treatment.
Not all children and adolescents respond to medication, and medication
dosage must be carefully monitored and titrated.
School nurses and community health nurses can work closely with
school staff, parents, and physicians in determining the efficacy of
treatment regimens.

The main goal of medication for school-age children is academic

improvement. If this does not occur, medication may need to be changed or
discontinued. School nurses and community health nurses can work closely
with school staff, parents, and physicians in determining the efficacy of
treatment regimens (Chan, Fogler, & Hammerness, 2016).

Medication Administration
Medication administration for a variety of conditions has historically been an
important responsibility for school nurses (NASN, 2017c). In schools where
a nurse is present every day, the nurse can personally oversee medication
administration. Unfortunately, many nurses cover more than one school and
so other school personnel (e.g., secretaries, health aides) may be tasked with

2393
overseeing medication administration. The majority of states have laws
allowing teachers or health aides to administer medication. In these
situations, school nurses should provide training and audit records to ensure
that proper guidelines are followed. In one study, over 800 schools were
surveyed and medication administration errors occurred 15% of the time
(Maughan et al., 2018):

58.4% occurred due to missed dose

19% for wrong time
18.3% for wrong dose
11.2% for wrong medication
10.6% for medication not documented
9.9% for wrong student
8.0% given without authorization

Another issue surrounding medication administration in the school

setting is regarding delegation. Each state's individual nurse practice act
provides rules on delegation of nursing tasks. School nurses must understand
their own state's act and the legal implications regarding their decisions.
School districts are responsible for including medication administration
guidelines in their policies, and school nurses must comply with established
guidelines (NASN, 2017c).
In a landmark case, the ANA filed a lawsuit on behalf of California
school nurses to prevent insulin administration by unlicensed personnel.
Their argument centered on the state's Nurse Practice Act and the need for
licensed nurses to administer this medication (with dosage often checked by
two nurses in hospital settings). However, the American Diabetes
Association and others argued that not all schools have adequate school
nurse coverage, and over one quarter of schools do not employ a licensed
nurse. Two courts ruled on the side of the school nurses, but the California
Supreme Court ultimately overturned those decisions, making it possible for
unlicensed personnel to give medications, including insulin, with parental
and medical permission (American Diabetes Association, 2017). The concept
of “in loco parentis” instructs school staff to provide care for the student in
the parent's place and with their consent (Alliance of Schools for Cooperative
Insurance Programs, 2017).

Health Services to Prevent Illness and Injury

School nurses emphasize prevention and focus many of their efforts on
prevention of communicable disease (via immunizations) and of injuries.

Immunizations

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School immunization rates continue to be high due to vaccine mandates for
school entry, yet areas where children remain unvaccinated affect herd
immunity rates causing outbreaks of measles and pertussis (NASN, 2020a,
2020b). See Chapter 8 for more on this.
Low immunization levels in many areas, in poor populations, public
concern for vaccinations, and increased disease rates signal the need for
constant surveillance, outreach programs, and educational efforts. School
nurses are deeply involved in each of these preventive activities. Health
departments and schools often work collaboratively to provide immunization
services. Compulsory immunization laws for school entrance, which vary
among states, have enabled public health personnel to carry out these
preventive services. All states require children to be vaccinated against
certain communicable diseases as a condition for school attendance (CDC,
2018d). Statewide immunization information systems can be beneficial for
schools, school nurses, and children and their families. School nurses, like
C/PHNs, may have access to not only viewing immunization records but also
the ability to update them. This provides ready access for children and
parents, as well as school nurses, to check immunization records, track those
children whose immunizations are incomplete, and provide critical
information during times of disease outbreaks.
School nurses often oversee and ensure that children are in compliance
with school entrance laws regarding immunizations. They may call parents
directly when they note that the student is out of compliance. They may also
arrange to help the student get immunized by facilitating appointments or, in
some school districts, by directly providing the immunizations.
The CDC provides information for National Immunization Awareness
Month and provides a toolkit for school nurses and others to follow when
developing successful immunization outreach programs in schools (CDC,
2018e). School nurses can be effective advocates in helping parents make
decisions about vaccines (e.g., HPV for adolescents), especially when they
have sufficient knowledge and recognize their role as an opinion leader
(Rosen, Ashwood, & Richardson, 2016). See Chapters 8 and 20 for more on
parental resistance to vaccines, and current immunization schedules for
school-age children and adolescents.

Safety
School nurses are also involved in ensuring that school environments are safe
places for students. School safety now incorporates more than just
playground equipment. Safety includes the following:

Safe neighborhood to walk to and from school

Car safety whether passenger or driver
Safety from gun violence

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 Bullying
Gangs violence
Sexual violence
Firearms, weapons, and mass shootings
Playground injuries, sport injuries including risk for concussion
Safety from natural disasters (CDC, 2017a)

Bullying behaviors affect 20% of students in their high school years;

bullying includes both in-person and cyberbullying (NASN, 2018f).
Cyberbullying occurs on social media sites and can have negative effects on
student's health; despite increased attention to this problem students,
including, LGBTQ students are at risk for physical, psychological, social,
emotional, and academic problems (Byrne, Vessey, & Pfeifer, 2018).
Youth violence is a significant issue and is the third leading cause of
death in the United States (CDC, 2016a). The rates and forms of violence
vary with gang and violent crimes higher in large cities, LGBTQ and females
having a higher prevalence of in-person and cyber bullying, and homicide
and physical injuries greatest for racial/ethnic males (CDC, 2016a).
Emergency departments treat more than 800,000 children for
concussions yearly; many concussions go undiagnosed (AAP, 2018b). New
guidelines have been implemented by the American Pediatric Association
using “age appropriate symptom scales to diagnose children and assess their
recovery” (AAP, 2018b, para 8). The guidelines were created in response to
health care providers asking for more evidence-based guidance, in addition,
the guidelines can provide information for families, coaches, and schools
(AAP, 2018b).
Another area of growing concern is student safety after natural disasters
or emergency situations. Recent earthquakes and potential bioterrorism
events may impact schools or not permit children to return home at the end
of a school day. School nurses are ideal persons to assist in
disaster/emergency relief. Students do spend much of their time in school,
and local schools are often designated as shelters in times of disasters
(NASN, 2016). School nurses can assist in the development of emergency
plans, as well as provide care and comfort to children and their families in
times of emergencies.

Health Education and Health Promotion

Another main function of school nursing practice involves education and
health promotion. This includes planned and incidental teaching of health
concepts and health curriculum development. In some states, school nurses
even teach the regular health classes. Education may be one-on-one to help a
child obtain better control over asthma or to explain to a newly diagnosed
diabetic student what is occurring in his body. As an educator, the school

2396
nurse may also teach an entire class regarding a student's severe food allergy
or the need for proper hand hygiene. The school nurse explains in simple
terms what allergies are and helps students understand that allergies are not
contagious, what to do in the case of an allergic reaction, and the importance
of not sharing foods that may contain potential allergens (NASN, 2016). The
application of research is important in school nursing. See Box 28-10.

BOX 28-10 Evidence-Based Practice

School Nursing A study by Benjamin-Chung
(2018) showed the impact of an elementary
school influenza vaccination program to
increase vaccination coverage, reduce school
absenteeism, and interrupt influenza
transmission in an elementary school in
California. Outcomes of the study also
identified influenza hospitalization numbers
were reduced with an indirect effect on elderly
hospitalization and nonelementary age groups.
An elementary-school influenza program can
profoundly impact absentee rates in school-
aged children and have an indirect affect in
older school-aged children and the community.
Another example of evidence-based practice in school nursing
involves testing for high-frequency hearing loss in adolescents (Sekhar
et al., 2016). Not all states perform mandated hearing screening, and of
those that do, not all test for high frequency hearing loss. This study
compared sensitivity of current adolescent hearing screening test results
with results from adolescents tested in a sound-treated booth. The
researchers felt that if current hearing tests added multiple high
frequencies this would improve sensitivity; the inclusion of a two-step
screening of initial referrals could then be used to reduce false positives.
Results of the study identified that traditional school-based testing
methods had poor sensitivity for hearing loss in adolescents. Hearing
screenings suggestions from the study include testing at 500, 1,000,
2,000, 4,000, and 6,000 Hz at 20 db HL with adolescents to identify
high-frequency hearing loss.

2397
 How could you use information from these studies to improve school
nursing practice and the health of school-age children?
Source: Benjamin-Chung (2018), Sekhar et al. (2016).

Because students trust school nurses, students often listen to them.

Educational subjects are limitless but should always apply to the specific
needs of the children in the school. The nurse must use creativity and
autonomy to identify and prioritize needs. A school nurse may also teach
about basic first aid, nutrition, physical exercise, sex education, and seat belt
safety, or provide information about careers in the health care professions.

Screenings: Opportunities for Teaching

Most local school districts provide some type of health screening services
such as hearing and vision screenings, usually through the school nurse or
local health care providers (California School Based Health Alliance, 2020).
Although the goal of all screening is to promote early intervention, screening
also provides the school nurse many opportunities to teach students and staff.
Referral information resulting from screening results is usually given to
parents, and school nurses may contact parents to encourage follow-through.
Children who are not present for school screenings may not receive the
benefits of these screenings (e.g., homeschooled and private school students).
School nurses often help to coordinate screening resources and benefits, and
they often carry out additional screenings for students who were absent when
mass screenings were held.

Vision
School nurses often oversee routine vision screenings at periodic intervals so
that vision problems that can interfere with learning may be detected and
treated early (e.g., nearsightedness, farsightedness, strabismus, and
amblyopia) (NASN, 2017d). School nurses also are involved in follow-up
and referral. They often send e-mails or letters to parents, make phone
follow-ups, and provide referrals and resources to ensure that corrective
eyewear is obtained.
The 2016 School Health Policies and Practices Study (SHPPS) noted that
82.7% of reporting school districts offered vision screening to kindergarten
or first-grade students (CDC, 2016b). Local Lions Clubs may be involved in
paying for area optometrists to assist with and/or direct screenings, as well as
to provide follow-up care (Lions Club, n.d.).

Hearing

2398
Hearing screenings for kindergarten and first-grade students reported 79.5%
of districts across the United States offered these services (CDC, 2016b).
These mass screenings are done to detect any serious hearing deficits that
may be related to recurrent ear infections or noise-induced hearing loss
(NIHL), often resulting from loud music, video games, or excessive exposure
to noise.

About 2 to 3 of every 1,000 school-aged children, aged 6 to 19, have

some type of detectable hearing loss in one or both ears (National
Institute on Deafness and other Communication Disorders, 2016).
Some have a type of sensorineural hearing loss—or one that involves
the inner ear or the nerves leading from the inner ear. It is permanent
and cannot be surgically or medically corrected (American Speech-
Language-Hearing Association, n.d.).
Similar to vision screening, school nurses screen and refer students with
suspected hearing problems to medical specialists (e.g., audiologists,
physicians).
School nurses can use the opportunity afforded by vision and hearing
screenings to provide education to students and their parents about
preventing problems such as NIHL.

Other Health Screenings

Height, weight, and sometimes blood pressure and cholesterol screenings
may be done to monitor normal growth and development and allow for early
intervention with populations who are especially susceptible to hypertension
and heart disease. In some areas, scoliosis screening is also done, frequently
during middle school years, to permit early detection and referral for medical
intervention (e.g., bracing, surgery). Scoliosis may be congenital but is often
idiopathic, and the efficacy of school screening programs has been
questioned. There is much controversy surrounding scoliosis screenings in
schools. One study found the lack of referrals, costs, or not having a school
nurse to conduct the screenings as concerns. However, the study concluded
that school screenings be conducted in the underserved populations that may
lack yearly pediatrician visits (Kadhim et al., 2019). A systemic review of
school screenings found screenings were successful in detecting problems in
the early, treatable stages (Altaf, Drinkwater, Phan, & Cree, 2017).
In Texas, and some other areas of the country, acanthosis nigricans
(hyperpigmentation from various causes, but sometimes a symptom of
diabetes) screenings are being done to look for early markers of type 2
diabetes, especially in high-risk populations (Texas Department of Health
Services, 2018).
Pediculosis (or head lice) in school-age children is a continual problem
for school nurses. Between 6 and 12 million children aged 3 to 11 each year

2399
are estimated to be infected with head lice, and school nurses are often called
upon to do “head checks” for pediculosis. Pediculicides (e.g., permethrin,
pyrethrins, dimethicone) are helpful in killing lice, and school nurses often
provide families with education on prevention and eradication methods
(Gunning, Kiraly, & Pippitt, 2019). In addition, a nonchemical based, heat-
based treatment has provided families with an alternate option for lice
treatment in many communities (Lice Clinics, 2019). See Chapter 20.

Oral and Dental Health: Teaching and Referral

Dental caries affect more than half of school-age children and are the most
common chronic disease for that age group. About 20% of 5-to 11-year-olds
and 13% of 12-to 19-year-olds have at least one untreated decaying tooth
(CDC, 2017b). The percentage of children and adolescents aged 5 to 19 years
with untreated tooth decay is twice as high for those from low-income
families (25%) compared with children from higher-income households
(11%) (CDC, 2017b). School nurses can address dental health issues in a
variety of ways.

At a community level, they can educate the public about the benefits of
dental fluoride treatments. They can advocate for fluoridation of
drinking water, school-provided fluoride rinses or gels, and dental
sealant programs. These are all cost-effective, proven methods of
reducing dental caries in school-age children.
At the classroom level, school nurses can provide dental education and
provide toothbrushes, toothpaste, and floss to ensure that students are
able to practice good dental hygiene habits.
Local organizations and businesses often will donate such supplies.
Many programs from the American Dental Association, the CDC, and
other organizations provide resource materials.
At an individual level, school nurses can assist in finding resources for
those with no dental health insurance.
Finally, school nurses can successfully educate parents, especially those
who are immigrants or have different cultural beliefs, regarding the
importance of oral and dental health (Hassmiller, 2016; Reza et al.,
2016).

Dental screenings or clinics may be conducted to determine the incidence

of dental caries, especially in elementary school children, and to encourage
follow-up with local dentists for necessary restorations. At the time of the
most recent national survey of schools, only 41.4% of districts reported
performing some type of oral health screening (CDC, 2016b). See Chapter
20.

Promotion of a Healthful School Environment

2400
A third function of school nursing practice includes maintaining and
promoting a healthful school environment. Promotion of healthful school
living emphasizes planning a daily schedule for monitoring healthy
classroom experiences, extracurricular activities, school breakfasts and
lunches, emotional climate, discipline programs, and teaching methods. It
also includes screening, observing, and assessing students to identify needs
early and to report illegal drug use, bullying, suspected child abuse, and
violations of environmental health standards (NASN, 2017e). Cyberbullying
is another area where school nurses can provide education to students,
parents, teachers, and school staff, as well as response to warning signs
among school-age children and youth (Byrne et al., 2018). Health promotion
also involves the nurse in supporting the physical, mental, and emotional
health of school personnel by being an accessible resource to teachers and
staff regarding their own health and safety.

Proper Nutrition and Exercise

Many factors can affect the school environment—heating, cooling, lighting,
safe playgrounds, and policies and practices to limit bullying and social
aggression or other forms of school violence. The school cafeteria and
physical education activities can promote health or contribute to obesity and
sedentary lifestyles.

Obesity
Obesity rates have steadily increased for all children since the 1980s; the
rates have doubled for children between ages 2 to 5 and adolescents (ages 12
to 19). Rates have tripled for those between ages 6 and 11 years.
Approximately 17% (or 12.7 million) of children and adolescents aged 2 to
19 years are obese (NASN, 2018g).

American children get less than the recommended 60 minutes daily

physical activity and over 90% of children have poor diets (NASN,
2018g).
Only 58.9% of school districts across the United States assess student
achievement of physical education standards (CDC, 2016b).
Obesity often begins in childhood and becomes a risk factor for
cardiovascular disease and diabetes later in life. With the increase in
child obesity rates, the number of children diagnosed with type 2
diabetes continues to rise, especially among youth of minority
race/ethnicity.
As children become older, families have less impact on food choices,
and peers begin to have more influence.
Results of the 2017 YRBS indicate that very few high school students
eat enough fruits and vegetables—of those surveyed only 13.9% of high

2401
 school students had consumed more than three servings of vegetables,
and only 18% had consumed more than three servings of fruit or 100%
fruit juice (CDC, 2018f).

School nurses should play an integral role in the prevention of

overweight and obesity, as well as addressing the health needs of overweight
and obese students (Box 28-11; NASN, 2018g). Many factors contribute to
this health issue: diet, lack of physical activity, genetics, family and social
factors, culture, socioeconomic status, and media marketing (NASN, 2018g).

BOX 28-11 Levels Of Prevention Pyramid

Obesity In A School Setting HEALTH ISSUE:
Obesity in a school setting

Homelessness and Hunger

Poor nutrition and obesity are not uncommon among adolescents, whose
diets often consist of snacks with limited nutritional value interspersed
among unhealthful meals. Homelessness and hunger can also have serious
consequences, one being an impact on the academic performance of children.

Irritability, lack of energy, and difficulty concentrating are only some of

the problems that arise from skipped meals or consistently inadequate
nutrition.

2402
 Infection and illness (e.g., ear infections, asthma, bronchitis,
gastroenteritis) that lead to loss of school days can affect academic
progress and interfere with the acquisition of basic skills, such as
reading and mathematics.
Dental caries are frequent.
Poor nutrition is frequently associated with poverty and hunger, but
social pressure to be thin can also spark purposeful malnutrition.
Homelessness and food insecurity can lead to overreliance on fast food
and convenience stores, and lack of stable housing triggers stress and
anxiety, which can lead to (Crawford et al., 2015) obesity.

School nurses can help coordinate services for children that are homeless
and advocate for better nutritional choices in the lunchroom and vending
machines. This may include working for policy changes to limit soft drink
sales in public schools. They can also teach all grade levels regarding proper
nutrition, and they can educate students and parents alike about nutritious
snacks in contrast to snacks with little food value, as well as provide
information on community resources (e.g., food banks, health clinics,
shelters). School nurses may also work with staff to provide nutrition and
exercise programs, support groups, and collaborative efforts to assist families
dealing with hunger and homelessness.

Eating Disorders
Eating disorders are another area of concern. Issues with body image and
control are at the heart of anorexia nervosa and bulimia nervosa, common
problems for adolescent girls. These diseases have emotional causes that
pose complex challenges to treatment. School nurses must be aware of the
signs and symptoms of eating disorders and be proactive in identifying
students at risk, working collaboratively with other members of the mental
health treatment service team to advocate for the child. Scoliosis screenings
are an optimal time to also observe for eating disorders, as examination of
the spine allows for visualization of the body core. School nurses can work
with students to develop a healthier self-concept and identify outside
treatment resources (National Eating Disorders Association, 2019).

Adolescent High-Risk Behaviors

Mortality and morbidity rates for adolescents are low overall and
demonstrate considerable improvement since the early 1900s. High-risk
behaviors that are directly related to morbidity and mortality in youth and
young adults: behaviors that lead to unintentional injury and violence,
tobacco use, alcohol and drug use, sexual behaviors that leads to pregnancies
and sexually transmitted infections, unhealthy dietary behaviors, and lack of
physical activity (CDC, 2018g). Many of the health problems faced by

2403
adolescents are choices and high-risk activity; for example, sexual activity,
substance abuse, injury, and violence are all high-risk behaviors in which
adolescents can choose to participate or not. The effects of such choices may
not be discovered for many years.

Suicide is a leading cause of death of adolescents, according to the

Youth Risk Behavioral Survey (2007–2017) 17.2% of students had
seriously considered attempting suicide.
Safety while driving or under the influence is other high-risk behaviors.
Nationally, 62.8% of student's text while driving, 64.5% of youth drove
when they had been using marijuana, 62.6% of students drove while
under the influence of alcohol (CDC, 2018f).
4,300 youth ages 10 to 24 were victims of homicide, and homicide is
the third leading cause of death for this age group (CDC, 2016a). 15.7%
of youth carried a weapon (gun, knife, and club) 1 day in the past 30
days, while 3.8% of youth carried a weapon to school (CDC, 2018f).
See Chapter 20.

Sexual Activity: Teen Pregnancy and STDs

Sexual activity is a sensitive issue. However, the 2017 YRBSS indicates that
39.5% of students surveyed reported they had had sexual intercourse, and
9.70% had had sexual intercourse with four or more partners in their lifetime
(CDC, 2018f).
One in four sexually active adolescent females has an STI (CDC, 2018h).
The overall rates of syphilis, gonorrhea, chlamydia, human papillomavirus
(HPV), and herpes simplex virus are climbing.
Providing STD services and HIV/AIDS education can be a daunting task.
Young people with STDs are often afraid or embarrassed to seek help. Those
who have been exposed to the HIV virus may not know that they are
infected. Although in some communities, the school-based clinic dispenses
condoms, in other areas, school nurses may be restricted in what safer sex
products they can provide. However, nurses can provide teens with education
and with information about resources that are available outside of school
property. School nurses can promote, at the local and state level, the HPV
vaccine that guards against cervical cancer. They can promote abstinence or
delaying sexual initiation, as well as fostering safer sex messages that
promote the use of condoms. Sex education is effective at both delaying the
onset of sexual activity and decreasing sexual activity in adolescents who are
already sexually active. See Chapter 20.
School nurses are sometimes restricted by state and/or district policies
from addressing the issues of sex education and STI (including HIV)
prevention. However, they can inform students and others in the community

2404
about the existence of youth development and family planning programs,
which are often stationed strategically in inner cities, near schools, or in
school-based clinics. These agencies are empowered to provide birth control
information and counseling to young people.

Substance Abuse
Substance abuse among young people was almost unknown before 1950 and
rare before 1960. Now, adolescent drug experimentation and use poses
serious physical and psychological threats. During the 30 days before being
surveyed, adolescent participants in the 2017 Youth Risk Behavior Survey
reported that:

35.6% tried marijuana.

8.8% had smoked tobacco.
42.2% had used electronic vapor product. Vaping has increased
significantly due to low perceived risk for youth with 12th graders
reporting 11% use in 2017 and 21% use in 2018; 10th graders have also
showed an increase with 8.2% use in 2017 and 16.1% use in 2018
(National Institute of Drug Abuse, 2018).
29.8% of students have had at least one alcoholic drink in the last 30
days (CDC, 2018f).

School nurses can assist in programs targeting all substance abuse.

Successful programs focus on protective factors, instead of just high-risk
behaviors. The programs focus more on the root causes, or why youth choose
high-risk activities. See Chapters 20 and 25.
School nurses can also provide resources for smoking cessation and
substance abuse programs. In addition to school-based education, programs
of peer leadership and parental education/involvement and community-wide
task forces have been developed to lobby for local legislation and strengthen
community–school ties. School nurses can be advocates at a community
level by lobbying the city council for tougher ordinances controlling
advertising content and zoning (especially near schools). School nurses often
work in conjunction with law enforcement officials, school district
administrators, and other community agencies to ensure compliance with
local regulations and prevent or delay tobacco use. Other groups, such as 4-H
clubs, religious congregations, the Catholic Youth Organization, and Boy
Scouts, use peer counseling to influence young people to assume
responsibility for healthy lifestyles, with the goal of developing decision-
making skills that lead to healthy lifestyle choices in adolescence and
through adulthood. The school nurse participates in and supports existing
programs in addition to counseling and referring young people who need
help.

2405
Mental Health Issues and Suicide
Depression, schizophrenia, and eating disorders may first appear during
adolescence. It is estimated that 13% to 20% of children experience a mental
disorder in a given year (NASN, 2018h). Many adolescents are reluctant to
seek help for emotional problems or help may not be readily available to
them.

It is estimated that only 10% to 40% of those who need treatment

actually receives it (NASN, 2018h).
Common mental health disorders in adolescence include anxiety,
depression, ADHD, eating disorders, bipolar disorder, and
schizophrenia (NIMH, n.d.).
Suicide is the third leading cause of death for young people between
ages 15 and 24 years; it is the second leading cause of death in children
between ages 5 and 14 years (American Academy of Child &
Adolescent Psychiatry, 2017).
School nurses must be aware of the signs and symptoms of mental
illness and suicidal intentions. They can work with school
psychologists, social workers, and other mental health workers to
address the needs of the students and provide grief counseling to peers
after a student commits suicide.
Recent suicides by youth have been attributed to the students being
bullied. School nurses also need to be aware of the increased issues
related to bullying in the schools and in cyberspace. The YRBSS states
that 19% of children had reported being bullied while at school, and
14.9% had experienced cyberbullying (NASN, 2018f).

Chapters 20 and 25 have more information on adolescent and behavioral

health issues.

Abuse and Maltreatment

In 2016, an estimated 676,000 children were victims of abuse and neglect. Of
these children, one in four experienced some form of abuse or neglect in their
lifetime with one in seven children being abused in the last year;
approximately 1,750 children die as a result of child maltreatment (CDC,
2018i).
Child abuse prevention education programs can be found in many school
districts as a primary preventive intervention. School nurses are required by
law to report suspected or confirmed cases of abuse. In addition, school
nurses can educate teachers and other school personnel regarding the signs
and symptoms of abuse.

2406
 Early identification of abuse and intervention is critical for the safety of
the child. Approximately 18.4% of suspected child abuse reports came
from education personnel (NASN, 2018i). It is important to be well
versed in subtle signs and symptoms of maltreatment and develop
strong collaborative relationships with social service professionals.
Signs that a child might be maltreated include reports of abuse, a sudden
change in behavior, lack of medical treatment follow-through, learning
problems of unknown etiology, child responses that are consistently
guarded or compliant, and an avoidance of home or certain individuals
(NASN, 2018i).

For more information on health problems and issues concerning children

and adolescents, see Chapter 20.

School-Based Health Centers

Because of the complex and intertwined emotional, physical, and educational
needs of school-age children and adolescents, a more comprehensive
interdisciplinary approach to services is needed than the piecemeal
approaches attempted previously. School nurses are able to do much to
influence school children's health. However, often they need to refer the
children to a health care provider. Yet, more parents are working and less
available to take care of their children's health care needs during the day.
SBHCs provide ready access to health care for large numbers of children and
adolescents during school hours, reducing absences from school due to
health care appointments. SBHCs provide a variety of services in a user-
friendly manner at a convenient location.

In 2016 to 2017, there were a total of 2,584 SBHCs in the United States,
Puerto Rico, and the District of Columbia, providing 6.3 million
children with access to school-based health care (School-Based Health
Alliance, 2017).
These clinics are distributed in high schools, middle schools, and
elementary schools and are generally established on school grounds. A
large majority (81%) of the clinics serve grades 6th through 12th
(School-Based Health Alliance, 2017).
The health care providers consist of nurse practitioners (85%) and
physician assistants (20%); 40% of the clinics have physicians (School-
Based Health Alliance, 2017).
Some clinics provide services only to schoolchildren, whereas others
extend services to their families and to other neighborhood families with
preschool-age children. Most centers are open full-time.
Many SBHCs in middle schools and high schools offer abstinence
counseling, pregnancy testing, sexually transmitted infection diagnosis

2407
 and testing, and pap tests (School-Based Health Alliance, 2017).
SBHCs are staffed by interdisciplinary teams of helping professionals,
paraprofessionals, and other staff and can include nurses, nurse
practitioners, and social workers. Many hospitals, HMOs, and health
departments are sponsors of these school clinics, because it is a cost-
effective way to decrease visits to the emergency department and
promote health, especially to underserved groups such as adolescents.
They help meet the need for patient-centered medical homes, as
outlined in the Affordable Care Act. Third-party billing, especially to
access Medicaid funding, is increasingly more common among SBHCs,
and private foundations have also been instrumental in providing
financial and technical support. School nurses support the clinics by
referring students who need additional attention. In some areas, school-
linked health centers are utilized. These clinics are not on school
property but may be nearby or easily accessible through mass transit.
Mobile vans also provide access to health services for school-aged
children, offering a wide range of services including medical, dental,
and behavioral health; in addition, they can assist with health care
enrollment (La Clinica, 2019; Metrohealth, 2019).

Evaluation research has demonstrated that SBHCs are effective in

increasing student access to health care. This is especially true for
adolescents, who often are difficult to reach and do not willingly access
health care. Onsite SBHC services are more appealing for adolescents, who
have been shown to utilize substance abuse and mental health counseling
services, as well as STD and family planning services (School-Based Health
Alliance, 2017).

School Nursing Careers

School nurses must be able to work autonomously. They need excellent
communication skills and the ability to prioritize and collaborate with many
others (professional and nonprofessional). The pay for school nurses depends
on location and employer (health department or school district). School
nurses save time for teachers and administrators, permitting them to focus on
their job of educating students. School nurses positively influence
management of student health concerns, student record accuracy, and student
immunization rates. Many nursing schools are utilizing schools as clinical
sites, with school nurses as preceptors, in an effort to bring more new nurses
into this specialty area.

There are many positive reasons to work as a school nurse: school

nurses generally do not work on weekends, many have contracts that
give them the summer off, and the daily work schedule and holidays

2408
 often coincide with those of the nurse's own school-age children, thus
allowing a parent to be home with children during off-school hours.
Finally, for most of those employed as school nurses, it is a wonderful
and rewarding experience to work with children whose eagerness and
innocence can often refresh the soul. It is an opportunity to protect and
heal our future leaders, who may become the ones who will eventually
protect and heal the world (Box 28-12).

BOX 28-12 PERSPECTIVES

A School Nurse Viewpoint on Community Health

Nursing A great aspect of being a school nurse is
being able to work with many different people. I
like being able to work with people who aren't
necessarily sick but can benefit from my help.
Additionally, school nurses must become familiar
with resources and people in the community and
surrounding areas. By making friends and
connections in facilities, and the community,
school nurses can involve local resources and
individuals to improve the population. Resources
aren't as readily available as they are for other
types of nursing. Unlike working in a hospital,
where results are apparent in just a few days,
school nurses must work tirelessly for long periods
of time to see the fruits of their labors.
Being a school nurse requires learning how to get funding for projects.
School nurses often don't have a model to work from, because each
situation may be unique. They must be innovative, resourceful, and
dedicated in order to stick with a project long enough for it to be beneficial
to the population.

2409
 School nursing is probably the epitome of what nursing was meant to
be. It is focused on service and improving the health and well-being of the
populace. The focus is on prevention; school nurses seem to get little
recognition for their work—because they are saving lives before they are
endangered, they are saving teeth before they fall out, and they are saving
families before they are lost. I believe their work is pivotal to the
improvement of society.

Neil P., school nurse

2410
CORRECTIONAL NURSING
Correctional nurses work within the criminal justice system—in
correctional facilities, prisons, jails, detention centers, and substance abuse
treatment programs—with clients spanning a range of ages from juvenile to
elderly, both male and female (Fig. 28-6; ANA, 2013). Bureau of Justice
Statistics dated December 31, 2016, reported an estimated 6,613,500 persons
were supervised by U.S. adult correctional systems. The decrease in the
incarcerated population was due to a decline in the prison population (down
21,200), while the jail population remained relatively stable (Kaeble &
Cowhig, 2018).

FIGURE 28-6 Correctional nurse taking an inmate's blood

pressure.

About 1 in 38 adults (or 2.6% of persons age 18 or older in the United

States) were under some form of correctional supervision at year-end 2016
(Bureau of Justice Statistics, 2018). An estimated 2% to 3% of RNs work in
corrections (Correctional Nurse, 2019) as compared to the total national
nursing workforce. This appears to be a low number considering there are
various career options for working in a correctional setting (e.g., part time,
contract service, academic affiliations, etc.) which may impact the total
estimations.

2411
History of Nursing in the Correctional Setting
In the past, the correctional system of prisons and jails has provided
minimal, if any, health care to inmates. Historically, nurses involved
with prisoner and mentally ill populations included Dorothea Dix, who
visited prisons around the country in the 19th century and found
prisoners in chains, without proper sanitation, living conditions,
nutrition, or clothing (ANA, 2013).
Prison was viewed as a punishment, and the inmates were seen as not
deserving of care that was being paid for through public dollars (Estelle
v. Gamble).
The historic Supreme Court ruling Estelle v. Gamble stated that not
providing medical services inflicted pain and denied inmates their
Eighth Amendment rights (Box 28-13) and led to major reforms in the
correctional health system. Medical providers were hired, and inmates'
rights were established (Akiyama, Feffer, Von Oehsen, & Litwin, 2018;
Dober, 2019).

BOX 28-13 The Rights of Inmates

Right to humane housing and treatment
Right to not be a victim of sexual crimes
Right not to be racially segregated
Right to complain about conditions
Rights provided by the American Disabilities Act
Right to necessary medical care
Right to necessary mental health care
Right to a hearing

Source: Findlaw (2020).

Although the correctional health system is a relatively new specialty, it is

under intense pressure from the courts to ensure that adequate and humane
care is provided. Specific issues include the provision of ethically
appropriate and timely patient care for inmates, the provision of adequate
mental health treatment, prevention of prisoner-on-prisoner violence,
maintenance of sanitary and safe conditions, and ending inmate neglect and
abuse. Ensuring that inmates' health needs are met amidst the growing
number of inmates and their increasing complex health concerns has imposed
a huge financial burden on correctional systems.
Funding for correctional health care derives from public tax dollars and
many are contesting that care and expense should be given to incarcerated

2412
persons National Commission on Correctional Health Care, 2017). This is an
ethical dilemma nurses working in correctional facilities must face every day.
In an attempt to decrease costs and save money, several states utilize
managed care organizations to provide some services for inmates and are
increasingly relying on private prison health care providers and managed
care organizations (Pew, 2017).
Correctional nurses must demonstrate nonjudgmental attitudes while at
the same time ensuring self-protection from assault. Correctional nurses
work in on-site medical units, clinics, or infirmaries housed in criminal
justice facilities. These facilities can be local jails or state and federal prison.
The care is focused on the individual, immediate, and ambulatory care,
emergency needs, and management of chronic conditions, screenings and
preventive services. Larger facilities offer ambulatory and inpatient mental
health services, and subacute care units for short-term therapies (e.g., IV
medications). In addition, the increased female incarceration rates highlight
that women's health care concerns must be addressed. As prisoners age, long-
term care and end-of-life care must also be provided (Sanders & Stensland,
2018); correctional systems are further challenged with these additional
specialty care needs.

2413
Education and Skills Needed
The preferred educational level for correctional nurses is a bachelor's degree.
The level of skill, judgment, and autonomy needed by nurses who work in
corrections is supported and developed within baccalaureate education.
National certification, through the National Commission on Correctional
Health Care as a certified correctional health professional-RN (CCHP)
(National Commission on Correctional Health Care, 2020) or the American
Correctional Association (ACA) as a certified correctional nurse (CCN)
(American Correctional Association, n.d.), is available. Some correctional
systems employ licensed professional nurses (LPN) and medical assistant
technicians (MATs).

2414
Functions of Correctional Nurses
Correctional nurses use public, community, and school health nursing skills,
along with skills acquired from the ED, occupational health, mental health,
orthopedics, and ambulatory care specialties. In general, primary care
interventions are provided for the inmate population with a focus on health
promotion and healthful lifestyles during incarceration.

Nurses assess patients for basic health needs and treat injuries and
minor acute medical conditions. As indicated, patients are scheduled for
regular appointments to manage chronic conditions of hypertension,
diabetes, pulmonary disorders, and mental health.
The correctional nurses also track and screen for communicable
diseases, providing essential related treatment as needed, provide health
promotion education, and provide transitional or discharge education
and preparation.
The correctional nurses may encounter a critical medical emergency
requiring stabilization before the inmate is transported to an outside
treatment facility for complex medical care. Most correctional facilities
do not have inpatient acute care medical units, while many have
inpatient mental health units for varied behavioral health conditions.

Because correctional facilities operate 24 hours a day, every day of the

year, it is vital that correctional nurses have cardiac life support
certifications, emergency preparedness, and disaster planning training. To
carry out its mission, the Federal Bureau of Prisons follows national
preparedness goals; preparedness planning and an emergency operations plan
are necessary (Johnson, 2018) (Table 28-1). A seminal study (Taylor &
Crianza, 2011) provides vivid examples of natural disasters affecting a large
jail system (over 10,000 inmates) and the need to plan for power, water, and
telephone outages, as well as housing and moving prisoners under
emergency conditions. Many correctional facilities include tabletop exercises
in their annual training program, and ensure resources are available to
provide adequate supplies to sustain health and wellness for a minimum of
72 hours post the impact of adverse weather. In many situations, nursing and
other staff are often asked to remain on-site for extended periods of time and
while making arrangements for their own families.

TABLE 28-1 Emergency Preparedness in Correctional

Facilities

2415
Source: Johnson (2018).

FEMA Guidelines recommend identifying hazards early and then taking

actions to mitigate those hazards before they become major problems
(FEMA, 2011). Correctional and medical staff training, and routine facility
inspections will enhance correctional disaster management outcomes (Boxes
28-14, 28-15, 28-16).

BOX 28-14 PERSPECTIVES

A Correctional Nursing Viewpoint on Community

Health Nursing When I completed my graduate
nursing program with an MSN and FNP, I
planned to work on a mobile clinic/van travelling
to several identified underserved communities
providing chronic and preventive health care.
Instead, I accepted the challenge of a uniformed
service enchanted by the mission of providing

2416
health care to underserved populations across the
nation. Little did I know I would start my NP
career working in a federal correctional facility.
Honestly, I was a little nervous for the first 3
months as I adjusted to the security restrictions of
the setting and the “inmate” population. One day
I went to work and told myself “these are
individuals coming to the clinic for health care
service.” They are “patients.”
From that time forward, I provided nonjudgmental, holistic nursing care to
all the inmates I served for over 10 years. I developed a passion for this
special, underserved population and became an advocate for preventive
correctional health care and obtained correctional health care certification
and a master's degree in criminal justice. What is most surprising about
correctional nursing is that the inmates are very appreciative of the health
care and preventive education provided. When told they are being
empowered to manage their individual medical conditions, there is a
motivation toward compliance. When measurable outcomes are presented
during chronic care visits or follow-up appointments, the pattern of
improvement and compliance is enhanced. It is a great feeling to see the
outcomes of one's nursing interventions in this population especially during
the chronic care appointments and/or during the release preparation process,
when the inmate can explain healthy lifestyle practices learned and they
plan to continue. What a validation of the impact of nursing practice!

CAPT Beverly Dandridge, USPHS Commissioned Corps

BOX 28-15 What Do You Think?

Potential Botulism Outbreak in Prison Inmates
During sick call today, your correctional nurse
colleague notices that four to five inmates from
the same housing unit have similar complaints—
blurred vision, feeling sick, and some difficulty

2417
breathing. It is flu season—could that be the
cause?
You know that homemade alcohol is not uncommon in prisons and
that it can be easily made from fermented fruit or other food waste.
Prisoners call it moonshine, pruno, hooch, brew, raisin jack, and other
names. You remember reading about a recent CDC report regarding
several outbreaks of botulism in California, Utah, and Arizona prisons.
Prisoners there had used potato peels, and the closed containers used to
produce alcohol permitted the toxin to grow during fermentation. With no
heat used to kill it, the bacteria grew and affected everyone who drank the
brew.
With botulism, it is most important to act quickly, as the toxin leads to
nerve paralysis, and when it reaches the respiratory muscles, it can cause
death. You talk with your colleague and decide to talk with the housing
correctional officers and the patients for further information. I think it is
better to be safe than sorry! What do you think?
Source: Schoenly (2016a).

BOX 28-16 Correctional System

Challenges for Nursing
Understanding of the population
Autonomous conditions
No universal standard for experience/no certifications
Strict facility protocols for safety and security
Employee burnout
Corrections fatigue
Source: Nursing @CSU Staff (2019).

2418
Future Trends
Because of advances in health care, longer prison terms, and more restrictive
policies, inmates are older, sicker, and remain in prison longer than they did
even 20 years ago. Historically, inmates have not taken good care of
themselves, hence, a 50-year-old inmate may have the health of a typical 65
year old in the general public (Schoenly, 2014).
Correctional nurses can increase efforts to improve transitional health
care programs, and serve as advocates, and lobby state and federal
legislatures to allocate funding for the additional resources needed within the
correctional health care systems (Hoke, 2015).
The female inmate population is also increasing. In addition to women's
reproductive health issues, females tend to have higher rates of major mental
illness, dental problems, insomnia, and chronic medical conditions (Mignon,
2016; Mollard & Hudson, 2016). Previous researcher has found that women
in jail have a high risk of cervical cancer and increased rates of abnormal
Papanicolaou (Pap) test results (Brousseau, Ahn, & Matteson, 2019).
Researchers have suggested that women in prison need trauma-informed,
gender-responsive treatment because of past trauma histories (Mollard &
Hudson, 2016). There has been a movement to provide trauma-informed care
and gender-responsive programs (GRPs) to women in prison.
One study discovered one third of inmates being released from prison
had at least one chronic condition; that number increased to 70% of those 55
years or older (Rosen et al., 2019). Correctional nurses can facilitate chronic
disease management by coordinating chronic care education programs and
empowering inmates to take better control their chronic conditions.
Correctional nurses should also conduct thorough family health histories, as
much as possible, as many health conditions tend to have a genetic
component and discuss screenings to identify conditions with correctional
health care providers to facilitate early intervention and decrease
complications and potentially, disease progression.
Ethical and legal issues in correctional nursing often center on the patient
(most often someone convicted of a crime, possibly involving violence).
Caring for the patient is vital, but custody must also be maintained, and
safety is essential. Correctional nurses have an opportunity, to help reduce
the burden of disease for communities by providing tri-level preventive
health care pre-, intra-, and post incarceration (La Cerra et al., 2017).

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CORRECTIONAL NURSING
CAREERS
Correctional nurses must have good mental health and assessment skills,
strong communication skills, and be strong advocates for nursing and their
clients. These nurses work in an intense environment where their safety
could be threatened, and they must deal with clients who may be
noncompliant, combative, and manipulative. Correctional nurses are also
increasingly becoming Certified Correctional Health Care Professionals (Box
28-17; National Commission on Correctional Health Care, 2020).

BOX 28-17 PERSPECTIVES

A Supervisor and a Director of Correctional

Nursing Viewpoint on Hiring New Nurses Do you
think you might like a job at a prison facility? A
Director of Nursing and a Supervisor of
Correctional Nursing provide some information
on the interview process. Before hiring new
correctional nurses, they ask candidates to review
the correctionalnurse.net blog and the (Schoenly,
2016b) Correctional Nurse Manifesto (Schoenly,
2014). The nurses who are hired receive civilian
training and are assigned a preceptor. The process
is designed to educate the candidate about the
realities and complexities of correctional nursing.
As the director notes, “No one dreams of going
into correctional nursing, but once you are in, you

2420
are hooked because you realize the difference you
can make.”
The interview process follows the guidelines set forth by the ANA
Correctional Nursing: Scope and Standards of Practice (2013) and the
textbook Essentials of Correctional Nursing (Schoenly & Knox, 2013),
which provides crucial information such as the ethical, legal, and safety
considerations of correctional nursing; common inmate-patient health care
concerns and diseases; nursing care processes; and professional role and
responsibilities. Also, unlike the nurses hired in the past, newer correctional
nurses do provide health care education and health care clinics for chronic
diseases on a regular basis. Because of the lack of an inpatient facility, 24-
hour nursing care is not provided in some correctional facilities. When 24-
hour nursing care is necessary, the inmates are transferred to a correctional
facility where such coverage is available or to an acute care facility if more
extensive care is required. In addition, the correctional officers are trained
to follow procedure and call 911 during an emergency.
Challenges to correctional nursing include the philosophy in the prison
setting that “safety comes first,” which could result in an inmate missing a
sick call. Should this occur, however, their medical needs are taken care of
as soon as it is safe and without compromise to their condition, according to
both the supervisor and the director of nursing. An emergency that
correctional nurses are occasionally faced with is suicide attempts—a
situation that is always “scary” even if you have seen it happen before. This
situation leads to a lock-down so that all resources can be focused on the
suicidal inmate, who sometimes is found hanging and needs to be cut down
and resuscitated.
The ability of correctional nurses to deliver medically appropriate care
is hindered by the lack of access to preexisting medical records and history.
Self-reporting is a far less reliable means for determining an inmate's risk
factors and overall wellness. This is one reason that civil litigation by
inmates, alleging medical negligence, is a weighty problem for all
correctional agencies.
Nurses have an incredible opportunity to improve the health of the
inmate population by returning their patients to the community healthier
than when they arrived.
Source: Schoenly (2014, 2016b).

Stan, Supervisor of Correctional Nursing Denise, Director of Correctional

Nursing

2421
 Correctional nurses usually receive extensive employee benefits and
insurance packages as government employees. Correctional nurses have the
ability to see recoveries from illnesses and injuries because they work with
the same patients for a longer time than hospital-based nurses. Correctional
nursing provides an opportunity to work with a vulnerable population and
practice the true art and science of nursing. It can be a challenging and
rewarding career. See Perspectives about the hiring process for new
correctional nurses.

2422
SUMMARY
C/PHNs manage a number of issues including communicable diseases,
chronic diseases, injuries, maternal child health, immunizations,
substance abuse, and disaster response.
C/PHNs work with all ages, ethnicities, socioeconomic groups, and
populations emphasizing health prevention and promotion.
C/PHNs work in several branches of the uniformed services.
School nurses work with school populations (elementary, middle, high
schools, and college/university levels) including students, their families,
and the school staff providing individual care and bridging the gap
between medical providers and schools.
School nurses provide direct nursing care, first aid, immunizations,
environmental assessments, and specialized health care for children
with special needs.
Correctional nurses work with inmates in federal, state, or local
facilities, including drug treatment and juvenile detention centers.
Correctional nurses provide individual care in facility clinics and
infirmaries while also identifying and developing programs to address
major population health concerns of inmates, including mental illness,
substance abuse, and communicable diseases.
The inmate population is growing older, staying longer, and
experiencing more from chronic disease. This, along with an increase in
female inmates, brings additional challenges for correctional nurses.
All nursing specialty areas provide valuable services which impact the
health of our communities. Because of the high level of nursing
knowledge, communication skills, autonomy, and leadership needed for
professional nursing practice, the educational entry level should be a
minimum baccalaureate degree.

2423
ACTIVE LEARNING EXERCISES
1. Interview a public health nurse asking the following questions: a.
Why did you choose public health nursing?
b. Within what area of public health nursing do you work?
c. Does an epidemiological background help with your work?
d. What is the most satisfying part of your job?
2. As a correctional nurse, you will care for people who are accused or
sentenced for a variety of crimes. How might a correctional nurse
utilize the 10 essential public health services to ensure high standards
of health care when working with this vulnerable population?
3. Go to this Web site
(https://www.nhlbi.nih.gov/files/docs/public/lung/asthma_actplan.pdf
) and print out a copy of the Asthma Action Plan. Discuss this with
the parent of a school-age child or adolescent who has asthma. Has a
school nurse or public health nurse ever gone over a plan with them?
Have they ever been shown how to use a peak flow meter or correctly
use an asthma inhaler? What methods have they used to control
asthma triggers?
4. Using “Utilize Legal and Regulatory Actions” (1 of the 10 essential
public health services; see Box 2-2 ), consider the following question:
Most schools require that children entering school show proof of
being fully immunized for a variety of communicable diseases. With
a partner, discuss what would happen if schools no longer had this
requirement. How would you educate parents who refuse to
immunize their child because of the unfounded fear that
immunizations cause autism?
5. List five (5) potential areas of employment as a member of the U.S.
Public Health Service. What types of services are rendered in each
agency? What are benefits of this type of nursing career (uniformed
service)?
6. Are prisons and jails appropriate facilities for meeting the needs of
individuals with mental health and substance use diseases? Why or
why not? If not, what other alternatives may be more effective?

thePoint: Everything You Need to Make the

Grade!
Visit http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, study aids for

2424
all learning styles, and more!

2425
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2439
CHAPTER 29
Private Settings
“All Nurses need a plan B. Drastic changes in the health care environment are resulting in a
reconfiguration of facilities and threatening job security for many nurses in this country. There is
good news[:] there are fantastic opportunities for nurse owned and operated businesses to
address these changes and challenges.”

—National Nurses in Business Association, n.d., para. 3

KEY TERMS
Case management
Comprehensive primary care center Entrepreneurial nurse Faith community
nurse (FCN) Federally qualified health center (FQHC) Nurseled health
centers/clinics (NLHCs) Occupational and environmental health nurses
Occupational Safety and Health Administration (OSHA) Safety-net health
care provider Sustainability
Total Worker Health (TWH) Transitional care

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Describe funding sources for nurseled health centers.
2. Articulate the importance of sustainability for nurseled health centers.
3. Describe the evolution of faith community nursing.
4. Describe and differentiate among the roles of the faith community nurse.
5. Explain the role of the occupational and environmental health nurse and
other members of the occupational health team in protecting and
promoting workers' health and safety.
6. Recognize at least three adverse working conditions that impact health
status.
7. Discuss the opportunities for nurse entrepreneurship in
community/public health practice.

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INTRODUCTION
Chapter 28 discussed a wide variety of practice opportunities in the public
sector. This chapter examines four unique private sector roles and practice
environments available in the United States and in many other countries:

Nurseled health centers offer the opportunity for more autonomous

practice and present excellent learning venues for nursing students.
Faith community nursing, begun in the mid-1980s, has gained
increasing attention in many religious communities and continues the
rich tradition of caring for those in need who may not have access to
services.
Occupational and environmental health is a specialty health practice that
focuses on the health and well-being of the working population and
therefore covers most of the country's working adults.
Entrepreneurial roles for nurses offer new venues for meeting the health
care needs in communities while providing challenging and autonomous
practice.

Each of these areas of practice offers Community/public health nurses an

avenue to address health disparities in their communities, increase years of
healthy life, and provide holistic, client-centered care to meet the current and
emerging health needs in their communities, as indicated in Healthy People
2030 and Leading Health Indicators (Boxes 29-1 and 29-2).

BOX 29-1 HEALTHY PEOPLE 2030

2441
Reprinted from U.S. Department of Health & Human Services (USDHHS). (2020). Healthy People
2030: Browse objectives.
Retrieved from https://health.gov/healthypeople/objectives-and-data/browse-objectives

BOX 29-2 LEADING HEALTH

INDICATORS 2030

2442
Key Health Indicators Applicable to Nurses
Working in Private Settings
Access to Health Services
Medical insurance
Health Care System Quality
Health Care Access
Clinical Preventive Services
Reduce the number of adults with hypertension Children between the ages
of 19 to 35 months receive the recommended doses of DTaP, polio, MMR,
Hib, hepatitis B, varicella, and PCV vaccines Determinants of Health
Equity

Environmental Quality
Environmental health
General health, health-related quality of life, well-being

Injury
Maternal, infant, and child health
Mental health
Obesity
Oral health
Reproductive and sexual health
Social capital/civic engagement
Serious illness
Social determinants
Substance abuse
Tobacco
Source: The National Academies of Sciences, Engineering, and Medicine (2020).

2443
NURSELED HEALTH CENTERS
Nurseled health centers/clinics (NLHCs), or nursing centers (sometimes
referred to as nurse-managed health centers), are organizations that give
vulnerable and/or underserved clients access to professional nursing services
(Fig. 29-1). NLHCs are found in convenient sites where people live, work,
learn, and worship and are overseen by a nurse executive with an advanced
degree. Traditionally, targets of service have been those who are least likely
to be engaged in ongoing health care services for themselves and their family
members. Currently, NLHCs serve population groups of all ages who are
uninsured or underinsured.

FIGURE 29-1 Bristol Health: an example of a nurseled health

center. Bristol Health has both physicians and nurse practitioners
who provide individual, couples, and family counseling and
manage medications for mental health conditions. Bristol Health
has physicians, nurse Practitioners, counselors, therapists, and
psychological testing services. They provide services to children,
adolescents, and adults. (Reprinted with permission from Bristol
Health. (2019). Services. Retrieved from https://bristolhealth.com/)

Historically, the most frequently cited definition of a nurse-managed

health clinic is the one developed in the mid-1980s by the American Nurses
Association (ANA) Nursing Centers Task Force: “a nurse-practice
arrangement, managed by advanced practice nurses, that provides primary
care or wellness services to underserved or vulnerable populations and that is
associated with a school, college, university or department of nursing,

2444
federally qualified health center (FQHC), or independent nonprofit health or
social services agency” (Compilation of Patient Protection and Affordability
Care, 2010, p. 542). The Compilation of Patient Protection and Affordability
Care supports nurse-managed health centers to:

Improve access to across-the-life span primary health care and wellness

services.
Provide services in medically underserved and vulnerable populations
regardless of income or insurance status.
Serve students as training sites in primary care.
Establish and enhance electronic methods for effectively collecting
patient and workforce data (U.S. Department of Health and Human
Services, n.d.).

With an amendment to Title III of the Public Health Service Act (42
U.S.C. 241 et seq.), the Nurse-Managed Health Clinic Investment Act of
2009 of the 111th Congress provides a more present-day definition of an
NLHC.
A nurse practice arrangement, managed by advanced practice nurses, that
provides primary care or wellness services to an underserved or vulnerable
population and is associated with a school, college, university, or department
of nursing; FQHC; or an independent nonprofit health or social services
agency (Nurse-Managed Health Clinic Investment Act, 2009, p. 2).
NLHCs represent a rising movement of health centers that have emerged
as vital safety-net health care providers in America's health care delivery
system (Aveling, Martin, Herbert, & Armstrong, 2017; Durovich & Roberts,
2018; Hansen-Turton, Sherman, & King, 2016). Although all NLHCs share
the core elements of these definitions, they vary in their practice models.
Services offered at NLHCs range from health promotion and wellness to
conventional primary care (Aveling et al., 2017; Durovich & Roberts, 2018).

A safety-net health care provider is a provider who, by mandate or

mission, organizes and delivers a significant level of health care and
other health-related services to the uninsured, Medicaid recipients, and
other vulnerable populations (Agency for Healthcare Research and
Quality, 2018; Institute of Medicine, 2000; U.S. Centers for Medicare
and Medicaid Services [CMS], 2019).
NLHCs differ from other public health agencies and tertiary medical
care facilities. Although some services overlap, the distinctiveness of
NLHCs is found in the community orientation of the nurse-managed
centers. This model is depicted by Lundeen's comprehensive
community-based primary health care model (Hong & Lundeen, 2009;
Lundeen, 2005), in which NLHCs are referred to as community nursing

2445
centers and are the central figure in this model of health care, which is
used at the University of Milwaukee, Wisconsin (Fig. 29-2).

FIGURE 29-2 Comprehensive community-based primary health

care model. (Adapted with permission from Hong, W. S., &
Lundeen, S. (2009). Using ACHIS to analyze nursing health
promotion interventions for vulnerable populations in a community
nursing center: A Pilot study. Asian Nursing Research, 3(3), 130–
138; ©Sally P. Lundeen, RN, PhD, FAAN, UW-Milwaukee
College of Nursing, 1993, 2005.)

2446
History of the NurseLed Model
Although today's NLHCs trace their roots to changes in national health care
laws begun in the mid-1960s, the nursing model of holistic care that focuses
on vulnerable populations and integrates primary care and public health dates
back to the nineteenth century. Florence Nightingale's passion for at-risk
populations, as well as her success related to health reform, provides a model
for NLHCs today. Visionaries such as Lillian Wald, who founded the Henry
Street Settlement, and Margaret Sanger, who initiated the first family
planning clinic, are two examples of nurses providing holistic care to
vulnerable populations (see Chapter 3). These nurse activists sought to
resolve twentieth century problems caused by immigration, urbanization, and
industrialization in the United States (Judd & Sitzman, 2014; Kurtzman et
al., 2017).

Since the late 1970s, in conjunction with the development of

educational programs for nurse practitioners, faculties in schools of
nursing have established NLHCs. Linkages have provided clinical sites
for educating nurses at all levels and settings, as well as for faculty
practice opportunities (Resick, Miller, & Leonardo, 2015).
The Health Resource and Services Administration (HRSA) reports
significant increases in the number of patients served in health centers
in the past decade (Fig. 29-3). Overall, these health centers have been
shown to improve health outcomes while reducing health care costs
(HRSA, 2018; Sofer, 2018).

FIGURE 29-3 Increase in numbers of patients served in health

centers. (Reprinted from Health Resources and Services

2447
Administration (HRSA). (2018). HRSA health center program fact
sheet. Retrieved from
https://bphc.hrsa.gov/sites/default/files/bphc/about/healthcenterfact
sheet.pdf)

2448
NLHC Models
There are several types of nursing centers; each has an individuality of its
own that reflects the community in which it is located and the particular
services it offers (Hansen-Turton, Sherman, & King, 2015):

Academic-based nursing centers, which are located within schools of

nursing, are a common organizational structure (Box 29-3).
Hospital-based and freestanding community-based NLHCs offer a
mixture of primary care, health promotion, wellness, and disease
prevention services.

BOX 29-3 Stories From The Field Three

NurseLed Clinics
University of California Los Angeles (UCLA) began providing primary
health care services to the homeless and indigent in 1983. It provides
access to health care for children and families who have no place else to
go—many suffering from the effects of an unstable home life or no
home at all. Student nurses participate in the clinic and learn valuable
lessons about the challenges of providing care for vulnerable
populations. At the same time, the students gain first-hand experience
working with resilient individuals who overcome significant hardships.
Many students find their experiences in the clinics inspiring. In 2018,
UCLA's Health Center at the Union Rescue Mission handled over 8,000
patient visits.
University of California Irvine (UCI) launched the first nurse-
managed clinic at El Sol Charter School in Santa Ana. This clinic
provides primary care to Orange County's underserved populations,
primarily from the Latino community. This clinic is funded by a $1.5
million federal grant and, like the University of California San
Francisco (UCSF) clinic, serves the dual purpose of providing care
while educating future nurses.
UCSF serves San Francisco's homeless and poor at the Glide Health
Services Center in the Tenderloin district. This clinic takes a holistic
approach, offering anything from acupuncture to behavioral health,
diabetes, and more. The nurse-run clinic accommodates 13,000 visits
each year, reaching people who historically felt marginalized by
traditional medicine.
All three of these clinics are nurseled, working in partnership with
underserved communities, while providing valuable experiential

2449
 learning opportunities for their student nurses.
Find nurseled health centers in your area. What populations are served,
and what services are provided?
Source: University of California San Francisco (2019).

NLHCs meet requirements for the federally qualified health center

(FQHC) designation as defined in Section 330 of the Public Health Service
Act. FQHCs are safety-net providers whose main purpose is to enhance
primary care services in underserved rural and urban communities (U.S.
Department of Health and Human Services, CMS, 2018). Health care reform
legislation has helped with this funding. This is an especially important
designation, as it enables NLHCs to qualify for many funding sources vital to
service provision that would not be available without this designation. The
specific requirements are that they:

Serve a medically underserved population.

Have a nonprofit, tax-exempt, or public status.
Designate a board of directors, a majority of whom must be consumers
of the center's health services.
Provide culturally competent, comprehensive primary care services to
all age groups.
Offer a sliding scale fee and provide services regardless of ability to
pay.

The variety of nursing center models currently in use and their

organizational structures demonstrate the diversity of contemporary NLHCs.
Box 29-4 describes the major types of centers, along with the various
organizational structures that influence their delivery models.

BOX 29-4 Nurse-Managed Health

Center Models
Center Types
Wellness Center: provides public health as well as health
promotion and disease prevention programs and focuses on
primary and secondary prevention strategies
Special Care Centers: provide programs that target specific health
conditions such as HIV or diabetes
Comprehensive primary care center: provides traditional primary
care and public health programs

2450
Organizational Structures
Academic Nursing Center: located within a School of Nursing
Freestanding Center: independent center with its own governing
board
Subsidiary: part of a larger health care system, such as home health
agencies, community centers, schools, and other venues
Affiliated Center: legal partnership with a health care or human
services organization
Adapted from Hansen-Turton et al. (2015); Kinsey and Miller (2016).

2451
Role of Students in NLHCs
Undergraduate and graduate students from many disciplines play a vital part
in the activities of NLHCs. These disciplines include, but are not limited to,
nursing, social work, mental health, dental and oral health, nutrition, speech–
language–hearing sciences, and public health. When students engage in
NLHC activities for their clinical experience, they become aware of the
distinctiveness of nurse-managed centers from other health care delivery
systems and the variety of models and organizational structures that exist and
are active participants in vital nursing center activities. Most often, students
are engaged in primary and secondary prevention strategies via health
education, outreach, immunization, and screening programs. Roles that
students fulfill are similar to the roles of their staff mentors (Box 29-5):

BOX 29-5 STORIES FROM THE FIELD

Wellness Screening Public health nurses from an
academic wellness NLHC, along with
undergraduate student nurses, are conducting
blood pressure and glucose screenings at a church-
sponsored health fair. This event is conducted on
Sundays from 10 AM to 2 PM, before, during, and
after church services. Approximately 50% of
adults screened have hypertension and/or
hyperglycemia. One participant, who was
asymptomatic, had severe hypertension (220/154)
and was immediately transported to the nearest
hospital for evaluation.
1. What are some feasible referrals that may have been made for those
with abnormal screening results?
2. What types of primary prevention strategies may benefit those
attendees who had normal screening results?
3. In what ways do student nurses benefit from participating at a health
fair?

Advocate
Case manager
Change agent

2452
 Educator
Referral agent

Faculty roles in NLHC academic models involve clinical supervision and

mentorship of undergraduate and graduate students assigned to the nursing
center for their clinical experience (American Association of Colleges of
Nursing [AACN], 2016).

2453
Community Service Learning in NLHCs
Additionally, schools of nursing and NLHCs are an excellent venue to
conduct community service learning (CSL) projects with both undergraduate
and graduate students. Using a “wall-less” concept of a nursing wellness
center, undergraduate and graduate nursing students can participate in CSL
activities in a variety of community settings. Outcomes for participating
students include (Marquette University, 2019, para. 3):
1. Appreciate people from diverse backgrounds.
2. Exhibit a commitment to social justice.
3. Demonstrate a commitment to be an involved citizen in his or her
community.
4. Demonstrate an increased sense of vocation.
One exemplar of a CSL project conducted at urban and rural schools is
the “Safety Town” initiative. This CSL project entails educating preschool
and early elementary school-age children on indoor and outdoor safety for
trauma prevention (Miller & Mest, n.d.). Qualitative feedback from nursing
students reveals personal and professional growth regarding primary
prevention in pediatric trauma in nontraditional clinical settings within the
community.

2454
Funding for NLHCs
As NLHCs vary in their models, so too do they vary in their methods of cost
reimbursement, including fee for service, sliding fees, contracts, grant
support, third-party payments, and cost-based reimbursement (Hansen-
Turton, et al., 2015). Most nursing centers' operational and salary budgets
entail a combination of these funding sources.

In comprehensive primary care centers, advanced practice nurses

provide primary care services. Such services are usually reimbursable
under Medicare, Medicaid, and managed care medical insurance plans
(Health Care Provisions in Bipartisan Budget Act of 2018).
In wellness centers, public health nurses and other interdisciplinary
team members provide a range of primary and secondary prevention
strategies (Box 29-6). These services are usually not reimbursed by
insurance plans but are often covered by grants and contracts (Hansen-
Turton, et al., 2015; Resick et al., 2015).

BOX 29-6 STORIES FROM THE

FIELD FAMILY-CENTERED CARE
Ms. Jones is a 22-year-old mother of three small children who recently
moved to an urban area. She brings her oldest child, age 6, to a local
comprehensive primary care nurse-managed health clinic for school
immunizations. During the course of the history and physical
examination, the nurse practitioner becomes aware that this mother also
has two younger children, aged 2 and 3, at home. The family rents a
small apartment in housing that was built in the mid-1950s. Ms. Jones
mentions that her mother (the children's grandmother) also resides with
them. The grandmother is the childcare provider, while Ms. Jones works
as a local hair salon. The grandmother mother smokes 1.5 to 2 packages
of cigarettes daily; Ms. Jones reports that she is a nonsmoker. Upon
further questioning, the nurse practitioner learns that the 3-year-old
child has a chronic cough and occasional wheezing. Ms. Jones also
confides to the nurse practitioner that she recently missed two menstrual
periods and is sexually active.
1. What are some possible health care needs of Ms. Jones? Her
mother?
2. What screenings should be performed on (a) Ms. Jones, (b) her
mother, and (c) her children?
3. What other interdisciplinary team members should be involved in
this family's health care?

2455
 4. What are some possible referrals that would benefit this family?

It is important to distinguish between grants and contracts as funding

sources for NLHCs. Funding organizations usually release guidelines
regarding what initiatives they will fund. Grant guidelines are frequently
termed request for proposal (RFP).

Grants can be a source of initial start-up funding as well as a support for

ongoing activities (Torrisi & Hansen-Turton, 2015).
A proposal submitted by the NLHC to the funding organization
describes how the center would meet the goals and objectives set
by the funding organization.
Outcomes, or the end results at a specific point in time, are
increasingly becoming more important to funders.
NLHCs must include measures to collect outcome data and project
what outcomes will occur in their submitted proposals.
Contracts are another source of funding for NLHCs.
Contracts are awards for a legal procurement relationship between
a funder and a recipient obligating the contractor to furnish a
product or service defined in detail by the funder (Find RFP, 2019).
A contract has specific goals, objectives, and activities, as well as a
time frame during which the activities are to be implemented and
evaluated.
Contracts are awarded on a noncompetitive basis and often are
renewable when goals and objectives are met.

Managing the various funding streams that feed the personnel and
operations budgets of an NLHC is an arduous task. To ensure that budgetary
dollars are spent in the manner specified by the funding organization,
meticulous recordkeeping and itemization of spending is another undertaking
that the nurse executive or an operations coordinator of an NLHC must carry
out. It is imperative that key personnel from the NLHC maintain precise
records and submit accurate quarterly, semiannual, or annual reports as
specified in the grant or contract award (Zimmer & Knowlton, 2016).

2456
Sustainability of Nurse-Managed Health Clinics
Sustainability, or the ability to carry on services and health promotion
activities, is one of the main challenges of NLHCs. NLHCs have much to
offer toward resolving the national health care crisis facing vulnerable
populations who are uninsured or underinsured. However, without the ability
to maintain fiscal sustainability, NLHCs may fail to reach their full potential
for positively influencing the future of health care (Hansen-Turton, et al.,
2015). A seminal document by Cutler (2002, p. 23) proposes “critical
sustainability questions” that can be used as a preliminary avenue of
consideration for organizations such as NLHCs when completing a grant
application for funding. The following are some strategies that can be
implemented to promote sustainability of NLHCs (Cohn et al., 2017; Sofer,
2018):

Demonstrate value for money, sometimes measured in terms of cost per

client served.
Track, monitor, and evaluate measurable outcomes that demonstrate the
delivery of quality, cost-effective care.
Hire and develop diverse and effective staff.
Manage travel costs for serving remote populations through telehealth.
Utilize technology.
Develop a sustainability plan.
Maintain strategic partnerships.

2457
The National NurseLed Care Consortium
The National NurseLed Care Consortium (NNCC, 2018a) strives to reduce
health disparities and meet people's primary care and wellness needs through
policy, consultation, programs, and applied research that advance nurseled
health care (Box 29-7). They lead advocacy efforts for nurse-managed health
care and support public health initiatives including the Nurse-Family
Partnership (NNCC, 2018b). For more information, visit
https://www.nurseledcare.org/.

BOX 29-7 National NurseLed Care

Consortium
Mission To advance nurseled health care
through policy, consultation, and programs to
reduce health disparities and meet people's
primary care and wellness needs.
Ways NNCC Supports NurseLed Care
1. Offering a variety of educational opportunities to build practice,
improve quality of care, and promote sustainability.
2. Advocate for policy that supports nurseled care in Washington, DC,
and in state legislature.
3. Provide members with additional resources and discounts on
educational opportunities and Annual Conference rates.
4. Build and manage public health programs, providing national
models for nursing and public health.

Source: National NurseLed Care Consortium (2018a, 2018b).

The NNCC conducts a Best Practice Conference, which brings together

nurses, staff members, funders, and political leaders to share best practices
and participate in networking opportunities. Continuing education credits are
available for attendance at scientific sessions.

2458
Nursing Research and NLHCs
NLHCs provide research opportunities for both primary prevention and
wellness initiatives (AACN, 2016). Descriptive data have been collected
about client demographics, types of service provided, funding methods, and
sustainability efforts. The increasing presence of NLHCs had led to an
increase in research primarily aimed at determining the quality and cost-
effectiveness of care provided (Randall, Crawford, Currie, River, &
Betihavas, 2017). NLHCs have been shown to have beneficial effects on
patient satisfaction and health outcomes, as well as improved access to care
(Sofer, 2018). Other studies include:

Randall et al. (2017) conducted a systematic review of 15 studies that

examined patient satisfaction, patient outcomes, objective clinical
measures, access to care, and, to a limited extent, cost-effectiveness.
Overall, results were favorable in all areas except for cost-effectiveness
(evaluated in only two studies), for which results were mixed.
Baker and Fatoye (2017) conducted another systematic review of 26
articles that provided data on the clinical and cost-effectiveness of
nurseled care of patients with chronic obstructive pulmonary disease in
a primary care setting. Initial results were favorable.

Chan et al. (2018, p. 61) examined outcomes for nurseled services in an

ambulatory community care setting and found some evidence of “better
outcomes in terms of health-related quality of life compared to physician-led
care.” They also noted the lack of cost-effectiveness studies, an area needing
further research to help guide future policy.

2459
Future Directions for NLHCs
In 2008, the IOM appointed a committee on the Robert Wood Johnson
Foundation Initiative on the Future of Nursing. The purpose of this
committee was to produce a report, making recommendations for the future
of nursing. This committee developed four key messages regarding the future
of nursing (IOM, 2011):
1. Nurses should practice to the full extent of their education and training.
2. Nurses should achieve higher levels of education and training through an
improved education system that promotes seamless academic
progression.
3. Nurses should be full partners with physicians and other health care
professionals in redesigning health care in the United States.
4. Effective workforce planning and policy making require better data
collection and information infrastructure.
The main areas of focus for health care reform are prevention and
improving the quality of care (Patient Protection and Affordable Care Act
[ACA], 2010).

In NLHCs, advanced practice nurses lead interprofessional teams as

critical safety-net providers in America's health care delivery system.
Nurses in NLHCs are vital change agents as they partner with the
community, interprofessional team members, and students to improve
access to care and health outcomes (Randall et al., 2017).
Community care centers, including NLHCs, have been shown to play a
significant role in providing access to care for underserved populations
on Medicare (Seo et al., 2019).
Primary care is being transformed by registered nurses using their skills
in coaching, case management, transitional care, chronic disease
management, education, and health promotion to help meet the
increasing demand for care (Josiah Macy Jr. Foundation, 2016).

Continued expansion of the NLHC model in the next decade and beyond
will meet key recommendations from the IOM report on nursing's future and
the goals of the ACA (AACN, 2017; Seo et al., 2019). See Box 29-8 for an
example of an NLHC that meets the needs of the population served, provides
continuity of care, and reduces the use of overcrowded and expensive
emergency department services for routine health care.

2460
 BOX 29-8 PERSPECTIVES

Viewpoint of an Executive Director of a NurseLed

Community Clinic In fall 2011, in our city of
120,000 in northeast Texas, many health care
organizations here held the view that low-income
or homeless population were “noncompliant” and
did not care about their health. I had learned
through volunteering that many barriers to their
care existed. These included minimal payment
amounts that were too high, service hours that
were not convenient to the low-income population,
and pre-enrollment criteria that many could not
meet. To avoid this, the low-income and/or
homeless populations tend to use the hospital EDs
for care.
I decided to set up a health clinic that didn't have unrealistic requirements.
Individuals needing health services simply have to fill out an income self-
declaration. The low-income and homeless populations are very mistrusting
of community health and social services. They live day by day. They have
to focus on the here and now: Where will my next meal come from? Where
will I shower? Where will I launder my clothes? Where will I sleep?
Guided by the understanding that the low-income population has its
own culture and very specific needs, the clinic was set up as a caring,
compassionate, and supportive environment for this population. Patients of
the clinic state that they feel “listened to,” even though the length of
appointments is still only 20 minutes. Strategies contributing to quality care
included:

Offering clinic hours in the early morning hours, lunch time hours, and
evening hours

2461
 Providing behavioral care, counseling, and social services
Treating patients' anxiety, depression, and other behavioral health
conditions
Building relationships with the patient and family
Coordinating care and support services to strengthen coping and
problem-solving skills

Outcomes of this approach included:

Ability of patients to manage chronic illnesses

Increased health-seeking behaviors at the Center rather than the ED
Positive self-reporting that patients feel “listened to,” even though
appointments are only 20 minutes long
Improved ability of patients to seek follow-up care should their
situation deteriorate

As a nurse, I find myself constantly advocating for patients and

ensuring maximal health for our clients at a lower cost. It is a rewarding
experience!

M. Alice Masciarelli, RN, DNP, FACHE, CPHQ Executive Director,

Denton Community Health Clinic, Denton, TX

2462
FAITH COMMUNITY NURSING
A faith community nurse (FCN) focuses on the mental, physical, and
spiritual health, using a holistic approach to prevention and treatment of
illness within the context of a community of faith (Deaconess Nurse
Ministry, 2019). Faith community nursing is one of the newest nursing
specialties and one of the oldest means of health care delivery.

2463
Historical Background of Faith-Based Nursing
For hundreds of years, deaconesses, sisters, and lay members of religious
communities have been involved in ministering to the sick. This tradition
was revitalized through the efforts of Reverend Dr. Granger Westberg. As a
hospital chaplain and Lutheran minister, Westberg observed a great need for
preventive and holistic health services, especially among the underserved,
and wrote several books. He launched several church-based holistic health
clinics in the 1970s, each staffed by a physician, nurse, and chaplain, that
provided health services to the underserved in the community for several
years (Westberg Institute for Faith Community Nursing, 2019b). The clinics
eventually closed, but the experience led Reverend Westberg to recognize the
unique ability of nurses to bridge the disciplines of medicine and religion.
Westberg first coined the term parish nurse when he initiated a pilot
project in 1984 in which nurses provided holistic, preventive health care for
six Christian congregations in the Chicago area. Gradually, more and more
churches sought to incorporate a parish nurse into their staff. The term faith
community nursing is now commonly used in the United States. The
Westberg Institute for Faith Community Nursing (2019b) provides
educational programs and resources for nurses who seek to practice as parish
nurses and for educators wishing to conduct training programs for parish
nursing.
The Health Ministries Association (HMA), along with the ANA, was
instrumental in writing the third edition of Faith Community Nursing: Scope
and Standards of Practiced (ANA & HMA, 2017). The term faith
community nursing was defined as “a specialized practice of professional
nursing that focuses on the intentional care of the spirit as well as the whole-
person health and prevention or minimization of illness” (HMA, n.d., para.
1). Today, nurses who practice in a faith community may be referred to as
FCNs, parish nurses, health ministry nurses, congregational nurses, or church
nurses depending upon preference and the traditions of the faith community.
No matter what title is used, a nurse who practices in a faith community
should adhere to the standards of practice, which can be obtained through the
ANA at https://www.nursingworld.org/nurses-books/faithcommunity-
nursing-scope-and-standards-of-practice-3rd-edition/.

2464
What Do FCNs Do?
Activities and interventions FCNs implement are as diverse as their faith
communities. Some examples include:

Advocating for the needs of the dying

Addressing health conditions that are stigmatized, such as HIV
Supporting patients with mental health issues
Providing guidance during life transitions such as marriage, divorce,
birth, death, illnesses, etc.
Promoting health education ( Faith Community Nursing Health
Ministries Northwest, 2019; Nelson, 2018)

FCNs have been instrumental in meeting the educational and health

promotion needs of underserved and older adult populations. A few
examples of specific programs that have been successful in faith-based
settings include:

University of California, San Diego, offers a comprehensive faith-based

wellness program that addresses health disparities in African-American,
Latino, and Muslim communities (UC San Diego, 2019).
The Bronx Health REACH Faith-Based Outreach Initiative provides
programs addressing diabetes prevention and management, nutrition,
fitness, and health disparities (Institute for Family Health, 2019).
Abuelas en Acción (Grandmothers in Action) promotes physical
activity, nutrition, and stress management in the Latino community
(University of Illinois at Urbana Champaign, 2016).
The “Fit Body and Soul” program strives to prevent diabetes among
African American populations (Sattin et al., 2016).

2465
Roles of the FCN
The goal of the FCN is “protection, promotion and optimization of health
and abilities; facilitation of healing, alleviation of suffering through the
diagnosis and treatment of human responses and advocacy in the context of
values, beliefs, and practices of the faith community, such as a church,
congregation, parish, synagogue, temple, mosque, or faith-based community
agency” (ANA/HMA, 2017, p. 2). Health promotion outcomes may be
primary, directed at prevention of disease, illness, or injury; secondary,
focused on early detection and appropriate intervention; or tertiary,
concerned with promoting a sense of well-being when preventing or curing a
condition may not occur. To achieve the goal of faith community nursing,
seven diverse nursing roles are central to incorporate into practice
(Schroepfer, 2016; Westberg Institute for Faith Community Nursing, 2019c;
Zeibarth & Campbell, 2016). The roles of the FCN (Box 29-9) support the
development, implementation, and evaluation of faith-based programs.

BOX 29-9 Assuring Congregational

Health And Wholeness
Roles of the Faith Community Nurse
1. Health educator
2. Health counselor
3. Advocate
4. Referral agent
5. Developer of support groups
6. Coordinator of volunteers
7. Integrator of faith and health

Accountability
1. ANA scope and standards of nursing practice 2. ANA scope and
standards of faith community nursing 3. Congregational standards
4. Institutional standards
5. ANA social policy statement
6. ANA code of ethics for nurses with interpretive statements 7. State nurse
practice act
8. Patients' rights
Source: Dandridge (2014); Schroepfer (2016); Westberg Institute for Faith Community Nursing
(2019c).

2466
Health Educator
A primary role of the FCN is as a health educator. Increasing awareness
of health issues through health education is the foundation for health
promotion and lifestyle changes. The FCN uses assessment skills to
determine the health issues that may be present in the faith community
and assesses the educational needs related to these issues.
The FCN may provide individual and group education strategies such as
providing health education materials, leading health education classes,
or providing health screenings. The FCN may also develop educational
displays or flyers or write educational articles for the faith community
newsletter or Web site.

Health Counselor
In the health counselor role, the nurse seeks to understand the
individual's perceptions, fears, and barriers that prevent the person from
taking action.
The FCN may use a five-step health counseling process described as the
five A's (Cooper & Zimmerman, 2017; Smoking Cessation Advice,
2018):

1. Ask about the person's perceptions related to a specific health concern.

2. Advise the person about the health concern and the benefits of taking
health-promoting actions.
3. Assess the person's readiness to take action.
4. Assist in planning ways to address the health concern.
5. Arrange follow-up support.

Advocate
The third role of an FCN is that of an advocate, helping individuals
obtain needed services or care whether in the hospital, a long-term care
facility, or at home. In the advocate role, the FCN uses knowledge of the
health care system and awareness of safe and effective care practices to
facilitate appropriate, timely intervention (Mock, 2017).
Advocacy is indicated when dealing with vulnerable populations, such
as older adults, children, or the homeless, who may not have the ability
to speak for themselves or may lack the knowledge or awareness of
what constitutes safe, effective care. FCNs have actively advocated for
those with mental health problems, finding treatment sources and
providing referrals and support (Foster, Dawood, Pearson, Manteuffel,
& Levy, 2019).

2467
Referral Agent
The role of referral agent involves several related aspects. First, the
nurse needs to develop knowledge of community resources and
contacts. Knowledge of what is available, how the service is accessed,
eligibility criteria, and limitations of the service is essential.
Next, the nurse networks with and develops collaborative relationships
with community leaders and agencies who provide the services.
Through networking with community agencies, the FCN becomes
aware of and is able to easily access a variety of community resources
to support the client's physical, social, financial, emotional, or spiritual
needs (Association of Public Health Nurses, 2016).

Developer of Support Groups

Receiving emotional support from persons who share similar
experiences can provide strength, comfort, knowledge, and a sense of
empowerment (Frykedal, Rosander, Berlin, & Barimani, 2016).
The FCN develops groups tailored to the faith community needs such as
coping with loss and grief, cancer, caregiver stress, chronic illness,
single parenting, addiction recovery, health promotion, and more
(Callaghan, 2016; Grebeldinger & Buckley, 2016).

Coordinator of Volunteers
The health ministry mission of a faith community typically includes a
variety of services and activities to provide holistic support of the
physical, social, emotional, mental, and spiritual needs of its members.
Such a diverse array of services cannot be provided by the FCN alone.
In the role of coordinator of volunteers, the FCN recruits, trains, and
coordinates other members of the faith community. Volunteers provide
or assist with a variety of services such as (Christian Community Health
Fellowship, 2019):
Home, hospital, or long-term care visitations
Respite care
Assisting with transportation needs of homebound individuals
Calling or sending cards to ill or injured members
Assisting with health screenings

Integrator of Faith and Health

A distinctly unique role of the FCN is as integrator of faith and health
(Fig. 29-4). This role emphasizes the holistic relationship between the

2468
physical, social, emotional, mental, and spiritual dimensions of the
person.
The FCN helps the person to improve health or enhance wellness by
appreciating how the dimensions of the person are interconnected and
by helping the person strengthen or support the weaker aspects, as
needed.
The FCN assesses community's strengths and health needs and
incorporates an understanding of the connection between faith and
health (Brewer et al., 2017; Tettey, Duran, Anderson, & Boutin-Foster,
2017).

FIGURE 29-4 A faith community nurse provides comfort.

2469
Faith Community Nursing Practice
Models of faith community nursing practice are diverse and may be
categorized according to volunteer versus salaried positions and institutional
versus faith-based sponsorship. The type of practice model adopted depends
on variables such as:

The number of faith community members served

The existing health ministry services in place
The faith community's governance structure and financial resources
Existing health care systems in the community at large

Early in the development of faith community nursing, FCNs were

typically part-time volunteers who were members of the faith community
they served. This voluntary, part-time status, coupled with the newness of
faith community nursing practice, has resulted in limited research on faith
community nursing. Nonetheless, studies that have been conducted have
validated the effectiveness of FCNs and the programs they have
implemented, such as the following:

A faith-based lifestyle intervention was initiated to prevent diabetes

among African Americans (Sattin et al., 2016).
A cardiovascular health education program conducted by trained lay
educators in 14 African American congregations found significant
reductions in weight and blood pressure (Tettey et al., 2017).
A 3-month program of coaching and blood pressure self-monitoring, led
by 39 FCNs, resulted in decreased blood pressure and improved scores
on a lifestyle satisfaction inventory (Cooper & Zimmerman, 2017).
A gospel rescue mission established a wellness center at a homeless
shelter for men and found improved access and treatment adherence
(Lashley, 2019).
A transition of care program led by an FCN reduced 30-day hospital
readmission rates by 67% (Strait, Figzgerald, Zurmehly, & Overcash,
2019).
A breast cancer education program was shown to be effective in
improving “general knowledge about breast cancer, higher breast cancer
mortality among African American women, warning signs, risks and
ways to mitigate risk, and the availability of low-cost or free
mammograms” (Brown & Cowart, 2018, para. 4).

There are growing trends in the types of FCN delivery models used
today. These include (Sabo et al., 2015):

Hire salaried full-or part-time staff positions serving one congregation.

2470
Hire salaried full-or part-time staff positions shared across multiple
congregations.
Maintain a separate health care facility.
Form partnerships with organizations such as universities or hospitals
that agree to provide nursing services to the faith community, possibly
involving individual faculty and student groups.
Invite student nurse participation in servicelearning projects that address
public health issues in the church setting.

2471
Becoming an FCN
The FCN practices community nursing with a high degree of independence
and autonomy. Often, the FCN deals with clients experiencing complex
health care situations who may have limited resources and extensive health-
related needs. The preferred minimum educational preparation for an FCN
includes a bachelor's degree in nursing (ANA/HMA, 2017) and completion
of additional education such as the 36-hour Foundations of Faith Community
Nursing course offered through the International Parish Nurse Resource
Center (The Center for Faith and Community Health Transformation, 2015;
Westberg Institute for Faith Community Nursing, 2019a). This course
addresses the roles of the FCN and provides information on establishing,
promoting, and maintaining an FCN practice. Participants gain experience in
resolving complex client situations using scenarios and case studies.

Several steps are involved in creating an FCN position within a faith

community. One of the first things to do is assess the community the
nurse plans to serve, identifying the health needs of the faith community
and the roles of the FCN that meet those needs through a needs-
assessment survey.
Once the nurse has assessed the needs of the faith community, the next
step is to identify how an FCN could help to meet those needs. The
FCN uses this information to seek the support of the faith community
members and staff.

The Westberg Institute provides information and resources regarding

establishing a program, along with the qualifications needed for the nurse.
The center also provides an educational program called The Ministry of
Church Health to guide the nurse in the many roles that the nurse will have in
the community (Westberg Institute for Faith Community Nursing, 2019a).
Web sites for information on Faith Community Nursing include the
following:

International Parish/Faith Community Nursing:

https://westberginstitute.org/international-faith-communitynursing/
HMA: https://hmassoc.org/
Nurses Christian Fellowship: http://www.ncf-jcn.org/index.php

2472
OCCUPATIONAL AND
ENVIRONMENTAL HEALTH
NURSING
Business and industry provide another group of settings for community
health nursing practice. Occupational and environmental health nurses
work with employers to cultivate creative and business-appropriate health
and safety programs. Program development must consider the business's
unique type of work, workforce demographics, and the work/community
environments. The practice of occupational health nursing uses an
interdisciplinary approach to advocate for the employee's right to have cost-
effective, prevention-oriented health and safety programs (Fig. 29-5).

FIGURE 29-5 An environmental health nurse works

collaboratively with the community. (Photograph courtesy of the

2473
 Centers for Disease Control and Prevention. Retrieved from
https://phil.cdc.gov/Details.aspx?pid=22796)

Organizations are expected to provide a safe and healthy work

environment in addition to offering insurance for health care. Businesses
often choose to hire occupational health nurses (OHNs) because occupational
health programs help maximize employee efficiency and decrease costs by
effectively reducing work-related injuries, disability claims, and absenteeism
and improving employee health and safety.

Present-day OHNs observe and assess workers' health status,

considering the workers' job tasks and hazards. Using their specialized
training, education, and experience, they use the nursing process to
prevent occupational illness and injury.
An equally important responsibility is to help organizations maintain
compliance with federal, state, and local laws, regulations, and
guidelines for workplace health and safety (American Board for
Occupational Health Nurses [ABOHN], n.d.).

2474
History of the Occupational and Environmental
Health Nurse
Community health nurses have a long history of involvement in occupational
health. Early on, the profession primarily focused on providing infant and
child health education to the employee families as well as the whole
community. World War II showed a marked increase in employment of
OHNs. In keeping with the changing times, the OHN's practice broadened to
include comprehensive health and safety programs designed to prevent
illness and injury for the US workforce. Historic examples include:

Betty Moulder provided care for coal miners and families in

Pennsylvania beginning in 1888 (American Association of Occupational
Health Nurses [AAOHN], 2019b).
In 1895, the Vermont Marble Company hired Ada Mayo Stewart, said to
be the first industrial nurse in the United States. Stewart provided care
for employees and their families, focusing on health promotion and
disease prevention (ABOHN, n.d.).

Although occupational and environmental health nursing has been in

existence since the late 1800s, the Occupational Safety and Health Act of
1970 led to the proliferation of occupational health nursing employment in
the United States. This important legislation established the Occupational
Safety and Health Administration ( OSHA, 1970 ) in the Department of
Labor, to ensure a safe working environment for workers in the United
States. To ensure that business and industries meet OSHA standards, OHNs
monitor the health status of individual workers, workforce populations, and
community groups. Other prominent practice guidelines come from:

US statutes, such as the Genetic Information Nondiscrimination Act

Family Medical Leave Act
Americans with Disabilities Act (2000)
Health Insurance Portability and Accountability Act
Department of Transportation and U.S. Environmental Protection
Agency

OHNs can implement evidencebased interventions to prevent or mitigate

negative health effects of the work environment by gathering health and
hazard data, evaluating the effects of workplace exposures, and developing
workplace prevention programs (ABOHN, n.d.).

2475
Settings for Occupational and Environmental
Health Nursing
OHNs work in a variety of settings:

The manufacturing sector has a strong tradition of employing OHNs,

but utility companies, mines, retail store chains (e.g., grocery,
department, home improvement), hospitals and medical centers, theme
parks, banks, school systems, and government also employ OHNs
(ABOHN, n.d.).
Consulting for companies is a more independent type of employment
for about 7% of OHNs, as noted in a seminal study by Harber, Alongi,
and Su (2014). Or entrepreneurial nurses may set up an occupational
health clinic in areas where many small businesses are located. See Box
29-10 for the perspective of a nurse entrepreneur.
Nurse-managed clinics may use OHNs, a nurse practitioner or physician
assistant, a physical therapist, a health educator, and a part-time
occupational physician.
A single-nurse unit is a common model of practice in many smaller
companies. In a single-nurse unit, OHNs typically build strong networks
of colleagues with whom they can discuss professional practice issues.
Some companies use a medical model of practice, in that a physician
determines clinic staffing and the department's approach to clinical
practice.

BOX 29-10 PERSPECTIVES

A Nurse Entrepreneur's Viewpoint

As a newly graduated nurse practitioner, I was excited to step into the role
in a small family practice clinic. I worked alongside a family physician who
owned the clinic. We took pride in the product we delivered because we
made decisions that directly impacted patient care.
A few years later, a corporation bought out that small family practice
clinic. Upon the sale of the clinic, the administrative decisions were made
by people not only unfamiliar with our patients but unfamiliar with family
medicine. Nameless faces on the other end of phone trees addressed my

2476
patients' concerns, as the corporation centralized the call centers under the
direction of corporate management.
I became frustrated with the dictates of others and the negative impact it
had on my patients. This frustration led to my desire to make a change. My
first entrepreneurial experience came when an owner of a manufacturing
plant approached me about creating and running an on-site clinic for his
employees. Together, the company owner and I talked about our vision of
the clinic. I created a model where I could run the clinic by myself, with
one medical assistant. Care was free to employees, and insurance
companies were not involved. The owner of the manufacturing plant paid
the overhead. This was a model unlike any other on-site medical clinic in
the area.
A few years after starting the on-site clinic, I saw the lack of access my
patients had to mental health care in my state. There was a serious shortage
of psychiatrists to manage psych meds, so I started a mental health clinic to
provide better access to those in my community. I eventually transitioned
out of my on-site employee clinic and expanded my mental health clinic to
provide a broader array of services. I became a nurse practitioner to help
others and make a difference in the world. In order to truly make a
difference, I assessed the needs in my community and did what I could to
fill the gaps.
Can you think of something that may frustrate you and see where you might
provide a much-needed service, like this nurse entrepreneur?

—Kelly Wosnik, DNP, NP-C

Areas of focus in occupational health nursing could expand to include

vulnerable populations, such as immigrant workers, and healthier
communities, while continuing to include attending to chronic health
conditions and promoting preventive approaches (McCauley & Peterman,
2017).

2477
Roles and Career Opportunities of Occupational
and Environmental Health Nurses
There are a wide variety of settings that benefit from OHN programs. In
addition to providing first aid for illness and injury that occurs in the
workplace, occupational health practices are moving toward a model that
provides not only basic occupational health services but also case
management, telehealth, care coordination, and primary care (AAOHN,
2019b).
According to the Workforce Management Data Bank, the primary
reasons employers establish an on-site clinic are to decrease health care
costs, improve workers' quality of life, and improve the company's cost-
effectiveness (National Association of Worksite Health Centers, 2019).
Comprehensive occupational worksite programs offer both health
protection and health promotion services. After employees are injured or
become ill at work, OHNs work to ensure a speedy and functional recovery,
frequently helping employees work through the workers' compensation or
insurance bureaucracy. Although some companies outsource case
management for work-related injuries, many OHNs coordinate and manage
cases to ensure the employee's optimum recovery while helping to control
costs.
Occupational health nursing practice can be divided into three main
categories: compliance, care, and health promotion. There is a wide range of
career opportunities for the occupational and environmental health nurse to
consider. Examples of the variety of roles and jobs in OHN practice beyond
the typical clinical setting include international opportunities, case
management, transitional care, and telemedicine.
OHNs practice around the world. There are positions with American
companies that have foreign operations as well as with international
companies. Depending on the global setting, OHN responsibilities and scope
of services may differ from practice in the United States. However, the goals
of mitigating factors that may affect a workplace population's health and
working to protect and promote safe working conditions are the same. If
going abroad sounds appealing, the AAOHN has published an international
resource list that outlines the educational and training requirements for
countries with an occupational health nursing specialty (Robinson, 2016).
Effective case management is one strategy for employers to not only
quantify health care costs but also to demonstrate savings and ensure quality
care delivery through coordination of services (Case Management Society of
America, 2016; Workplace Health & Safety, 2015).

2478
 Case management is the process of assessment, planning, facilitation,
care coordination, evaluation, and advocacy for services to meet an
individual's and family's comprehensive health needs using resources to
promote patient safety, quality of care, and cost-effective outcomes (Case
Management Society of America, 2017).
Case management is a care-coordinated strategy that is patient-centered,
continuous, and often used in transitional care situations. It is an approach
that can be found across many specialties of nursing, from acute care to
public health nursing. For example, an employee with asthma may be
followed by an OHN for case management, as well as an employee who has
been injured on the job. A C/PHN may follow a young mother and her
healthy new infant, helping to remind the mother of vaccination clinics and
educating on normal child development. If the child develops a chronic
condition, such as sickle cell anemia, the C/PHN will help with arrangements
for transportation, referrals, and finding resources. A patient may be
followed from home to the hospital and back home again, with one nurse as
the case manager. This represents the continuum of care. Case management
may also be accomplished through a team effort of care collaboration, with
physicians, nurses, occupational health specialists, and others involved in
coordinating care.
A meta-analysis of studies evaluating the effect of case management on
4,000 patients with type 2 diabetes found statistically significant reductions
in hemoglobin A1C and low-density lipoprotein levels, demonstrating the
effectiveness of case management over a control group (Zeng, Shuai, Yi,
Wang, & Song, 2016). Various methods of case management, from phone
consultation to in-person visits, were included in the analysis.
Careful case management can ensure efficient, less fragmented, and more
cost-effective use of the health care system, producing better patient
outcomes while decreasing costs (Joo & Huber, 2018). It is especially helpful
for fragile, vulnerable clients needing an advocate within the health care
system.
Transitional care involves managing care from one level to another
across the health care spectrum (Naylor et al., 2018). Transitional care
strategies have been shown to reduce unnecessary use of health services and
improve patient outcomes in chronically ill, injured, and older workers
(Social Programs that Work, 2017). There are several models of transitional
care (Ortiz, 2019):

Colman's Care Transitions Intervention Model

Naylor's Transitional Care Model
Better Outcomes for Older Adults Through Safe Transitions
The New York State Department of Health (NYSDH) Transitional Care
Model

2479
 The NYSDH model is founded on five elements (Ortiz, 2019):
1. Determining the patient's strengths (e.g., emotional/cognitive, physical,
medical, economic, abilities, support system) 2. Assessing the patient's
functioning before admission to help determine potential resources
needed on discharge 3. Informing decision-making through ongoing
collaboration among the patient, family, and interdisciplinary transition
team 4. Providing both verbal and written information on available
options and the range of community services 5. Allowing the patient
and family to select preferred providers when possible
One role of the OHN's practice is management of a program to help
workers successfully return to work following work-related illness or injury
and transition through the often-complex pathway to recovery. Collaboration
between all members of the interdisciplinary transitional care team is
essential to improve the proportion of employees who successfully return to
work (Awang, Shahabudin, & Mansor, 2016).
Transitional care is also found in many nursing specialties and has been
especially emphasized since 30-day readmission rates were tied to hospital
Medicare payments (see Chapter 6). For example, one large-scale study of
over 30,000 patient records found that case management by diabetes
educators reduced the 30-day hospital readmission rate from 20.1% to 17.6%
over an 18-month period (Drincic, Pfeffer, Luo, & Goldner, 2017).
OHNs can use telemedicine or telehealth (see Chapter 10) to teach,
observe processes in distant locations, or provide consultations, to reduce or
eliminate OSHA recordable incidents and loss of work time (American
Telemedicine Association, 2019). The Chronic Care Act of 2017 expanded
the use and reimbursement of telemedicine, addressing complaints by health
care providers of their lack (Arndt, 2018).

In 2018, the U.S. Department of Veteran Affairs (2018) launched an

expanded telehealth program that enabled Veterans to access care from
their homes, including mental health and suicide prevention programs.
School nurses have explored the use of telehealth as a means of
extending their availability and potential for meeting the health needs of
all students, no matter how remote their locations (Reynolds &
Maughan, 2015).
A secondary analysis of a 2017 survey of registered nurses working in
Vermont found that almost one fifth of the respondents reported
working in telehealth/telephonic nursing. Although there is no real
preparation for this skill in nursing school, there are concerns about
providing “safe, effective, culturally relevant telehealth, and virtual
care” and the need for policy development in this area (Rambur,
Palumbo, & Nurkanovic, 2019, p. 64).

2480
Cost-effectiveness of telemedicine has been demonstrated. Anderson et
al. (2018, p. 2031) found that electronic consultations (eConsults) with
specialists in dermatology, gastroenterology, endocrinology, and
orthopedics at a large, multisite safety-net health center had “average
specialty-related episode-of-care costs” that were $82 per month lower
than patients having face-to-face appointments.
Digital health interventions such as short message service, telephone
support, mobile applications, video conferencing, telemonitoring with
digitally transmitted physiological data, and wearable medical devices
were evaluated for cost-effectiveness of cardiovascular disease
management interventions in a systematic review of 14 studies
published largely between 2015 and 2018 (Jiang, Ming, & You, 2019).
Overall, the use of digital health interventions demonstrated higher
quality-adjusted years of life (QALYs) while also saving costs in 43%
of the studies reviewed. The remainder of the studies had QALY gains
but higher costs, making them less cost-effective interventions.

2481
Health Promotion and Wellness
OHNs play a vital role in advocating for health promotion and wellness
programs for the workforce they serve. OHNs are in an ideal position to
provide guidance, counseling, education, and coaching for employees who
want to improve their health. Faced with high health care costs, many
employers are turning to worksite health programs to help employees adopt
healthier lifestyles and lower their risk of developing costly chronic diseases
while improving worker productivity (AAOHN, 2019b).

The Total Worker Health (TWH) initiative is designed to provide

holistic approaches to employee wellness. It integrates occupational
safety and protection of health along with health promotion to prevent
worker injury and illness and improve worker well-being and health
(National Institute for Occupational Safety and Health [NIOSH], 2018).
Because American workers spend a large part of their day at work, the
workplace is now considered a social determinant of health; job-related
factors include salary, the work environment, time spent at work,
physical and psychological stress, employee–employer dynamics, and
work–life balance (see Chapters 1 and 11).
The AAOHN also crafted a position statement that calls for a
multifaceted approach to address the rising opioid crisis as it affects the
workplace, calling on OHNs to become actively engaged in workplace
educational programs and other interventions, such as drug testing
policies and procedures (AAOHN, 2018).

2482
The Occupational Health Team
OHNs work in a team environment with a variety of other professionals.
Depending on the size of the company, the occupational health team may
include the following:

Safety specialist
Industrial hygienist
Ergonomist
Industrial or organizational psychologist
Toxicologist
Physical or occupational therapist
Physician
Lawyer
Employee assistance counselor

Human resources, management, security, and emergency response

personnel are also part of the team. The employee is central to the team and
is the reason for the team's existence. Team collaboration is essential to the
success of the occupational and environmental health program, and the OHN
has a key role in ensuring adequate and appropriate communication among
the members of the team. Establishing working relationships is paramount to
the success of a functional and effective team (OSHA, 2018). Strong
interpersonal relationship skills are extremely valuable in a team
environment.
Finally, the occupational health team is not complete without the workers
themselves. Employees can help identify problems and needs while
contributing to decision-making about health programs. Their cooperation in
implementing and evaluating programs is essential for an effective health
protection and promotion effort.

2483
Educational Preparation and EvidenceBased
Practice
OHNs are the largest group of health professionals working in occupational
health (de Castro, Shapleigh, Bruck, & Salazar, 2015). In many work
settings, the occupational and environmental health nurse is the only health
professional. Independent decision-making is critical. Nurses in occupational
settings must also have strong communication skills, including listening,
speaking, and writing. The broad knowledge base requirement necessitates a
minimum of a bachelor's degree in nursing. During the last two decades,
several nursing educational programs (primarily on the graduate level) have
developed a specialty focus in occupational and environmental health.
Additionally, OHNs may become certified in this specialty field through
ABOHN. Founded in 1972, ABOHN is an independent not-for-profit
organization that sets professional standards and conducts occupational
health nursing specialty certification. ABOHN is the sole certifying body for
OHNs in the United States and has the stated purposes of (ABOHN, 2018):
1. Establishing standards and examinations for professional nurses in
occupational health 2. Elevating and maintaining the quality of
occupational health nursing service 3. Stimulating the development of
improved educational standards and programs in the field of
occupational health nursing 4. Encouraging OHNs to continue their
professional education
In addition to formal training in occupational health, continuing
education plays an important role in keeping abreast with evidencebased
practice, as well as maintaining specialty certification. Opportunities range
from formal in-person conferences to short, online courses addressing
specific topics in occupational health (AAOHN, 2019a).

2484
The Effect of Work on Health
Workers in the United States generally spend more time at work than on any
other activity except sleep. Thus, the work environment can have a
significant impact on workers' health. A safe and supportive work
environment can contribute to the well-being of employees (Fig. 29-6).
However, the type of work that people engage in dictates the hazards they
encounter. For instance, think about the work of hospital-based nurses. They
encounter physical hazards, such as lifting patients in bed without
mechanical lifting devices. There are biological hazards associated with
blood and body fluids as well as infectious diseases. Some nurses are at risk
for chemical exposures, such as those associated with operating room gases
or chemotherapy. Radiation hazards may exist when working with patients
undergoing radiation therapy.

FIGURE 29-6 Example of workplace safety equipment.

Firefighters in fireproof uniforms are well prepared to extinguish
fires.

Hazardous substances can get into a person's body through inhalation,

ingestion, or absorption (percutaneously). Although personal protective
equipment (PPE) is available to workers, some may not use PPE
consistently, or the equipment may not be entirely effective. Workers
exposed to chemicals may not wash their hands sufficiently before
eating or smoking, thus providing an opportunity for chemicals to get
into their system through ingestion or inhalation. Employers are
responsible for training employees (OSHA, n.d.).
Employees who work in awkward positions or who do repetitive tasks
that use the same muscle groups are at risk for musculoskeletal
disorders (MSDs). Carpel tunnel syndrome is often associated with

2485
 repetitive movements, such as typing at a computer keyboard (Hegmann
et al. 2016).
Workers who compound a workplace exposure with off-work
activities that use the same muscle groups in similar actions will
accelerate or aggravate a problem. For instance, an office manager
may spend hours using electronic devices (cell phone, tablet,
computer) in the evenings and on the weekend, so the muscles that
are used every day never really get a chance to rest and recover.
A research study examining the prevalence of MSDs among office
workers found the highest number of MSDs noted in the lower
back (almost 50%) and neck (49%) areas (Piranveyseh et al.,
2016).

Shift work, particularly rotating shift work, negatively impacts sleep and
rest cycles. NIOSH offers a free online course that trains nurses and nurse
managers on the risks associated with shift work and long working hours,
including training on strategies to reduce such risks (NIOSH, 2018).
Insufficient sleep is associated with obesity and diabetes (Gibson-Moore &
Chambers, 2019). Low-paying jobs may drive workers to get a second or
even a third job to make ends meet. Personal stressors or balancing work and
family demands, plus employer expectations at work, can have an adverse
effect on worker health (Box 29-11).

BOX 29-11 STORIES FROM THE

FIELD
Creating a Safety Culture A family-owned
beverage distributing company with 150
employees is experiencing a higher than
average injury rate. This prompted the onsite
occupational health team consisting of an
occupational health nurse, industrial hygienist,
and safety manager to conduct a walkthrough.
They identified hazards, such as frayed
electrical extension cords, blocked egress (exit)
doors, missing machine guarding, and air
quality concerns.
1. What actions should the occupational health nurse take?

2486
 2. What preventive measures could be put into place to inspire a
more proactive safety culture?
3. What measures might motivate employees involved to prevent
exposure to serious hazards?

A systematic review of research on workplace mental health

interventions found moderate evidence for effectiveness of these
programs and their outcomes. Programs that included both physical and
mental health interventions and multicomponent interventions had
greater evidence of support (Wagner et al., 2016).
Education to reduce the stigma associated with mental illness has also
been shown to be effective in improving worker knowledge and
promoting more supportive behavior toward peers with mental health
issues (Hanisch et al., 2016).

2487
Future Trends
Future practice considerations for occupational health professionals' center
on promoting and maintaining the highest level of physical, social, and
emotional health for all workers. Occupational health and environmental
nurses play a key role in making positive strides toward this goal by
embracing evidencebased research and best practices. Strategic visionaries
from the nursing and occupational safety and health (OSH) fields stress the
need for working collaboratively (ILO, 2017; 2019a). The Future of Nursing
committee of the Institute of Medicine (now named the Health and Medicine
Division of the National Academies of Sciences, Engineering, and Medicine)
concluded that, “no single profession, working alone, can meet the complex
needs of patients and communities” (Lynch, 2015, para. 2). Collaboration
with all stakeholders in the health care sector, private industry, government
agencies, trade unions, workers, employers, researchers, educators,
consultants, administrators, managers, policy makers, technology developers,
and human resource professionals is required to advance worker safety and
health and create a culture of prevention.
In the progress report, the Future of Nursing committee gave specific
recommendations in the areas of removing barriers to practice and care;
transforming education; collaborating and leading; promoting diversity; and
improving data. The update included progress made to date, remaining
challenges, and recommendations towards reaching the goals of The Future
of Nursing: Campaign for Action (Campaign for Action, 2019). As nurse
specialists, OHNs must keep engaged and abreast of the direction of our
nursing profession. The following updates convey highlights of the in-depth
work done over the past 5 years. The full report is available for review at
https://campaignforaction.org/about/our-story/.
Occupational and environmental health nurse practice will continue to
evolve. To respond to these challenges, OHNs need to stay current and
connected to the continuously growing body of OSH practices evidence. The
International Labour Organization (ILO) is a United Nations agency that is
tasked with bringing together “governments, employers and workers
representatives of 187-member states, to set labor standards, develop policies
and devise programs promoting decent work for all women and men” (ILO,
2019a, para. 1). ILO (2017) outlined five challenges:
1. The need for “OSH data that is reliable and comparable coupled with
key indicators that will drive improved performance” (para. 9).
2. Giving priority to “those most vulnerable at work.” This requires that
“the safety and health of migrant workers must be a global concern”
(para. 10).

2488
 3. Upgrading OSH within global supply chains. Developing methodologies
for “identifying OSH vulnerabilities in the agricultural supply chain and
developing targeted interventions” to address them (para. 11).
4. Creating processes for the “global sharing of OSH data, knowledge and
expertise and finding the means to sustain such networks” (para. 12).
5. The importance of proactively recognizing the “impact that future jobs
and future ways of organizing work will have on the safety and health
of workers” (para. 14).
There is still work to be done. The new global estimates on work-related
illnesses and injuries represent (ILO, 2019b):

Costs associated with the illnesses, injuries, and deaths amount to

3.94% of the global gross domestic product per year, or US $2.99
trillion.
2.78 million workers continue to die each year from work-related
injuries and illnesses.
2.4 of the 2.78 million deaths can be attributed to work-related diseases
alone.

How the future of nursing is forged will have the greatest impact on this
and the next generation of OHNs and the populations they serve and protect.
It is critical to continue to develop skills and competencies, champion
innovation, and collaborate with stakeholders to effect change in an evolving
occupational and environmental health landscape. To accomplish this, “the
nursing community, must build and strengthen coalitions with stakeholders
both within and outside of nursing” (Lynch, 2015, para. 2). The occupational
and environmental health nurse will particularly need skills in effective
communication, leadership, change management, research, business acumen,
and assertiveness. These tools will be crucial for effectively interpreting the
OHN's role and promoting future worker population needs.

2489
NURSE ENTREPRENEUR IN
COMMUNITY/PUBLIC HEALTH
NURSING
C/PHNs often work within an organization to address unmet needs in the
community, with the ultimate goal of enhancing service delivery. These
positions are often nonexistent until the nurse is able to identify a need and
take the necessary steps to start a stand-alone service or to develop a role
within an existing agency, often through grant writing. But a growing trend
in nursing seeks a more independent practice through entrepreneurship. The
National Nurses in Business Association (NNBA, 2018) was first started in
1985 as a grassroots effort for business-minded nurses to connect and share
ideas. It has grown into a nursing organization that provides resources for
nurses transitioning from traditional nursing positions to self-employment
and business ownership. As you think about your own career in nursing, can
you envision yourself running a health care business, seeking a small
business loan to start a venture, or having the courage to explore other
professional options? Independent practice is not for everyone, and nurses
are often socialized to view their role as working within a larger
organization, such as a health department, a community clinic, or, most often,
a hospital. At some point in your career, you may find yourself working with
a nurse entrepreneur or becoming one yourself.

An entrepreneurial nurse is one who is willing to take on the risks of

starting a new business within a health care or social context. Common
examples of nurse entrepreneurs include legal consultants, forensic
nurses, home health care agency owners, authors, and nurse consultants
in a variety of areas.
The NNBA (2018) offers membership and resources for those
entrepreneurial nurses who are self-employed or small business owners.

For the community/public health nurse, these and many other options
offer the independence to provide services in perhaps a new and innovative
way. For health care to continue to respond to the changing environment, the
innovators are often the ones who have the courage to test those new
methods.

2490
Steps to Becoming a Nurse Entrepreneur
One of the first steps to becoming a nurse entrepreneur is to have an idea. It
doesn't have to be a new idea or even a “big” idea, but it must address an
unmet need within a community. Community/public health nurses are often
the first to identify the challenges and needs within a community and to
explore solutions. Very often, participation in professional organizations
helps to identify health care issues that can be addressed by nurses. The
common refrain “why doesn't someone just (invent, build, provide, etc.)?”
can often be answered by a nurse. Nurses are problem-solvers, and using the
nursing process, they assess the situation, identify the problem, determine a
course of action, and evaluate the results. This nursing skill can be leveraged
for entrepreneurship (e.g., to start a new business venture, to develop a
nonprofit agency, or to create educational tools for use by other health care
professionals or the general public).
Entrepreneurial nurses in the community often require skill with grant
writing, agency and personnel management, collaboration both inter-and
intraprofessionally, fiscal management, and agency promotion. Whatever the
health care need, nurses can and do find the solutions. Hahn and Cook (2018)
highlight the potential nurse practitioners with full practice authority have as
entrepreneurs in their state. These nurse practitioners are finding new ways to
practice outside the hospital while addressing gaps in direct patient care
systems. They are able to serve vulnerable groups while leveraging
reimbursement. Credentialing and payment from private insurance
companies can be cumbersome. Legal consultation should be part of every
nurse entrepreneur's business plan.
A business plan is essential to starting a business, growing a business,
and obtaining financial support. At the very minimum, the business plan
should include the description of the business; marketing strategies;
competitive analysis, design, and development plan; operations and
management plan; and financial factors (Box 29-12).

BOX 29-12 Small Business Start-Up

Information
1. Write a detailed business plans with goals, objectives, and financial
costs. Include market research and competitive analysis for your
business.
2. Set up the legal business structure. This might require legal
consultation.
3. Register your business and obtain a Federal Employee
Identification (FEI) number.

2491
 4. Obtain start up collateral. Create business or merchant bank
account.
5. Determine whether business licensing is required for your business
activities. What other government rules and licensing might need
to be considered? Be aware of rules in all states you will interact
with for business. Will you need business insurance?
6. Establish place of business including all contact and corresponding
information.
7. Create a sales and marketing plan. Address marketing for your
business including Web site and registered URL, advertising plan,
and marketing products. Consider how you will “sell” your
product. How will you establish a presence in your community or
reach your target audience?
8. Establish accounting and payroll processes.
9. Create internal documents (this can include safety, education, and
hiring process within your business).
10. Connect with local small business resources in your community.

Adapted from U.S. Small Business Administration (2018).

2492
Opportunities
As the health care needs of the population demand newer, better, and less
expensive solutions, nurse entrepreneurs are well positioned to address those
needs. Although there are many examples in your own communities of nurse
entrepreneurship, the role of the community/public health nurse can serve as
a strong base for meeting the health care challenges locally, nationally, and
internationally. Some examples of nurse entrepreneurship include (NNBA,
2018):

Nursing registry and staffing services agency

Home care agency
Specialty agencies (vascular, diabetes, dialysis)
Nurse consultant for local and federal government, and organizations
Legal, wellness, and coaching consultation
Elder care managers
Forensic nursing
Nurse educators (seminar companies, national speakers, online courses,
assisting with accreditation, writing, diabetes educator, podcasts, yoga,
wellness, and training programs)
Retail businesses (patient care products, wellness products, health
foods, medical equipment and devices)
Independent nurse contractor (private care and therapy)
Nurse practitioner–owned clinic or wellness agency
Esthetic care
Adult day care
Foot care services

One example of a nurse entrepreneur is Barbara Philips, a family nurse

practitioner who opened a hypnotherapy practice in Missouri. After years of
working in a pain management group in Washington that included use of
hypnotherapy, Philips expanded her interest in this area, completing training
and certification, and opened her own business in 2016. Her practice assists
patients with such health issues as smoking, anxiety, and fibromyalgia. As
practice authority can be different in every state, it is prudent to understand
the laws affecting your nurse practitioner license and make every effort to
practice to your full potential. In addition to Philips's hypnotherapy practice,
she also consults on business start-up basics with other nurse entrepreneurs.
She says many nurses want to have their own business but don't always
consider the whole process. Her suggestions include:

Know your potential customer.

Do research and have a business plan.
Investigate requirements such as regulations and credentialing.

2493
 Have a financial plan.

Philips says that nurses do need to understand the money aspect and that
having an expense and income report is a must (personal communication,
Barbara Philips, APRN, GNP, FNP-BC, FAANP, NP, business owner).
The opportunities are limitless for nurse entrepreneurship; the only
missing piece is the nurse willing to take that leap, come up with an idea,
explore the options, create a business plan, garner funding, and make a
difference. Community/public health nurses are uniquely qualified to address
the ever-growing challenges in our communities. As opportunities in one
area of nursing practice recede, other avenues open up. What is needed are
nurses who enjoy a challenge and are willing to take risks to provide needed
services and improve patient outcomes.

2494
SUMMARY
Private sector practice opportunities for public health nurses include
NLHCs, faith community nursing, occupational and environmental
health, and entrepreneurial roles. Each of these areas of practice offers
community health nurses an avenue to address health disparities in their
communities, increase years of healthy life, and provide holistic, client-
centered care.
NLHCs represent a growing movement of health centers that have
emerged as vital safety-net providers in America's contemporary health
care delivery system and typically provide care to vulnerable or
underserved populations.
The Health Care Provisions in Bipartisan Budget Act of 2018 and the
ACA of 2010 provide funding streams for NLHCs as an avenue to reach
vulnerable populations and reduce the burden on traditional health
models.
Faith community nursing is a specialized area of practice that focuses
on the care of the spirit as well as the whole-person health.
The ANA and the HMA have published Faith Community Nursing:
Scope and Standards of Practice, 3rd edition, which should be used to
guide nursing practice in this area.
FCNs act as health educators, health counselors, advocates, and referral
agents. They also establish support groups, coordinate volunteers, and
integrate concepts of faith and health.
The Occupational Safety and Health Act of (1970) led to the
proliferation of occupational health nursing employment in the United
States and established OSHA, which developed standards for
occupational health and monitors the health status of workers and
community groups.
OHNs play a vital role advocating health promotion and wellness
programs for the workforce they serve, and OHN duties fall into three
categories: compliance, care, and health promotion. OHNs are often
involved in case management, transitional care, and telemedicine.
Occupational and environmental health nurses work with employers to
cultivate creative and business-appropriate health and safety programs,
using an interdisciplinary approach to advocate for the employee's right
to have cost-effective, prevention-oriented health and safety programs.
OHNs can become certified in this specialty field through ABOHN.
The TWH initiative is defined as a strategy that integrates occupational
safety and protection of health along with health promotion to prevent

2495
worker injury and illness and to improve worker well-being and health
through a holistic approach.
Case management is an approach used in many areas of nursing. It
involves assessment, planning, facilitating, care coordination,
evaluation, and advocacy for resources to meet client needs. Current
research demonstrates cost-effectiveness and better patient outcomes.
Transitional care is concerned with management of care across the
health care system (e.g., hospital to home). Research has shown
beneficial effects for patients and cost benefits to hospitals and health
care agencies.
Telemedicine is expanding and being used in a wide variety of settings.
It can cut costs and shorten wait time for patients needing to see
specialists. Several methods of digital health interventions were
discussed (also see Chapter 10).
There is a growing trend in nursing to seek a more independent practice
in health care delivery through entrepreneurship. Common examples of
nurse entrepreneurs include legal consultants, forensic nurses, home
health care agency owners, authors, and nurse consultants in a variety of
areas.
The NNBA provides valuable resources and guidance on how to
establish an independent practice (or health-related business).

2496
ACTIVE LEARNING EXERCISES
1. Using “Enable Equitable Access” (1 of the 10 essential public health
services; see Box 2-2 ) locate a NLHC or a federally qualified health
center in your community. Interview a public health nurse or a nurse
practitioner employed there. Ask the nurse to describe his or her role
and duties. What types of patients are most often seen? What are
typical problems or illnesses? If this clinic did not exist, where would
those patients get care?
2. Contact a faith community nurse (FCN) in your area and arrange to
interview or shadow the nurse. Explore the services offered by FCNs
in your area. Identify the knowledge and skills needed to function
effectively in the role. Discuss the process the nurse used to establish
an FCN practice.
3. Search for current evidencebased practice research articles on case
management, transitional care, and telemedicine in nursing practice.
Where is most of this research being done (e.g., acute care, public
health, ambulatory care, chronic illness care, palliative care)? How
can these strategies be effectively employed in public health nursing,
faith community nursing, and occupational health nursing and at
nurseled clinics?
4. Research occupational hazards for nurses. You may find that hazards
vary depending on specialty areas or geographic locations. Think of
the kind of nursing that you see yourself doing after graduation.
Identify the occupational risks associated and develop a list of
strategies for mitigating those risks. Compare your findings with
those of other class members.
5. Think about your clinical experiences in community/public health
nursing. Are there unmet needs in the community that could be
addressed through a nurseled business? What elements would you
include in a business plan? Locate a nurse entrepreneur and discuss
the challenges the nurse met in starting the business; how were those
addressed?

thePoint: Everything You Need to Make the

Grade!
Visit http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, study aids for
all learning styles, and more!

2497
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2507
CHAPTER 30
Home Health and Hospice Care
“People from all walks of life agree that someone who is sick deserves, in principle, compassion
and care.”

—Paul Farmer, American anthropologist and physician

KEY TERMS
Care coordination Centers for Medicare and Medicaid Services (CMS)
Compassion fatigue Home health care Homebound Hospice Medicaid
Medicare home health benefit Medicare hospice benefit Medicare
prospective payment system Outcome and Assessment Information Set
(OASIS) Palliative interventions Postacute care Value-based care Visiting
Nurse Associations

LEARNING OBJECTIVES
Upon mastery of this chapter, you should be able to:
1. Summarize the history and contemporary circumstances of home health
and hospice care.
2. Describe reimbursement and payment models for home health care and
hospice programs.
3. Explain family caregiver burdens of providing home and hospice care.
4. Describe essential characteristics of home health and hospice nursing
practice.
5. Identify unique challenges of home and hospice nurses.
6. Contrast the goals of home health care and hospice.
7. Explain the gaps and future needs of home health care and hospice in the
United States.

2508
INTRODUCTION
A home health nurse sits in an upscale condominium with a frail, older man
tethered to his home oxygen unit and experiencing air hunger as he struggles
to speak of the “good old days” when he was young, full of vigor, and taking
on the world. During her next visit to a trailer park, she inspects an infected
pressure sore that has become smaller and cleaner with each home visit, as
the client's wife carefully follows through with wound care teaching. Next,
she monitors the pulmonary and cardiac status of a patient newly discharged
to his aging bungalow, detecting early signs of cardiac decompensation and
treating him at home in close collaboration with his physician. At that same
time, her hospice nurse colleague on arriving at the home of a woman near
the end of life finds the patient in pain and vomiting and the family in chaos;
by the time this colleague leaves, however, the family is calm and the patient
comfortable.
These are the kinds of experiences that make up the daily lives of nurses
who work with home care and hospice clients. Indeed, home health and
hospice programs allow nurses to practice what some see as the very heart of
compassionate and highly skilled nursing care. Home health care and hospice
programs are expanding and are the work settings for more and more nurses.
Almost 2% of registered nurses work in home health care settings (United
States Department of Labor, 2018). This chapter considers the history and
current status of home health care and hospice care, how these services are
reimbursed, the unique burdens of caregivers in these settings, key aspects of
nursing practice in these areas, and expected future trends. (Children and
adults with disabilities also receive home health services. Specific care
regarding these populations can be found in Chapters 20 and 24,
respectively.)

2509
HOME HEALTH CARE
The need for health care at home continues to accelerate as Americans live
longer lives. An aging US population means an increasing number of people
living with multiple chronic conditions, cognitive impairments such as
dementia, and functional limitations that affect daily living. In addition,
medical costs continue to escalate despite national insurance programs such
as Medicare and Medicaid and expansion of private health insurance options
as a result of the Patient Protection and Affordable Care Act (ACA).

Early hospital discharges resulting from third-party payers' efforts

toward cost containment have forced clients to return home quickly to
recuperate from surgeries and severe illnesses. Likewise, a growing
population survives and yet suffers from complex chronic and life-
threatening illness that they struggle to manage at home.
Advanced technologies such as telehealth monitoring, point-of-care
devices, intravenous (IV) antibiotics, chemotherapy, total parenteral
nutrition, dialysis, and mechanical ventilation are now routinely
provided and maintained in the client's home.

As the population ages, and particularly now that the baby boomers are
entering their elder years, home health nursing is challenged to respond.
Professional home health care agencies seek to maximize the client's level of
independence and to uphold the right to access high-quality health care and
supportive services (National Association for Home Care and Hospice
[NAHC], 2018). Those most in need of home care services are older adults
and those with chronic illnesses. As the number of multiple chronic
conditions rises, specifically for older beneficiaries, the need for health care
in the home is critical.
Historically, home health care was delivered in the home as a house call
(Landers et al., 2016). Today, C/PHNs provide home health care much like
their early predecessors, where the focus of care is on maximum
independence (Landers et al., 2016). The nurse's role in the home can be
extensive. The nurse may be the coordinator of care, managing and providing
a plan of care for the patient. The nurse monitors the progress of the patient,
makes referrals as necessary, assesses for home safety, provides care such as
dressing changes or blood pressure, coordinates communication with the
health care team and family members, reviews the medication regime, and
educates and advocates for the patient and family. Today's health care system
requires nurses to employ a greater understanding of health care cost and

2510
reimbursement, a population focus for improving health, and inclusion of
quality and satisfaction in the care provided (Landers et al., 2016).

2511
History and Politics of Home Health
As the practice of home health care has evolved, so have the approaches to
pay for it and contain its costs.

History of Home Health

Home health, or home-based, care is as old as the nursing profession itself.
For centuries, care of the sick and infirm in the home setting was the
standard of practice. In the United States, the earliest known organized effort
to care for the sick poor at home was made by the Ladies Benevolent Society
in Charleston, South Carolina, in 1813 (Fitzgerald, 2016). Later in the 19th
century, women were able to receive training to become nurses in the manner
of Florence Nightingale, and wealthy women began to hire them as visiting
nurses and to sponsor visiting nurse services. Visiting Nurse Associations
were established in many American cities (Fulmer, 2017). In 1893, Lillian
Wald began home visiting in New York City and is famed for
professionalizing visiting nursing.

Evolution of the Laws and Models Governing Home

Health Coverage
The payment system for home health care has changed dramatically over
the last 100 years, from the initiation of its coverage by health insurance to
today's value-based models of care:

20th century insurance companies saw the benefit of home care as a less
expensive alternative to hospitals. Private home health agencies evolved
as a result of the demand to provide care for chronically ill clients in
their homes.
During the latter half of the 20th century, Medicare and health insurance
companies began to cover home health care, allowing patients to
rehabilitate in their homes.
Medicare home health benefit was established to provide intermittent
home visits in which nurses and therapists would provide services and
instruct clients and families in self-care.

Initially, Medicare and other payers required the period of home health
care to be brief and the provision of direct skilled care to be temporary.
Home health care services were seen as extensions of medical care, with
physicians certifying needed services for short-term treatment of sickness.
The number of Medicare-certified home care agencies grew rapidly until
enactment of the Balanced Budget Act of 1997 (Public Law 105-33), which

2512
explicitly sought to reduce federal payments for home health care. Payment
to providers was changed from reimbursement for each visit to the Medicare
prospective payment system, which determined Medicare payment rates
based on patient characteristics and need for services. Most private insurance
agencies followed suit and adopted the standards of the Medicare prospective
payment system.

Standardized reimbursement rates forced Medicare-certified home

health agency closures. Patients, requiring intensive skilled and personal
services, needed to become independent in providing their health care
needs at home. The focus of the home health nurse changed from
provision of care to education and training, including evaluation of
patient progress.
The enactment of the ACA impacted the provision of home health care
through programs and outcome-based quality care:
Supplemental payments for rural home care providers were
reinstated for 2010–2015 to address the lower ratio of home care
professionals in rural areas throughout the United States as
compared with more urban areas.
The Community First Choice Option allowed states to offer
homeand community-based services to people with disabilities
through Medicaid rather than institutional care in nursing homes.
The Community Care Transitions Program helped high-risk
Medicare beneficiaries who were hospitalized avoid unnecessary
readmissions by coordinating care and connecting patients to
services in their communities.
A 2012 ruling by the U.S. Supreme Court (National Federation of
Independent Business et al. vs. Sebelius, Secretary of Health and
Human Services, et al., 2012) allowed for states to opt out of the
provision in the act to expand Medicaid services. Medicaid services are
provided primarily to low-income populations. With a growing
percentage of payments for home health coming from Medicaid, this is
of concern to care providers and consumers of care. Home health care
expenditures from Medicaid are expected to exceed Medicare payments
in the coming years. The shift in payment source and the limitation that
many states may impose on Medicaid coverage is unknown at this time.
The Centers for Medicare and Medicaid Services (CMS) oversee
expenditures and policy implementation.
The Improving Medicare PostAcute Care Transformation Act of 2014
required postacute care facilities to submit standardized data and
changed the requirements for home care agency reimbursement. As a
result, Medicare-certified agencies must provide outcome-based quality
improvement measures for home care services. The Home Health
Quality Reporting Program (HH QRP) uses outcome and process

2513
 measures and considers patient care, avoidable events, utilization, cost,
and resources to mitigate costs and improve care (CMS, 2018a).
It is mandatory for Medicare-certified home health agencies to
participate in HH QRP, and their reporting must include data required
by both Outcome and Assessment Information Set (OASIS) and
Home Health Care Consumer Assessment of Healthcare Providers and
Systems (CMS, 2018b).
The Veterans Administration now pays for homeand community-based
services for extended care away from nursing homes (Miller et al.,
2017).
The CMS has also implemented the Home Health Value-Based
Purchasing Model (Maddox, et al., 2018).

By 2050, the number of people needing home health care services will
increase from 15 to 27 million (United States Department of Health and
Human Services [USDHHS], 2018). Currently, 40% of Medicare
reimbursement dollars are spent on home care services (MedPac, 2017).
Today, over 12,000 home care agencies provide skilled, nonskilled, and
therapeutic care services; 98% of these agencies are Medicare certified and
78% Medicaid certified. Home health referrals will continue to increase as an
alternative to costly hospital stays as cost containment becomes a driving
factor for care (Jones et al., 2017).

Home health care agencies are increasingly relied on to provide

postdischarge care as patients prefer to recover in their homes,
shortened hospitalization stays become the mainstay, and insurers
benefit from cheaper home care costs (David & Kim, 2018).
Prior to the ACA, home health agencies had little incentive to reduce
hospital readmission. With the current focus on cost containment and
better patient outcomes, home care agencies are now held accountable
for measurement outcomes as they vie for reimbursement dollars.

Value-Based Care and Cost Containment

HH QRP ensures a value-based care reimbursement process for home health
care, which has the potential to provide better care and improved patient
outcomes at a reduced cost. With reduced readmission, a driving force in cost
reduction, postacute care following hospitalization will need further
scrutiny.
A systematic review by Ma, Shang, Miner, Lennox, and Squires (2018)
determined that limited research has been done on patients in home health
care who are at high risk for hospital readmission. Patients who were
readmitted did not always have an identifiable reason documented, although
heart failure and respiratory conditions were noted complications. Further

2514
studies that identify the reasons for hospital readmission as well as risk
factors associated with readmission are needed to mitigate the challenges
associated with postacute home care.
Improving patient outcomes through better care transition processes will
assist coordination efforts between agencies and providers. In addition, other
models associated with cost reduction are being trialed. Home visit program
models with practice-extended teams provide care coordination that is
organized around patient and consumer engagement. These nurse-led teams
show promise in reducing emergency department visits, Medicare
expenditures, and hospitalizations through home visits and illness
management for older patients and those with stroke, dementia, and late-
stage illness (Ruiz et al., 2018).

Care Coordination
The transition from acute care settings to home health requires coordination
of services for seamless care. Care coordination is defined as “the
organization of patient care activities between two or more participants
(including the patient) involved in a patient's care to facilitate the appropriate
delivery of health care services” (Agency for Healthcare Research and
Quality, 2018, para. 1). Care coordination requires effective communication
between agencies and health care providers to support the complex needs of
patients.
Care coordination is centered on the patient and family, with attention to
navigation through the health care system; care is proactive and planned. As
health care shifts from acute to population-based care, the focus is not on
episodic events but on postacute care, in which a plan of care and quality
transition from the hospital to the community is imperative (Allen,
Hutchinson, Brown, & Livingston, 2017). Care coordination models that
educate and support families and patients, use registry-based information
systems, and promote a team-based care delivery system have been shown to
have good patient outcomes (Georgiadis & Corrigan, 2017; Noel,
Kaluzynski, & Templeton, 2017; Smith & Treschuk, 2018). Currently, home
health care is used to provide postacute care and, in many aspects, is
considered a continuation of the acute care setting. However, today's
community health nurses may find themselves providing increasingly
complex care that requires advanced skills in case management, advocacy,
and plan of care to support the comprehensive health care needs of patients
and their families.

2515
Home Health Agencies
Home health agencies are organizations that provide various home health
care services and equipment to patients in their homes, including skilled
health care, custodial (unskilled) care, high-technology pharmacy services,
and durable medical equipment (DME). These agencies may be nonprofit or
for-profit, public or private, community-or hospital-based, and certified or
noncertified.

Skilled home health care is care provided by specialists with licenses,

certifications, or specific qualifications, such as nurses, social workers,
physical therapists, occupational therapists, and home health aides.
Home care agencies who offer skilled care typically have internal and
external standards that guide the practice of these skilled practitioners.
One such external standard is the code of ethics developed by the
NAHC (2020), which serves as a guideline for agencies in ensuring that
patients and families are treated with a high standard of care and in an
ethical manner. Professional home care agencies may receive referrals
from hospitals or other facilities for postacute follow-up. These patients
are considered homebound and have a plan of care signed by a
physician.
In contrast, custodial care involves unskilled or nonprofessional
services, such as cleaning and assistance with daily living, and DME
includes wheelchairs, commodes, beds, or oxygen. Agencies that
provide such services are not held to the same standards as those that
offer skilled care.
Nonprofit agencies traditionally have a charitable mission and are
exempt from paying taxes. They are financed with nontax funds such as
donations, endowments, United Way contributions, and third-party
provider payments.
For-profit agencies are expected to turn a profit on the services they
provide, either for the individual owners or for their stockholders.
Public agencies, such as city and county agencies, are government
agencies created and empowered through statutes enacted by legislation.
These agencies include the nursing divisions of state or local health
departments, which may or may not combine care of the sick with
traditional public health nursing services, including health promotion,
illness prevention, communicable disease investigation, environmental
health services, and maternal–child care.
Private agencies are those owned and operated not by government but
rather by private individuals or large regional or national chains that are
administered through corporate headquarters.

2516
Community-based agencies provide services outside of hospitals within
a well-defined geographic location.
Hospital-based agencies operate as separate departments within
hospitals and may be nonprofit or for-profit. The referrals to such
agencies usually come from the hospital staff. Similar agencies may be
found as home health departments in rehabilitation and skilled nursing
facilities.
Certified agencies are those that have been certified by Medicare and/or
Medicaid to provide and be reimbursed for skilled home health care
services.
Noncertified agencies remain outside the federal Medicare and/or
Medicaid system that reimburses skilled nursing. Such agencies are
usually private and derive their funding from direct payment by the
client or from private insurers. They may be governed by individual
owners or by corporations. For instance, some agencies offer private
duty shifts, unskilled assistance in the home with homemaking or
housekeeping, and live-in personal care.

2517
Clients and Their Families
The client in home health care is not only the individual patient but also the
family and any significant others. The nurse must consider how the
environmental, political, emotional, social, economic, cultural, and religious
dimensions impact the client's illness and ability to meet the goals outlined in
the plan of care. Not all patients in need of home care are able to pay for
these services.
Home care recipients are predominantly older patients with acute and
chronic health needs. The medical diagnoses coincide with the morbidity
rates of the region. Many have chronic conditions that complicate any acute
conditions they experience.

In the United States, home care agencies serve over 5 million patients,
with 82% of the patients over the age of 65 years. A majority of patients
are women (70%) and non-Hispanic White; half of all clients cared for
in home health have a diagnosis of diabetes (USDHHS, 2018).
Individuals recovering from severe illness or living with debilitating
chronic illness rely on family members or other sources of unpaid
assistance. Forty-three million people provide informal caregiving for
an adult family member or friend (Family Caregiver Alliance, 2018).
Seventy percent of all caregivers are women, with an average age of
49.2 years. Family caregiving tasks range from personal care such as
bathing and feeding to sophisticated skilled care, including managing
tracheostomies or IV lines.

Nurses must assess the home environment and be responsive to family

who may exhibit signs of compassion fatigue. These informal caregivers
assume a considerable physical, psychological, and economic burden in the
care of their loved one at home. As a result, caregivers often describe
themselves as emotionally and physically drained and may need information
about resources to assist them. Frail older caregivers are especially
vulnerable to deterioration of their own health because of their caregiving
burden. Likewise, the economic cost of providing home care places a
significant burden on informal caregivers. Out-of-pocket expenditures
include medications, transportation, home medical equipment, supplies, and
respite services. These costs may be nonreimbursable and are often invisible,
but they are very real to families struggling to provide care on a fixed
income. Home health nurses must continually assess the strain on caregivers
as they seek to develop a realistic plan of care.

2518
Home Health Care Personnel
Direct care workers (home care aides and personal care attendants) provide a
majority of the functional assistance for the home care team and are expected
to increase in number by 70% in the next 10 years (Fig. 30-1; Institute of
Medicine [IOM], 2015). Wages in this sector of home care are low and have
been stagnant for years. Turnover rates are between 60% and 75% and can
affect continuity and the quality of care (IOM, 2015).

FIGURE 30-1 Skilled care provided in the home setting.

Home care nurses, physical therapy staff, occupational therapists, social

workers, and administrative personnel comprise the rest of the home health
team. The business and office personnel of a home health agency are critical
to the agency's ability to deliver services to clients.

2519
Reimbursement for Home Health Care: Medicare
Criteria and Reimbursement
Corporate and governmental third-party payers, as well as individual clients
and their families, pay for home health care services. Corporate payers
include insurance companies, health maintenance organizations, preferred
provider organizations, and case management programs. Government payers
include Medicare, Medicaid, the military health system (TRICARE), and the
Veterans Administration system. These governmental programs have specific
conditions for coverage of services, which are often less flexible than those
of corporate payers. For a general description of these reimbursement
systems, see Chapter 6. The Medicare policies for home health programs set
the precedent for all other reimbursement sources and are discussed below
(Fig. 30-2).

FIGURE 30-2 Home health care services and benefits by payer.

(Reprinted with permission from Alliance for Home Health Quality
and Innovation. (2018). Home health care services and benefits by
payer. Retrieved from http://www.ahhqi.org/images/pdf/what-is-
hhc-services-available.pdfFigure)

2520
 Medicare is the largest single payer for home care services in the United
States and has set the standard in establishing reimbursement criteria for
other payers. Therefore, it is essential that home care nurses seek to
understand the complex Medicare home health requirements and rules for
determining eligibility for home care services. It is important to acknowledge
that a person may be in dire need of care at home, yet not meet eligibility
standards for home health care under Medicare. There are five criteria that
must all be met to be eligible for reimbursement by Medicare (CMS, 2019;
Boxes 30-1 and 30-2).

BOX 30-1 Medicare Home Health

Eligibility Criteria
1. The patient must be confined to the home or homebound.
2. The patient must need skilled services (from a nurse or therapist).
3. The patient must be under the care of a physician.
4. The patient must receive services under a home health plan of care
(POC) that is established and periodically reviewed by a physician.
5. The patient must have had a face-to-face encounter that is related to
the primary reason the patient requires home health services with a
physician or an allowed NPP (this must be done 90 days prior to
the home health start-of-care date or within 30 days of the start of
the home health care).

BOX 30-2 PERSPECTIVES

A Nursing Instructor's Viewpoint on Medicare

Guidelines It is vital to develop an expanded
vision about the health care needs of frail elders
and the kinds of services that are needed in the
community. Sometimes, after nurses have been
working in Medicare home health for a while, they
may begin to identify more with the Medicare
guidelines than with their patients. Too often, I

2521
have heard experienced home health nurses say
about a patient living with severe chronic illness,
“She doesn't deserve services. She doesn't have
skilled needs.”
In contrast, I would hope knowledgeable nurses would say to families and
decision makers, “She needs and deserves services, but the Medicare home
health benefit will not pay for them. Our agency cannot continue to provide
care because of the limits imposed on us. We'll do everything possible to
find help for her, but resources are limited.” This kind of insight leads to
patient advocacy, development of community networks, and becoming
outspoken about needed changes in health policy. Visiting nurses witness
the struggles of chronically ill people living at home; we must not abandon
them.

Beth L., nursing instructor

The following steps are implemented while the patient is under

Medicare-reimbursed home health care:
1. The Medicare prospective payment system pays an agency for a 60-day
“episode of care.” All services and many medical supplies must be
provided under the payment amount adjusted to geographic location and
determined by the patient's clinical and functional status at the start of
care, as well as the projected need for services over the anticipated 60-
day period (CMS, 2018c).
2. When the patient is admitted, the patient is comprehensively assessed
using an assessment tool called OASIS. OASIS is used to measure
home health quality measures and is the basis for measuring patient
outcomes and adherence to best practice for quality improvement.
3. The nurse also completes the Medicare plan of care at admission, and
the physician must sign this. It is then used to assess agency compliance
with Medicare and state requirements. All follow-up services must
match the plan of care.
4. It is a Medicare requirement that patients receiving home health care
must be recertified every 60 days. A determination of continued visits is
then made based on the objective data obtained (CMS, 2018c). Box 30-
3 provides consumer information on quality home care agencies by zip
code or city.

2522
BOX 30-3 Compare Home Health Care
Providers The Medicare.gov Web site
offers information for consumers about
the quality of home health care agencies.
It includes data on how frequently best
practices are used in patient care and if
patients improved in relation to certain
aspects of care. It also includes patient
feedback about recent home health
agency experiences.
You and/or your clients can go to
https://www.medicare.gov/homehealthcompare/search.html and enter
your zip code (or city, state), and you can see a list of all agencies and
the services provided by each (that meet certain criteria). You may
select agencies for comparison, and general information is provided,
along with the quality patient care information and results of patient
surveys. For quality patient care, star ratings are used to denote
summaries of 9 out of 29 quality measures, with 4 or 5 stars indicating
better performance than other agencies. Star rankings of one or two
indicate below-average performance. Most agencies nationwide fall
within 3 or 3.5 stars. Survey results include percentages related to how
often care was given in a professional manner, how well the team
communicated with clients, if they discussed pain, medications, and
home safety with clients, how the client rates their overall care from this
agency, and would they recommend the agency to family/friends.
Overall percentages can be graphed for comparison with state and
national averages.

2523
Home Health Nursing Practice
The practice of home health nursing has roots in community/public health
nursing (see Chapters 2 and 3). The nurse provides home health nursing care
to acute, chronic, and terminally ill clients of all ages in their homes while
integrating public health nursing principles that focus on the environmental,
psychosocial, economic, cultural, and personal health factors affecting the
client's health status and well-being. Home health is a unique field of nursing
practice that requires a synthesis of public health nursing principles with the
theory and practice of medical/surgical, geriatric, mental health, and other
nursing specialties. According to the American Nurses Association (ANA)
Scope and Standards of Practice for Home Health Nursing (2014), home
health nursing goes beyond providing skilled nursing care in the home; it
requires the ability of the nurse to coordinate a broad variety of services and
professional caregivers to manage patients' complex health problems (the
standards of practice are available on ).

Nursing Practice During the Home Visit

A home visit by a home health nurse involves several steps: locating,
promoting self-management, detecting, collaborating, mobilizing,
strengthening, teaching, and solving problems.

Locating the Client and Getting through the Door

The first step in making a home visit is finding where the person lives.
Directions and household identification can be unclear. In rural areas,
tracking down clients can involve vague instructions involving barns,
bridges, trees, and other colorful local landmarks. When families are
unstable, clients may not be staying in households designated on the nurse's
paperwork. They may have moved in with relatives or friends or be back
home alone despite major care needs (Box 30-4).

BOX 30-4 STORIES FROM THE

FIELD
Beyond the Front Door I received a home visit
referral from the VA clinic after the client
missed two appointments. The client was a 77-
year-old male veteran with a diagnosis of
diabetes and right heel ulcer who needed IV

2524
antibiotics, and wound care twice a day. I had
the address; I circled around the block a couple
of times; the house was in a residential
neighborhood in the middle of town, a block
from an elementary school. The client did not
have a phone. I parked close to the address and
walked; only then did I see through the 5-foot
weeds in front of the house. I approached the
door, knocked, and called for Mr. P a couple of
times. He finally answered. An unkempt,
unbathed elderly man crawling on his knees
(due to his inability to put weight on his right
foot), with a toothless smile, let me in and sat in
an old chair by the door. Introductions were
made. The home was very dark and dusty; piles
of books, magazines, and newspapers were
stacked 3 and 4 feet high in between furniture
leaving a small maze in which to walk through
the house. The VA had sent 2 months of
supplies, which were in dozens of boxes by the
front door. The house was dark, but the kitchen
windows provided some light. I noticed there
were no appliances in the kitchen, only piles of
books, a Styrofoam ice chest on the floor (inside
was warm milk and green lunch meat), and
open cans of food in the sink.
Assessment reveals blood glucose of 355, 4-inch diameter stage 3
wound on the right heel, and pain level of 8 out of 10 (had not taken
prescribed pain meds). Mr. P is very cooperative and talkative. He has
lived alone in the house for over 40 years and never married. Family
lives an hour away; he has not seen them in 10 or more years. No
friends locally, many have passed on. Mr. P has no car; the closest VA

2525
 clinic is 90 miles away. He purchases food from the corner grocer but
says he has been unable recently to walk to the store.

1. What are your nursing priorities?

2. Reflect on Mr. P's lifestyle. What do you think would have
happened to Mr. P. if the nurses did not find him?
3. Apply the nursing process to comprehensively identify and
prioritize nursing diagnoses and propose interventions. Use
Figure 30-3 to guide your care planning.

Anne Stokman, MSN, RN, CDE

FIGURE 30-3 Home health nursing caregiving wheel.

Even when the wheels stop at the correct household, there is the
challenge of getting through the closed door and making the connection.
Always remember that you are a guest in the home. Respect and attentive
listening are the foundation for establishment of trust between the client and
nurse. Agendas must be laid aside initially as the nurse focuses on the
concerns and realities of both the client and family. Assumptions and
stereotypes are overturned in the process of discovering how clients live,
what they believe, and who comprises their family and community. The
nurse must take into account the spiritual, cultural, and developmental, as

2526
well as environmental, realms of the client in order to be able to develop
individualized plans of care to promote health.
The home health nurse is aware that the client is the driver of the plan of
care. To have effective outcomes, the nurse must develop a therapeutic
relationship in which the client identifies the desired outcomes. Autonomy
should be respected, and the family should be empowered by actions
recognizing that they are in charge of their lives. The nurse, the patient, and
family must work together to establish mutually agreed-upon goals (see
Chapter 10).

Hub of the Family Caregiving Wheel: Promoting Self-

Management
The practice competencies of home health nurses can be illustrated with the
home health nursing caregiving wheel (Fig. 30-3). The hub, or most essential
competency, of this wheel is promoting independent self-care and self-
management. The challenge to the home health nurse is often assisting the
severely chronically ill client be able to adapt in the community to be safe
and functional. Coordination with other professionals must often be instituted
to provide comprehensive quality care. This may include social workers,
clergy, physical therapists, occupational therapists, as well as mental health
professionals.

Rim of the Home Health Caregiving Wheel: Detecting

Nurses in the home are challenged by an extraordinarily complex
environment with much to investigate and continuing assessment process as
the nurse seeks to understand the client's health in the context of home. The
nurse keeps her ears and eyes “wide open.” Who lives in the home? How do
they interact? Who are the caregivers, and how do they care? What is the
relevance of culture and religion in the life of the household? How does the
physical environment impact patient safety and security? Home visits reveal
discoveries that can never be imagined in clinic or hospital settings. Take for
example the client whose refrigerator no longer chills and whose impaired
vision prevents awareness of the expanding family of roaches in the kitchen.

Spokes of the Home Health Caregiving Wheel:

Collaborating, Mobilizing, Strengthening, Teaching,
Solving Problems.
Home health nursing competencies that radiate from the hub and contribute
to promotion of self-care and family care include collaborating with multiple
team members and mobilizing resources in the community that can sustain
the client after discharge. The home health care nurse usually is the

2527
coordinator of all other home health team members. Working with the social
worker, the nurse proposes needed connections with community services.
Likewise, strengthening involves development of self-management or family
caregiving ability. The home health nurse is constantly teaching clients
and/or family caregivers through concrete explanation, discussion, and
modeling behavior. Concerns and relevant feelings must be validated, and the
nurse leads the person to consider options for change. The solution develops
through a mutual, participatory process. Ultimately, people are responsible
for their own health decisions (see Chapter 11).
Finally, home health nursing competency requires flexibility and
creativity in solving health care problems and the challenges of everyday
living. All outcomes of care can be achieved only by adapting to the skills
and resources available in the home. Although people of all socioeconomic
backgrounds present with severe health problems requiring home health
nursing, many families live on the margins. The home health nurse must
often be creative in obtaining supplies and adjusting to conditions in the
home. For example, how do patients and families with no running water
wash their hands before providing care, such as dressing changes? This may
lead the home health nurse to contact social agencies in order to provide
services or teach the patient and family the use of alcohol-based gels to clean
their hands. The home health nurse must be nonjudgmental but work with the
patient and family to help them understand the need to keep areas clean.

Home Health Nursing Case Management

The home health nurse is the case manager for each client and responsible
for coordination of the other professionals and paraprofessionals involved in
the client's care.
The home care nurse is frequently the primary contact with the client's
physician, collaborating on the initial plan of care, reporting changes in the
client's condition, and securing changes in the plan of care. The nurse may
conduct case conferences among team members to share information, discuss
problems, and plan actions to affect the best possible outcomes for the client.
The nurse case manager also supervises the paraprofessionals, such as home
health aides, who also serve the homebound client.

Selected Nursing Challenges in the Home

Working in the home immerses the nurse in challenges unlike anything
encountered in controlled institutional environments. Some of these include
infection control, medication safety, fall risk, technology at home, and nurse
safety (see Chapter 22, Older Adults).

2528
Infection Control
Home health nurses frequently need to work with the family to prevent
infection in clients who are debilitated and may be immunocompromised; in
addition, many are now dwelling at home with invasive medical devices that
make them especially vulnerable to infection. Likewise, nurses are
challenged to consider how to protect the home health care team, family, and
community from a client with contagious disease. In such cases, all people
living in the home will need instruction. Some households have inadequate
facilities to control disease transmission. There may be no access to running
water, no heating unit to boil equipment, or inadequate facilities to dispose of
contaminated equipment. These conditions necessitate the development of
creative solutions to control infection.
To guide the nurse, home health agencies have adapted infection control
policies and procedures based on the Centers for Disease Control and
Prevention's (CDCs) Infection Control Precautions for health care settings
with each agency setting up their own specific policy and procedure based
upon the standard (CDC, 2018a).

Medication Safety
The home health client taking multiple medications is at particular risk of
multiple errors in self-administration, including incorrect medication, dose,
time, interval, or route. Often, doses are missed or doubled. Clients may
discontinue a drug or not complete the full course. Sometimes, the drug or
drugs ordered are inappropriate considering the patient's condition at home.
The home presents risk of medication errors that are different from those
found in hospital or nursing home. Every visiting nurse has stories of finding
drawers and cupboards filled with multiple prescriptions from various
physicians, some current and some outdated for many years. Polypharmacy
becomes obvious in the home setting. Clients often have received
prescriptions from multiple sources for similar drugs. Also, well-meaning
friends often share their prescriptions with the attitude that it “helped them.”
Even if the client is well organized and taking every drug prescribed, those
prescriptions may have originated from several providers over time and may
have contradictory side effects. Sometimes, medication errors at home
include failure to clearly reconcile hospital or nursing home orders with
home discharge orders. Although weekly medication organizers can helpfully
put medications in order, they can also confuse new or impaired users.
Distraction, visual impairment, forgetfulness, depression, and cognitive
impairment are common causes of unintentional medication noncompliance.
The home health nurse investigates how the medication is taken by
reviewing and reconciling the current list of medications and having the
patient explain and demonstrate the process he or she goes through.

2529
Intervention requires clear and repeated instruction, updating the medication
list, charting or diagramming the schedule for medication taking, and
assuring that the client or caregiver knows how to use the medication box.

Risk of Falling
Falls are a serious issue especially for the elderly. Estimates are that one in
four adults 65 years and older will fall each year, and falls are the number
one cause of injury and death from injuries in the United States (CDC,
2018b). Physiological risk factors include orthostatic hypotension and
cardiac dysrhythmias, dizziness, neurologic and musculoskeletal effects on
gait and balance, urinary urgency, impaired hearing or vision, alcohol or drug
abuse, and medication effects impairing alertness, balance, urinary
frequency, and blood pressure. Clients should be observed as they move
through their home and carry out activities of daily living (Fig. 30-4). It is
important to investigate factors that obstruct movement or threaten balance.
The nurse in the home should inspect sidewalks, stairs, and surfaces outside
the home; floor, rugs, electrical cords, stairs, lighting, and clutter inside the
home; kitchen safety; and bathroom features including grab bars and a raised
seat for the toilet and safety modifications for the bathtub. Common home
modifications, such as eliminating throw rugs and loose mats and the use of
nonslip bathmats, have a significant protective effect.

FIGURE 30-4 Fall risk patients need safe home environments.

Technology at Home
Advances in home health care technologies have the potential to improve
care that is provided in the home setting and support community-based
independence for the patient (National Institute of Aging [NIA], 2017).
Active (real-time vital signs and remote reporting) and passive (action

2530
through cameras and sensors) monitoring devices are now used to capture
information and to make determinations regarding safety and health.
Low-level technologies such as stove sensors or door alarms can assist in
keeping patients safe while also providing trended information for patterns
and behaviors. Technology in the home can range from using a telephone to
smart homes. Technology use has the potential to improve collaboration, care
coordination, and communication with providers (NIA, 2017). Data gathered
from technology devices can be compiled and used to evaluate patient
outcomes and processes for better home care (Box 30-5).

BOX 30-5 PERSPECTIVES

A Home Care Nurse's Viewpoint on Home Care

Technology During my early years in home care,
we carried pagers, which resulted in delayed
patient care coordination. Today, we have
improved patient care transitions and outcomes
with advances in home care technology.
I recently visited a 98-year-old man discharged from the hospital with
newly diagnosed heart failure. Prior to my visit, a home telehealth device
was installed in his home. It was programmed to provide heart failure
education daily for 1 year. The patient attaches a blood pressure cuff and O2
oximeter and steps on a scale, and the device automatically records his
blood pressure, pulse, O2 saturation, and weight. A remote telehealth RN
daily reviews his health data. Working from a standard order set, the RN
had increased the patient's diuretic dose.
During the visit, the patient provided me health data from his telehealth
log, and he had questions about his diuretic therapy. I accessed his clinic
and hospital records through my laptop computer using a protected hotspot
with my cell phone. I operated a mobile lab device to obtain laboratory
results. The patient received immediate information about his diuretic
regimen. Technology played an important role in preventing another
hospitalization for this high-risk patient.

2531
 Janelle Culjis, RN, PhD, ANP

In addition, real-time information is now used in home health to update

and change the plan of care. Nurses may use handheld devices to chart.
Medical records may be available instantly on the nurse's laptop or tablet,
and daily telemedicine monitoring of electrocardiogram, blood pressure,
oxygen saturation, and other vital measures can be transmitted electronically
to a home health agency or physician office. These assessments can be
monitored, and the patient plan of care may be altered based on the analysis.
See Chapter 10 for more on technology in the community.

Nurse Safety
Home health nurses face risks not only in driving to their client's homes but
also because of environmental hazards: the nurses must be constantly aware
of personal safety and surroundings. Client homes are uncontrolled
environments, and nurses may face instances of family violence and illegal
drug activity, or weapons may be present. The surrounding neighborhood
also may pose risks of violence, car theft, vandalism, and robbery. Many
home health organizations and their nurses work closely with local law
enforcement agencies to identify the wisest process for visiting dangerous
neighborhoods and isolated rural areas. Every home health care agency
should have a carefully developed program to assure the safety of personnel
traveling to homes and training on how to predict aggressive behaviors and
diffuse threatening circumstances, along with methods of self-protection if
threats escalate (see Chapter 15 for more information on home visits).

2532
The Future of Care in the Home
Home health care has high value as it is patient preferred and low cost and
has improved patient outcomes as compared to other postacute care settings
(IOM, 2015). However, the current framework of home health care was not
designed to support our aging demographic population.

Key challenges for home health care include fragmented care

coordination, delivery of optimal care with current Medicare
restrictions, value over volume, and an infrastructure to support aging in
the home (IOM, 2015).
Rising medical costs support home health care as it is a cost-effective
means of delivering care. System reforms that address value-based care,
quality of care, cost reduction, and coordination of care are needed.
Emerging models for payment and care delivery are starting to address
these issues and to realize the full potential of home health for
population care.

2533
HOSPICE CARE
Although science and technology have advanced in the world of health care,
death is ultimately inevitable for all of us. The contemporary circumstances
of death in America are often dehumanizing; most people die in hospitals and
long-term care institutions, surrounded by strangers. Uncertainty and denial
often prevail during the final stage of life because prognoses are uncertain,
and many serious illnesses are now treated aggressively until the last breath.
The battle against the “evil” of death seems to be the primary emphasis, with
patient, family, and professionals wanting to believe that it is possible to win
the final struggle. In the 21st century, fatal conditions have been turned into
expensive chronic illnesses. Too often, discomfort is not relieved, and
treatment causes further suffering. And as the period of disability extends
and the body deteriorates, social isolation develops. In dramatic contrast to
the dehumanization of death, the hospice movement has developed to
humanize the end-of-life experience and provide palliative care. Palliative
interventions relieve suffering without curing underlying disease. The
hospice movement has emphasized four major changes in end-of-life care:

Care should encompass body, mind, and spirit.

Death should be discussed and not considered off-limits.
Medical technology should be used only when absolutely necessary.
Clients should be actively involved in discussions about treatment
decisions.

Table 30-1 contrasts home health with hospice. This section explores the
evolution of hospice care in the United States, describes hospice agencies,
and examines Medicare criteria for hospice reimbursement. It concludes with
an exploration of the unique characteristics of hospice nursing practice.

2534
TABLE 30-1 Contrasts Between Home Health and Hospice

2535
Evolution of Hospice Care
In medieval Europe, hospices were refuges for the sick and dying. The
contemporary hospice movement originated in England, where a physician,
Dame Cicely Saunders, founded St. Christopher's Hospice in 1967. Dr.
Saunders was credentialed as a nurse, social worker, and physician, and she
developed a unique program based both on compassion and skillful relief of
physical discomfort through around-the-clock analgesics administered by
mouth. It had been previously assumed that only injections, administered
sparingly, could be used for terminal pain control. In 1974, the first hospice
in the United States was established in Branford, Connecticut. Florence
Wald, who was then Dean of the Yale School of Nursing, led this movement.
Because even in the 1970s, there was concern about saving money by
keeping less critical patients out of the hospital and shortening hospital stays,
and hospices in the United States came to focus on providing care in the
home. To that end, Congress established the permanent Medicare hospice
benefit in 1986, with the intention of keeping people at home, yet receiving
comprehensive services that are less expensive than hospitalization (National
Hospice and Palliative Care Organization, 2015).
Hospice characteristics have changed over time. Initially, nearly all
clients suffered from terminal cancer; presently, people with a variety of end-
stage diseases are served. The criteria for being accepted into hospice care
are that the patient has been diagnosed with a life-limiting disease and death
is likely within 6 months or less. Hospice care is designed not only for the
patient but also for support of family members. While cancer remains the top
disease qualifying a patient for hospice services, cardiac, circulatory, and
respiratory disorders and dementia are also predominant. Palliative care
provided in hospice services is designed to ease pain and suffering and
improve quality of life and can be offered in earlier stages of illness, along
with continuing medical treatments. With prognoses difficult to predict and
denial of death by the patient and family a continuing issue, some hospice
referrals are now made very late in the disease process. The National
Hospice and Palliative Care Organization (NHPCO) (2020) cites the fact that
in 2016, 48% of all Medicare decedents or 1.43 million Medicare
beneficiaries had received one or more days of hospice care (p. 3). The
NHPCO (2020) also cites the average length of hospice services as 71 days
with a median of 24 days of service (p. 4).

2536
Hospice Services and Reimbursement
As in home health care, Medicare has determined the way services are
provided. The Medicare hospice benefit requires that a client who has a
prognosis of 6 months or less must sign up for the comfort-focused hospice
benefit and waive regular Medicare health services, except for conditions
unrelated to their terminal illness. This mandates that the client
acknowledges a terminal prognosis and chooses comfort care instead of life-
extending care from a Medicare-approved hospice. When this choice is
made, the hospice coordinates care in all settings, functioning both as clinical
and financial case manager. The government pays a flat rate to the hospice
for each day the patient receives care. There are four payment levels:

Routine home care with intermittent visits

Continuous home care when the patient's condition is acute and death is
near
Inpatient hospital care for symptom relief
Respite care in a nursing home to relieve family members (CMS, 2015)

Hospices coordinate home care and direct inpatient care if needed. The
emphasis is on palliative care, with a focus on physical, psychosocial, and
spiritual comfort. Palliative care is caring for the patient holistically with an
emphasis on improving the quality of life through caring and decreasing the
severity of the symptoms of the illness. A strong emphasis is placed on
caring for the entire family.
The hospice team includes nurses, physicians, home health aides,
physical and occupational therapists, social workers, volunteers, palliative
medication and medical equipment specialists, and bereavement counselors.
Staff members meet regularly to explore together the challenges of assuring
comfort at the end of life. A nurse or physician is available on-call 24 hours a
day/7 days a week (CMS, 2015).
Trained volunteers fill an important need in hospice care. They act as
companions to the client when the family must be somewhere else or is away
for short respite. They run errands for family members, shop, organize hot
meals prepared by friends and neighbors, provide childcare, and perform
other services as needed.

2537
Hospice and Palliative Care Nursing Practice
The nurse's role is central in the hospice interdisciplinary team. The
hospice/palliative care nurse functions as case manager and visits the client
more frequently than other members of the team. Nurses work in close
collaboration with physicians in the development of a plan of care to assure
management of symptoms. This plan of care changes rapidly as the end of
life nears. In addition to home visits focusing on palliation and
interdisciplinary planning, hospice nurses rotate through 24-hour call 7 days
a week to assure continuous availability by telephone and visits for emergent
problems reported by the client or family. Hospice nursing competencies and
challenges are similar to those described for home health nurses, with the
added expertise needed to relieve physical and emotional suffering of
terminally ill clients and their families. Hospice and palliative care nurses
become expert clinicians in symptom management as they anticipate and
treat the physiological and psychological effects of the disease process on the
patient. The ANA and the Hospice and Palliative Nurses Association
(HPNA) (2014) have established standards of practice for hospice and
palliative nursing. Certification of hospice and palliative nursing is available.
An overview of palliative care nursing standards encompasses the same
general standards as home health nursing standards, with specific
competencies delineated (e.g., comfort care, suffering and symptom
palliation, support of patient/family throughout illness course, reaffirmation
of goals with families during regularly scheduled family meetings, care
coordination with interdisciplinary team members).
Nursing practice in hospice settings is a continuation of acute care
nursing. The emphasis is on holistic care not curative care. While the nurse
has an expert role in pain management, he or she also plans a managerial role
in controlling symptoms and adverse effects on the body from the disease
process. The ultimate objective is to support the patient while on the journey
to a peaceful dignified death (Fig. 30-5). Care is centered on patients and
families, generally begins with life-threatening illness, and ends with family
bereavement care.

2538
 FIGURE 30-5 Providing comfort and emotional support to
patients and their families is an essential role of hospice care.

Hospice caregiving can be illustrated as a tree, strongly rooted in the

process of nurses deliberately practicing self-care for themselves (Fig. 30-6).
This tree has been drawn to explain the expert competencies of hospice
nurses who were interviewed to capture the essence of their practice, as
described by Zerwekh (1995, 2006). Each of the hospice nursing practices
visualized by the tree diagram is briefly summarized below.

FIGURE 30-6 The hospice caregiving tree.

2539
Roots of Hospice Nursing: Sustaining Oneself
Effective hospice nurses understand that to care for others, they must care for
themselves. Caring for clients at the end of life can be physically and
emotionally draining. The hospice nurse works with clients and families to
psychologically prepare for death of a loved one. The nurse often becomes
emotionally attached to the dying client and needs to sustain their own
emotional well-being to be an effective advocate for the client and family.
Sustaining oneself requires deliberate effort to maintain one's own physical,
emotional, and spiritual well-being. Knowing oneself, identifying sources of
stress, and learning how to care for self are important and provide the roots
for hospice caring. Expert hospice nurses keep themselves healthy by
maintaining a balance between giving and receiving, letting go of
predetermined agendas and idealistic hopes to achieve more than is humanly
possible, being emotionally open and clear, and deliberately replenishing
themselves to restore their energy. Hospice nurses described their emotional
challenges as being simultaneously draining and enriching experiences
leading to personal and professional growth and development (Ingebretsen &
Saghakken, 2016, p. 1).

The Trunk Reaching Upward: Connecting, Speaking

Truth, and Encouraging Choice
Rooted in self-care, hospice nurses practice connecting, which refers to the
centrality of relationships in providing hospice care. The hospice nurse seeks
to understand the emotional and spiritual distress common to the end of life,
particularly the progressive experience of loss after loss. Guided by that
understanding, hospice nurses emphasize attentive listening to understand
each individual's unique story. This requires quieting your own thoughts to
truly hear what is being expressed. Sometimes, listening involves simply
being present in the moment, paying attention. Having heard the client's
story, it is important for hospice nurses to speak honestly when other
professionals and family feel obliged to keep being cheerful and positive.
Hospice nurses openly seek to speak truthfully about many issues that can be
painful to discuss. Speaking truth is visualized as encircling the entire top of
the caregiving tree. Hospice nurses bring up difficult subjects, so that the
client is freed to speak about his greatest fears and concerns. After truth has
been discussed and the client has made a decision, the hospice nurse often
advocates for client wishes against the resistance of various authorities.
Remember that these are the final decisions in a dying person's life.

Collaborating

2540
Interdisciplinary teamwork is an essential branch on the tree. The hospice
interdisciplinary team members share information and work
interdependently. The hospice nurse coordinates the plan of care and day-to-
day efforts to provide physical and psychosocial comfort. The hospice nurse
supervises licensed and unlicensed personnel in carrying out comfort
interventions. The physician is responsible for medical care and serves as
liaison with the client's primary care physicians. Social workers, spiritual
counselors, physical therapists, pharmacists, and volunteers are integral
members of the hospice team as they provide environmental, developmental,
and spiritual interventions to aid the patient with psychological peace. The
hospice interdisciplinary team is constantly challenged to work creatively
together to find solutions for complex end-of-life suffering with emotional,
spiritual, and physical components.

Strengthening the Family

The death of a family member causes great disruption for all involved. When
family members are in a caregiving role in the home, they experience
significant personal suffering. Caregivers are vulnerable to physical and
emotional illness themselves. The process of taking care involves managing
the illness as well as all practical assistance, seeking information and
resources, and preparing for death itself. Family members often are caught
up with family issues and struggles with the health care system. An
extremely important role in hospice nursing involves supporting family
members' abilities as caregivers. Teaching caregiving requires creative
teaching methods and flexibility. The hospice nurse often acts as a liaison
between the patient and family as well as among family members.

Comforting
Hospice nurses develop extensive expertise in pain and symptom
management. The fear of many hospice clients and families is that pain will
not be controlled. Most pain can be controlled through careful monitoring
and intervention. Box 30-6 lists fundamental palliative principles, and Box
30-7 identifies four important components of pain relief.

BOX 30-6 Fundamentals of Palliative

Care
Make no assumptions about what is wrong.
Believe the patient's report of symptoms.
Relieve discomfort to the extent that the patient chooses and finds
acceptable.

2541
 Investigate the biologic, psychosocial, and spiritual dimensions of
discomfort.
Anticipate symptoms and relieve them before they occur again.
Use nursing and complementary (integrative) interventions.
Become an expert in the use of palliative medication.
Continually evaluate the effectiveness of interventions.
Choose the least complex and most manageable interventions that
patients and families can manage themselves at home.
Never give up. Persist in trying different palliative strategies.
Remember the patient and caregiver are both involved in treatment.

BOX 30-7 Essential Components of Pain

Relief
1. Continually assess the extent of pain and the relief afforded by
interventions.
2. Schedule analgesics around the clock to maintain continuous blood
levels, and prevent the return of pain.
3. Use the least invasive route for analgesic administration, with oral
as first choice.
4. Follow the World Health Organization (2016) three-step ladder:
Step 1 for mild pain: Nonopioid (acetaminophen or NSAID) plus
adjuvant such as corticosteroid, antidepressant, anxiolytic, or
anticonvulsant Step 2 for persisting pain: Opioid and nonopioid and/or
adjuvant Step 3 for moderate to severe pain: Strong opioid and
nonopioid and/or adjuvant

Note: The WHO also offers guidelines for persisting pain in children:
www.who.int/medicines/areas.quality_safety.guide_perspainchild/en/
Source: World Health Organization (2016).

Spiritual Practice and Letting Go

As death draws near, spiritual needs often intensify as the client searches for
meaning and hope. Death is a developmental milestone as well as a spiritual
and physical journey. The effect of the journey on the client is impacted by
the environmental and cultural habits and customs the client has experienced
through the lifetime. Spirituality is a broad concept that the individual client
defines as to what has given his or her life meaning and purpose. Religion
and spirituality are related in that religion is a system of beliefs and doctrines
that aid the client in expressing what gives the client meaning and hope. In a
multisite study of quality of life for advanced cancer patients being treated
with palliative radiation, researchers found that those who used religious and
spiritual coping reported improved quality of life on all outcome measures.

2542
Spiritual distress has been long recognized by nurses as a factor that can rob
the client of peace. Spiritual peace comes when the client realizes his or her
life had meaning, purpose, and hope. Attainment of the spiritual peace calms
the patient. Nurses may be called upon to intervene with their patient through
prayer and active listening as they help the client to reframe life events and
accept love and support from others. Guiding letting go is a truly unique
nursing practice that involves helping the client to let go of former activities
and hopes, including life itself. This involves listening to intense emotions
and helping the person and family find resolution (Raingruber & Wolf,
2015). Sometimes, it involves participating in a vigil at the bedside of the
dying person and encouraging loved ones to say their final words of farewell.
It is this action that often is that one thing that gives the client peace (Box 30-
8).

BOX 30-8 PERSPECTIVES

A Hospice Nurse's Viewpoint on

Hospice/Palliative Care Nursing When I
graduated from nursing school, I went directly
into the intensive care unit. I loved it! I enjoyed
the challenge of working intensely with one or two
patients, as well as the supportive work
environment with my close-knit group of
colleagues.
With marriage and children (my first pregnancy resulted in twins), the 12-
hour shifts and full-time schedules were more difficult to balance with
family life. At first, I dropped down to working one weekend a month. But,
with our growing family, it seemed that I would not be able to remain in the
ICU.
I talked to a friend and learned about our hospital's hospice agency; she
enjoyed working there, and I thought I would give it a try. It was a perfect
fit for me and for our four boys. People always think of hospice/palliative
care as depressing, but I find it to be very fulfilling. I think about it as
“joining with a family” at their most vulnerable time. The patients let you

2543
in, sharing very personal things about their life with you, and they are
grateful for your assistance at this time of transition. It can be a very
spiritual experience, and I consider it a privilege to be able to share this
time with my patients and their families.
The only difficult cases for me are the children; our agency doesn't have
a large pediatric hospice, but it is beginning to expand. It is difficult for
parents to lose a child, as one would expect. I remember coming home after
a long night with a family whose young child lost his long battle with
cancer and hosting my 2-year-old's birthday party with family and friends. I
couldn't help but think about the contrast—my happy, healthy toddler and
the loss of a young boy to cancer. But, I know that I made a difference for
that family and child; I am honored to be a hospice/palliative care nurse.

Jessica, hospice RN

2544
Ethical Challenges in Hospice Nursing
The hospice nurse confronts striking ethical challenges at the end of life. As
an advocate for the client, the hospice nurse must integrate his or her own
knowledge of the pathophysiology of the disease process with the
physiological needs of the dying client while accounting for the
psychological and cultural needs of the client and family (Storch, 2015). As
client advocates, we, as nurses, must be aware of the ethical challenges
surrounding the dying experience. Wide-ranging issues include respect or
disregard for client autonomy, relief or disregard for client suffering, and
avoidance of killing at the very end of life (Fernandes, 2015). The hospice
nurse needs to develop their own knowledge of nursing and medical ethics in
order to question the ethical implications of interventions and to advocate for
the client and family. An example is patient families will often insist that the
patient be fed and given fluids. This may come from the aspect that in our
culture food is thought to be comforting. Commonly, a patient close to death
will not want to eat or drink; the body no longer needs those nutrients to
sustain itself. This refusal on the part of the dying patient stresses the
caregivers and the nurse may need to intervene to advocate for the patient's
wishes. Ethical unrest in the client, family, as well as the nurse is best
addressed through the institutional ethics board. This board consists of
various disciplines specializing in health care, ethics, legal, and spiritual care.
When the nurse is unsure of the ethical ramifications of decisions by the
client or family, it is the nurse's obligation to bring the case before the board
following the procedures of the institution. See Chapter 4 for more on ethics.
See Box 30-9 for information on how nurses can recognize and manage
compassion fatigue.

BOX 30-9 Evidence-Based Practice

Nurses and Compassion Fatigue Do you wonder
how hospice nurses sustain compassionate
practice as they work every day with suffering
patients who always die? Expert hospice nurses
embrace the suffering of the client and family
and become susceptible to compassion fatigue.
Compassion fatigue is often viewed as
secondary stress. It is the stress felt by the
caregiver from exposure to a traumatization.

2545
Nurses often describe this as overload.
Although signs of compassion fatigue are
individualized, they often include exhaustion
and a reduced ability to express empathy for
the client. This may result in withdrawal by the
nurse emotionally from the client and family, as
well as the role of nurse.
Staying psychologically as well as physically healthy as a hospice
nurse requires a high level of self-awareness. Nurses must be aware of
the signs and symptoms that they may have a tendency to exhibit.
Symptoms are individualized based on how a particular nurse adapted to
stress in the past and are often subject to developmental, spiritual,
cultural, and environmental influences. Recognition of the symptoms
allows the hospice nurse to institute stress-relieving activities early in
the process. According to the Compassion Fatigue Awareness Project
(2017), some symptoms that a nurse may experience include the
following:

Isolating oneself; poor self-care (appearance, hygiene)

Repressed emotions; apathy; mentally/physically exhausted
Always finding blame with others; many complaints about
job/administration
Substance abuse; compulsive behaviors (e.g., eating, spending,
gambling)
In debt; legal problems; recurrent flashbacks/nightmares; chronic
health problems
Problems concentrating; feeling preoccupied; denies problems

Compassion fatigue can affect an agency, if enough nurses suffer

from the problem and nothing is done to assist them. It can cause
problems between nurses and administrators, lead to high turnover and
absenteeism, and lead to self-perpetuation. Organizations may exhibit
these symptoms:

Poor teamwork; high absentee rates; continually changing

coworker relationships
Challenging/breaking agency rules; aggression among staff
members
Poor task/assignment completion; unable to meet deadlines; lack of
flexibility
Negative feelings toward management; reluctance toward change

2546
 Poor vision of future; not able to believe that improvements can be
made

(Compassion Fatigue Awareness Project, 2017) Compassion fatigue

is not isolated to hospice nurses. All nurses are susceptible to the
effects. This may lead to higher rates of turnover and an increase in the
nursing shortage as nurses leave the profession.
Often, caregivers experiencing compassion fatigue are unable to
identify it in themselves.

1. What ways can you identify compassion fatigue in others?

2. What recommendations can you make to reduce compassion
fatigue for yourself?
3. How can you transform the organization to reduce compassion
fatigue?
Source: Compassion Fatigue Awareness Project (2017); Upton (2018).

2547
The Future of Hospice Care
Given a rapidly expanding population of elders living longer with
challenging chronic illnesses, home health and hospice care in the home will
soon need to transform into a community-based long-term care system that
doesn't discharge after an acute episode or admit only at the very end of life.
In response to out-of-control medical inflation, federal and state governments
have sought to hold down expenses in all areas, including restrictions on
home health and hospice care. However, costs keep rising in step with
technologic and pharmacologic innovation and marketing. Containing costs
will eventually force a shift in services from expensive institutional and high-
technology interventions to community-based home services.
The entire model for service provision in the home must change to a
health care delivery system that continuously serves those living with
disabling and terminal illness to maximize well-being at home, anticipate and
prevent crises, and minimize emergent and inpatient interventions. Hospice
care is focused on symptom management, not curative interventions. Care
revolves around maintenance of quality of life, not necessarily quantity.
Clients in hospice care, under Medicare regulations, receive care for
symptom management. If care is needed for other health conditions not
related to the terminal diagnosis, care is received under their original
Medicare benefit. Hospice services should be based on client choice and the
reality of a terminal diagnosis. The physician must sign a declaration stating
that the terminal diagnosis, if it follows the normal course of the disease
process, will cause death in a finite period of time (6 months or less). A
sustainable, affordable approach to care in the home requires ongoing case
management to coordinate and manage resources with incentives that control
cost while assuring quality of life and comfort. The hospice nurse becomes a
coordinator of an interprofessional team of health care, spiritual, and
community resources. Team members often include volunteers, who, after
training, become involved with respite care for the family. Determination of
the team members is defined in collaboration with the client and family to
allow them independence and minimize the disruption to their individual
lifestyle. Although inpatient hospices do exist, the goal of the hospice nurse
is to keep the client in their home environment for as long as possible. The
purpose of palliative care is symptom control, thereby decreasing stress for
the dying client.
Nurses, nurse practitioners, and home visiting physicians will need to
have the diagnostic and therapeutic resources to monitor physiologic status
and intervene in the home. Telehealth and home monitoring will be essential.
The focus must change from doing everything possible to prolong

2548
physiologic survival to promoting meaningful and comfortable lives. Nurses
will have an active role in this process.
The IOM (2015) report Dying in America: Improving Quality and
Honoring Individual Preferences Near the End of Life gives direction for
needed changes that put the requirements of patients and families first. The
report encourages policy changes and serves as a charge for all of us to
advocate for improved social, spiritual, and psychological support and care
for those of us nearing the end of our lives. As health care providers, we need
to strive to provide compassionate, quality-centered, evidence-based care that
is consistent with the wishes of our patients and their families (Box 30-10).

BOX 30-10 Population Focus

Hospice Care for Children Although it may be
difficult for a family to accept hospice care for
their terminally ill child, there is increasing
evidence showing that a pediatric palliative care
program reduces stress and worry for
caregivers. Also, because medical care is
received in a stress-free setting, the quality of
life as well as length of life may be increased
(Gans et al., 2015). Hospice plays an important
role in supporting the child and family in the
areas of medical, social, spiritual, and
psychological support. The value of this service
and underutilization justify research in this
area. The National Hospice and Palliative Care
Organization is committed to care of the child
and family who can benefit from hospice care.
They provide professional resources and
education, as well as patient education
information.
Children with life-threatening illnesses are hospitalized more often
and spend more days in the hospital than those whose diseases are not
life threatening. This causes additional stress on the child as well as the

2549
caregivers. Also, the child may be exposed to other diseases, which may
affect the quality of their lives. There are many reasons hospice services
are underutilized for children. Lack of education on the part of the
health care team is a primary cause. Often the health care team is
hesitant to recommend hospice until death is imminent on the hope that
a curative treatment may be found. Families are often hesitant to
commit to hospice as they remain in the denial phase of grieving.
Hospice enables care for dying children by a multidisciplinary team
supporting the child.
Most important to nursing practice is the limited access to ongoing
education and the lack of consistent professional experiences with these
children and their families. The National Hospice and Palliative Care
Organization (NHPCO) offers palliative care resources for families and
professionals at their website. Educating the health care team and family
members regarding resources available through hospices services can
increase the use, decrease acute care hospitalizations, and increase
family satisfaction and coping.

1. Do you think most nurses working in hospitals are aware of

hospice and palliative care services for children?
2. What could you do to help communicate the availability and
effectiveness of hospice services for children with life-
threatening illnesses?
Source: Gans et al. (2015).

2550
SUMMARY
Nurses have an important role in working with clients who receive
home care or hospice services. As the population continues to age, the
need for nurses to work with older adults where they live, as they are
discharged from acute care settings earlier and earlier, and, if they are
terminally ill, during their final months and days, will only increase.
Services are also needed for clients across the lifespan.
Many types of home care agencies exist: voluntary, proprietary, hospital
based, official, homemaker, and hospice. Both formal and informal
caregivers provide service. Professional staff members, such as nurses,
social workers, therapists, and certified nursing assistants, work in
collaboration with family members and, in some situations, with friends
and neighbors.
Medicare covers hospice care without the restrictions experienced by
skilled home care clients. Hospice and palliative care programs provide
holistic care to clients during the last months of life. Many programs are
home based, and they may be offered by a home health agency. In
addition to in-home hospices, inpatient hospices exist; these can be
located in a freestanding building, in an area of a SNF, or in a section of
an acute care facility. The focus of hospice care is not historically aimed
at cure, and it employs holistic caregiving practices that involve family
members, professionals, and volunteers.
The nurse provides direct physical nursing care both in home health
care and with hospice clients. In addition, the nurse teaches clients,
family members, and volunteers; supervises; collaborates with team
members; and case manages. Nurse assessment of clients assists in
determining plan of care and working toward client management of
disease processes in a value-based health model.

2551
ACTIVE LEARNING EXERCISES
1. Search the Internet for home health and hospice agencies in your city
or town. Select two agencies and compare services provided and the
employment opportunities of each (one nonprofit and one for-profit).
How do these job descriptions and the published pay ranges compare
to hospitals in your area? What are the benefits of working in home
health and hospice? Will the agency hire new graduates, or do they
require prior acute care experience? What care is provided by these
agencies? Where do you see gaps in services? What type of
interventions does the agency utilize to prevent compassion fatigue
among its staff?
2. Using “Communicate Effectively to Inform and Educate” (1 of the 10
essential public health services; see Box 2-2 ), how would you assist
the following client? Mr. H is a 72-year-old male who has just been
sent home from the hospital following his second stroke and has
right-sided weakness. He has a G-tube in place and requires a walker
for ambulation. He lives alone but has family in the area. What are
your priorities? Using the nursing process, determine a plan of action.
3. Review your personal health insurance policy or that of a family
member. What coverage, if any, is provided for home health or
hospice care? What restrictions are stated in the coverage—total
reimbursement, source of care, or length of service? Do you think this
will be adequate to meet your or your family member's needs when
these services may be needed? What other options might be available
to help defray the cost of this type of care?
4. Interview a home health, hospice, or palliative care nurse to find out
the most rewarding part of their job. What things are problematic?
Ask about a typical case and home visit. How does this compare to
your experiences in your community health nursing clinical course?
Do you feel that home health, hospice, or palliative nursing might be
something you will consider in the future? What are some safety
considerations taken by the home health nurse?
5. Informal caregivers assume additional duties and burdens when caring
for a loved one. Find a systematic review or research study on
caregiver burden and compare your findings with another classmate's
findings. What are the most common issues, and how can the C/PHN
address them?

2552
 thePoint: Everything You Need to Make the
Grade!
Visit http://thePoint.lww.com/Rector10e for NCLEX-style
review questions, journal articles, supplemental materials, study aids for
all learning styles, and more!

2553
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2558
 APPENDIX Quad Council Tier 1
Community/Public Health
Nursing Competencies

Domain 1: Assessment and Analytic Skills

Assessment/Analytic Skills focus on identifying and
understanding data, turning data info information for action,
assessing needs and assets to address community health needs,
developing community health assessments, and using evidence
for decision making.
1A1. Assess the health status and health literacy of
individuals and families, including determinants of
health, using multiple sources of data.
1A2a. Use an ecological perspective and epidemiological data
to identify health risks for a population.
1A2b. Identify individual and family assets, needs, values,
beliefs, resources, and relevant environmental factors.
1A3. Select variables that measure health and public health
conditions.
1A4. Use a data collection plan that incorporates valid and
reliable methods and instruments for collection of
qualitative and quantitative data to inform the service
for individuals, families, and a community.
1A5. Interpret valid and reliable data that impacts the health
of individuals, families, and communities to make
comparisons that are understandable to all who were
involved in the assessment process.
1A6. Compare appropriate data sources in a community.
1A7. Contribute to comprehensive community health
assessments through the application of quantitative and
qualitative public health nursing data.

2559
1A8. Apply ethical, legal, and policy guidelines and
principles in the collection, maintenance, use, and
dissemination of data and information.
1A9. Use varied approaches in the identification of
community needs (i.e., focus groups, multi-sector
collaboration, SWOT analysis).
1A10. Use information technology effectively to collect,
analyze, store, and retrieve data related to public health
nursing services for individuals, families, and groups.
1A11. Use evidence-based strategies or promising practices
from across disciplines to promote health in
communities and populations.
1A12. Use available data and resources related to the
determinants of health when planning services for
individuals, families, and groups.

2560
DOMAIN 2: POLICY
DEVELOPMENT/PROGRAM
PLANNING SKILLS
Policy Development/Program Planning Skills focus on
determining needed policies and programs, advocating for
policies and programs; planning, implementing, and evaluating
policies and programs, developing and implementing strategies
for continuous quality improvement; and developing and
implementing community health improvement plans and strategic
plans.
2A1. Identify local, state, national, and international policy
issues relevant to the health of individuals, families, and
groups.
2A2. Describe the implications and potential impacts of
public health programs and policies on individuals,
families, and groups within a population.
2A3. Identify outcomes of health policy relevant to public
health nursing practice for individuals, families, and
groups.
2A4a. Provide information that will inform policy decisions.
2A4b. Implement programs and services based on policy
decisions.
2A5. Use organizations’ strategic plans and decision-making
methods in the development of program goals and
objectives for individuals, families, and groups.
2A6a. Demonstrate knowledge of laws and regulation relevant
to public health nursing services.
2A6b. Plan public health nursing services consistent with laws
and regulations.
2A7. Function as a team member in developing
organizational plans while assuring compliance with
established policies and program implementation
guidelines.
2A8. Comply with organizational procedures and policies.

2561
 Use program planning skills and CBPR (i.e.,
2A9. collaboration, reflection, capacity building) to
implement strategies to engage
marginalized/disadvantaged population groups in
making decisions that affect their health and well-being.
2A10. Apply methods and practices to access public health
information for individuals, families, and groups.
2A11. Participate in quality improvement teams by using
quality indicators and core measures to identify and
address opportunities for improvement in services for
individuals, families, and groups.

2562
DOMAIN 3: COMMUNICATION
SKILLS
Communication Skills focus on assessing and addressing
population literacy; soliciting and using community input,
communicating data and information; facilitating
communications; and communicating the roles of government,
health care, and others.
3A1. Determine the health, literacy, and the health literacy of
the population served to guide health promotion and
disease prevention activities.
3A2. Apply critical thinking and cultural awareness to all
communication modes (i.e., verbal, nonverbal, written,
and electronic) with individuals, the community, and
stakeholders.
3A3. Use input from individuals, families, and groups when
planning and delivering health care programs and
services.
3A4. Use a variety of methods to disseminate public health
information to individuals, families, and groups within
a population.
3A5a. Create a presentation of targeted health information.
3A5b. Communicate information to multiple audiences
including groups, peer professionals, and agency peers.
3A6. Use communication models to communicate with
individuals, families, and groups effectively and as a
member of the interprofessional team(s) or
interdisciplinary partnerships.
3A7. Describe the role of public health nursing to internal
and external audiences.
3A8. Apply communication techniques and models when
interacting with peers and other health care team
members including conflict management.

2563
DOMAIN 4: CULTURAL
COMPETENCY SKILLS
Cultural Competency Skills focus on understanding and
responding to diverse needs, assessing organizational cultural
diversity and competence, assessing effects of policies and
programs on different populations, and taking actions to support a
diverse public health workforce.
4A1. Use determinants of health effectively when working
with diverse individuals, families, and groups.
4A2. Use data, evidence, and information technology to
understand the impact of determinants of health on
individuals, families, and groups.
4A3. Deliver culturally responsive public health nursing
services for individuals, families, and groups.
4A4. Explain the benefits of a diverse public health
workforce that supports a just and civil culture.
4A5. Demonstrate the use of evidence-based cultural models
in a work environment when providing services to
individuals, families, and groups.

2564
DOMAIN 5: COMMUNITY
DIMENSIONS OF PRACTICE
SKILLS
Community Dimensions of Practice Skills focus on evaluating
and developing linkages and relationships within the community,
maintaining and advancing partnerships and community
involvement, negotiating for the use of community assets,
defending public health policies and programs, and evaluating
and improving the effectiveness of community engagement.
5A1a. Use assessments, develops plans, implements, and
evaluates interventions for public health services for
individuals, families and groups.
5A1b. Assist individuals, families, and groups to identify and
access necessary community resources or services
through the referral and follow-up process.
5A2. Use formal and informal relational networks among
community organizations and systems conducive to
improving the health of individuals, families, and
groups within communities.
5A3a. Select stakeholders needed to address public health
issues impacting the health of individuals, families, and
groups within the community.
5A3b. Function effectively with key stakeholders in activities
that facilitate community involvement and delivery of
services to individuals, families, and groups.
5A4. Build stakeholder capacity to advocate for the health
issues of individuals, families, and groups.
5A5. Use community assets and resources, including the
government, private, and nonprofit sectors, to promote
health and to deliver services to individuals, families,
and groups.
5A6. Use input from varied sources to structure public health
programs and services for individuals, families, and
groups.

2565
 Interview individuals, families, and groups to identify
5A7a. community resource preferences.
5A7b. Build preferences into public health services.
5A7c. Identify opportunities for individuals, families, and
groups to link with advocacy organizations.
5A8. Identify evidence of the effectiveness of community
engagement strategies on individuals, families, and
groups.

2566
DOMAIN 6: PUBLIC HEALTH
SCIENCES SKILLS
Public Health Sciences Skills focus on understanding the
foundation and prominent events of public health, applying public
sciences to practice, critiquing and developing research, using
evidence when developing policies and programs, and
establishing academic partnerships.
6A1. Use the determinants of health and evidence-based
practices from public health and nursing science, when
planning health promotion and disease prevention
interventions for individuals, families, and groups.
6A2a. Determine the relationship between access to clean,
sustainable water, sanitation, food, air, and energy
quality on individual, family, and population health.
6A2b. Assess hazards and threats to individuals, families, and
populations and reduce their risk of exposure and injury
in natural and built environments (i.e., chemicals and
products).
6A3. Use evidence-based practice in population-level
programs to contribute to meeting core public health
functions and the 10 essential public health services.
6A4. Participate in research activities impacting the health of
populations.
6A5. Use a wide variety of sources and methods to access
public health information (i.e., GIS mapping,
Community Health Assessment, local/state/and national
sources).
Use research to inform the practice of public health
6A6a.
nursing.
6A6b. Identify gaps in research evidence that impact public
health nursing practice.
6A7. Demonstrate compliance with the requirements of
patient confidentiality and human subject protection.
6A8. Model public health science skills when working with
individuals, families, and groups.

2567
DOMAIN 7: FINANCIAL
PLANNING, EVALUATION, AND
MANAGEMENT SKILLS
Financial Planning and Management Skills focus on engaging
other government agencies that can address community health
needs, leveraging pubic health and health care funding
mechanisms, developing and defending budgets, motivating
personnel, evaluating and improvement program and organization
performance, and establishing and using performance
management systems to improve organization performance.
7A1. Explain the interrelationships among local, state, tribal,
and federal public health and health care systems.
7A2. Explain the public health nurse’s role in emergency
preparedness and disaster response during public health
events (i.e., infectious disease outbreak, natural or
manmade disasters).
7A3. Implement operational procedures for public health
programs and services.
7A4a. Demonstrate knowledge of funding streams to support
programs.
7A4b. Select the data for inclusion in a programmatic budget.
7A5. Interpret the impact of budget constraints on the
delivery of public health nursing services to individuals,
families, and groups.
7A6. Explain implications of organizational budget priorities
on individual, groups, and communities.
7A7. Explain public health nursing services and
programmatic needs to inform budget priorities.
7A8a. Identify data to evaluate services for individuals,
families, and groups.
7A8b. Contribute to the evaluation plan for public health
nursing services targeting individuals, families, and
groups.

2568
7A9. Deliver public health nursing services to individuals,
families, and groups based on reported evaluation
results.
7A10. Provide input into the fiscal and narrative components
of proposals.
7A11. Use public health informatics skills pertaining to public
health nursing services of individuals, families, and
groups.
7A12. Provide input for contracts and other agreements for the
provision of public health services.
7A13. Organize public health nursing services and programs
for individuals, families, and groups within budgetary
guidelines.
7A14a. Participate in the implementation of the organization’s
performance management system.
7A14b. Use self-reflection to identify one’s performance in the
organization’s performance management system.
7A14c. List contributions to the organization’s performance
management system.

2569
DOMAIN 8: LEADERSHIP AND
SYSTEMS THINKING SKILLS
Leadership and Systems Thinking Skills focus on incorporating
ethical standards into the organization, creating opportunities for
collaboration among public health, healthcare, and other
organizations; mentoring personnel; adjusting practice to address
changing needs and environment; ensuring continuous quality
improvement; managing organizational change; and advocating
for the role of governmental public health.
8A1. Demonstrate ethical standards of practice in all aspects
of public health and public health nursing as the basis of
all interactions with individuals, communities, and
organizations.
8A2. Apply systems thinking to public health nursing
practice with individuals, families, and groups.
8A3. Participate in stakeholder meetings to identify a shared
vision, values, and principles for community action.
8A4a. Identify internal and external factors affecting public
health nursing practice and opportunities for
interprofessional collaboration.
8A4b. Explain environmental hazards and emergency
preparedness to protect individuals, families, and
groups.
8A4c. Respond to environmental hazards to protect
individuals, families, and groups.
8A5. Use individual, team, and organizational learning
opportunities for personal and professional
development as a public health nurse.
8A6. Model personal commitment to lifelong learning,
professional development, and advocacy.
8A7. Identify organizational quality improvement initiatives
that provide opportunities for improvement in public
health nursing practice.
8A8. Facilitate the development of interprofessional teams
and workgroups.

2570
 Interpret organization dynamics of collaborating
8A9.
agencies.
8A10a. Provide feedback on the organization’s mission and
vision and the impact on individuals, families, and
groups.
8A10b. Influence others to provide feedback on the
organization’s mission and vision and the impact on
individuals, families, and groups.
8A11. Select advocacy strategies to address the needs of
diverse and underserved population.
8A12. Identify organizational policies and procedures that
meet practice and public health accreditation
requirements.
8A13. Influence health as a shared value through community
engagement and inclusion of individuals, families, and
groups.

Reprinted with permission from Quad Council Coalition

Competency Review Task Force. (2018). Community/Public Health
Nursing Competencies. Retrieved from
http://www.quadcouncilphn.org/wp-content/uploads/2018/05/QCC-
C-PHN-COMPETENCIES-Approved_2018.05.04_Final-002.pdf

2571
2572
INDEX

A
Abuse
babysitters
child See also (Child abuse) elder
emotional
partner (intimate partner)
physical
reporting
sexual
tools
Abusive head trauma (AHT)
Acanthosis nigricans
Access to care
rural
in vulnerable populations
Accidents
in adolescents
in adults
farming
in infants, toddlers, and preschoolers in school-age children
Accountable Care Organizations (ACOs) Accreditation
Acne
Acquired immunodeficiency syndrome (AIDS) in adolescents
education on
in migrant workers
in pregnancy
in rural populations
with tuberculosis
Action, in stages of change model Active immunity
Active listening
Activist
Activity
limitations

2573
Acute observational skills
Acute respiratory illnesses
Acute respiratory tract infection (ARI) Adaptable, nursing process
Addiction. See also specific addictions Adjourning stage of group
development Adolescent(s)
health of
acne in
eating disorders in
emotional and psychiatric problems in health objectives for
immunization in
injury deaths in
nutrition in, poor
sexually transmitted diseases in smoking and tobacco use in
substance abuse in
teen sexuality and pregnancy in
violence in
health services for
health promotion programs
health protection programs
preventive health programs
high-risk behaviors in
immunization in
poverty
Adolescent mothers
Adolescent pregnancy
Adolescent unmarried parents. See also Teenage pregnancy Adult(s)
causes of death
community health nurse role for
definition of
demographics of
health disparities among See also (Health disparities) health
literacy of
life expectancy of
major health problems of
arthritis
cancer

2574
 chronic lower respiratory diseases coronary heart disease
and stroke diabetes mellitus
obesity
osteoporosis
substance use
unintentional injuries
men’s health in See also (Men’s health) physical profile of
screenings and check-up schedule for women’s health in See
also (Women’s health) Adult immunization
Advance health care directives (advance directives) Advanced
disease stage
Adverse childhood experiences (ACE) Adverse selection
Advisory groups
Advocacy
for homeless
professional
Advocate role
community and public health nurses actions
goals
rural community health nurse role in Affective domains
Affordable Care Act (ACA)
Age dependency ratio
Ageism. See also Older adults definition of
misconceptions about
misconceptions in
Agency for Healthcare Research and Quality (AHRQ). See also
Evidence-based practice (EBP) Agency for Toxic Substances
and Disease Registry (ASTDR) Agent
in epidemiology
toxic
Agent factors
Aging in place
Aggregates
Agricultural accidents
Agriculture, health and
Air pollution
Air Quality Index

2575
 EPA guidelines on
indoor
outdoor
Air Quality Index
Airborne transmission
Alcohol
and health
Alcohol related birth defects
Alcohol use and abuse. See also Substance use and abuse in
adolescents
grounded
homelessness and
in pregnancy
standard drink
Alcohol Use Disorders Identification Test (AUDIT) Alcohol-related
Healthy People goal of reducing alcohol use Alcohol-related
neurodevelopmental disorder Allergies, food
Alliance of Nurses for Healthy Environments (ANHE) Alzheimer
disease (AD)
Ambulatory service settings, settings for community and public
health nursing practice America, opioids in
American Association of Colleges of Nursing (AACN) American
Council of the Blind (ACB) American Nurses Association
(ANA) nursing, scope and standards of practice American
Public Health Association (APHA) American Red Cross
American Sign Language (ASL)
Americans with Disabilities Act (ADA) Anabolic steroid use
Analogy
Analysis, in epidemiological research Analytic epidemiology
Anorexia nervosa
in adolescents and young adults
school nursing for
Anthrax
Antibody
Anticipatory guidance
Antigen
Antigenic drift

2576
Antigenic shift
Antigenicity
Antistigma strategies
Application
client
of epidemiological research
Armed conflict
Arriving at the home
Arthritis
in adults
in elderly
Assessment. See also specific topics assets
Outcome and Assessment Information Set (OASIS) in teaching
Asset-based community development (ABCD) Assets assessment
Assisted living
Assistive devices and technology Association
Association of Community Health Nursing Educators (ACHNE)
Association of State and Territory Health Officials (ASTHO)
Assurance
environmental justice
home
severe weather events
Asthma
in infants, toddlers, and preschoolers school nursing for
Asthma action plan
At-risk alcohol use
Attack rate
Attention-deficit/hyperactivity disorder (ADHD) Authoritative
knowledge
Autism, in infants, toddlers, and preschoolers Autism spectrum
disorder (ASD)
in school-age children
Autonomy
B
Balanced Budget Act of 1997
Barton, Clara

2577
Behavioral health
community interventions
continuum of care model
services, integration
substance use in See (Substance use and abuse; specific
substances) terminology
Behavioral Model for Vulnerable populations Behavioral problems.
See also specific problems school nursing for
in school-age children
Behavioral Risk Factor Surveillance System Benchmarking
Beneficence
Benign prostatic hypertrophy (BPH) Beta-amyloid
Betty Neuman’s Systems Model
Bickerdyke, Mary Ann “Mother,” 56
Big data
Binge eating
in adolescents
in young adult women
Bioaccumulation
Bioethics
Biologic warfare
Biological gradient
Biomedical view
Biomonitoring
Bioterrorism
anthrax
infectious diseases
smallpox
Birth certificate
Birth rate
Birth weight
Bisexual
Black Death
Blended families
Body functions
Body structures
Booster seats

2578
Botulism
Boundaries, in collaboration
Braille
Brain development, infant, parentchild interactions and
Brainstorming
Breast cancer
Breast self-examinations (BSE)
Breast-feeding
Breckinridge, Mary
Bronchiolitis
Brownfield’s sites
Bubonic plague
Budgets, for public health
Built environment
Bulimia (nervosa)
in adolescents
school nursing and
in young adult women
Bullying
Burn injuries, in infants, toddlers, and preschoolers C
Cancer
in adults
in school-age children
in women
Capacity building
Capitation
Cardiovascular disease (CVD)
in adult men
in rural populations
Care coordination
Carefronting
Caregiving wheel
Case fatality rate
Case file, on child drowning
Case management. See also specific topics aging America, health
nurse in
home health care

2579
 homeless
manager role
occupational and environmental health nursing older adults care
TB
Case-control studies
Casualty
Causal matrix
Causal relationships
Causality
definition of
multiple causation in
in noninfectious disease
web of causation in
Causation. See also specific topics web of
Census data
Census tract
Centers, school-based health
Centers for Disease Control and Prevention (CDC) Centers for
Medicare and Medicaid Services (CMS) Certified agencies
Cervical cancer
Cesarean section deliveries
Chain of causation
Chancre
Change
definition of
evolutionary
flexibility in
interdependence
models
nature of
participation
planned
positive, effecting
proper timing
resistance to
revolutionary
self-understanding

2580
 stages of
Change agent/researcher, rural community health nurse role in
Charity Organization Society’s (COS) tuberculosis committee
Chavez, César
Chemical warfare
Chia powder
Child
health care for See (Adolescent(s); Infants, toddlers, and
preschoolers) homeless
Child abduction
Child abuse
protection from
school nursing and
school-age children and adolescents Child birth. See Pregnant
women and infants Child booster seats
Child care
Child maltreatment
Child neglect
protection from
school-age children and adolescents Child Protective Services
Childproofing
Children
with disabilities, health promotion programs for hospice care for
Children’s Health Insurance Plan (CHIP) Chlamydia
in adolescents
in pregnancy
in U.S.
in young adult women
Chronic disease. See Chronic illness Chronic disease epidemiology
Chronic fatigue syndrome (CFS)
Chronic illness
civil rights legislation on
community/public health nurse
definitions for
families in
with child with autism, support
cope with

2581
 impact on
web sites assisting
health
health care disparities
health promotion and prevention needs with misconceptions on
improvement in missed opportunities in
Healthy People 2030 on
international classification of
nursing process for
organizations serving needs of
overview of
universal design
universal design
WHO model of
World Health Report 2002
Chronic lower respiratory diseases (CLRD) Chronic obstructive
pulmonary disease (COPD), in rural populations Chronically
homeless
Civil rights legislation, on disabilities Claims payment agents
Clean Air Act (CAA)
Clean Water Act (CWA)
Clear responsibilities, in collaboration Client. See also specific topics
community as See also (Community as client) as equal partner
Client application
Client empowerment
Client environment
Client focused, nursing process
Client participation
Client perceptions
Client readiness
Client satisfaction
Client-centered approach
Climate changes. See also Environment Clinical disease stage
Clinical reasoning
Clinician role, community and public health nurses expanded skills
holistic practice
wellness

2582
Clinics, rural health
Club drugs. See also specific drugs CMS. See Centers for Medicare
and Medicaid Services (CMS) Cocaine
Cochrane, Archie
Cochrane Public Health and Health Systems Cocooning
Cognitive domains
Cohabitating couple
Cohort studies
Collaboration
barriers to effective
characteristics of
culture
fostering client participation
interprofessional
levels of prevention
SAMHSA’s strategic prevention framework Collaboration and
partnerships. See also specific topics interprofessional
Collaborative services
Collaborator, rural community health nurse role in Collaborator role,
community and public health nurses Colorectal cancers
Commercial sexual exploitation of children (CSEC) Commitment, in
contracting
Common-interest community
Commonwealth Fund
Communicable disease
definition of
ethical issues in
evolution of control of
Healthy People 2030
in infants, toddlers, and preschoolers infectious diseases of
bioterrorism in legal issues in
new and emerging
nursing process for control of
prevention of, primary See also (Immunization) cocooning
education in
immunization in
prevention of, secondary

2583
 prevention of, tertiary
reemerging
reportable
reporting of
in school-age children
transmission of
airborne
direct
food-and water-related
indirect
vector
in U.S.
Chlamydia
genital herpes
gonorrhea
hepatitis A
hepatitis B
hepatitis C
HIV/AIDS
influenza (seasonal)
overview
pandemic preparedness
pneumonia
smallpox
STD prevention and control
syphilis
tuberculosis See (Tuberculosis) viral warts
Communicate clearly
Communication
barriers
emotional influence in
filtering information in
with groups
decision making in
decision making in, enhancing
group development in
relationships

2584
 task, maintenance, and nonfunctional roles in health
literacy and health outcomes and interpreter in
language barriers in
language of nursing
with low-literacy clients
selective perception in
Community. See also specific topics aggregates in
common-interest
competent
definition of
geographic
healthy
populations in
settings and public health nursing practice ambulatory service
settings
community at large
faith communities
homes
occupational health settings
residential institutions
schools
solution
Community action model
Community and public health nurses (C/PHNs) advocate role
actions
goals
clinician role
expanded skills
holistic practice
wellness
collaborator role
educator role
leadership role
manager role
case management
management behaviors
management skills

2585
 nurse as controller and evaluator nurse as leader
nurse as organizer
nurse as planner
researcher role
Community as client
community data
community forums and social media descriptive
epidemiologic studies focus groups
geographic information system analysis international
sources
national sources
primary and secondary sources
sources of
state and local sources
surveys
community diagnosis formation
community needs assessment
community assets assessment
community subsystem assessment
comprehensive assessment
familiarization
problem-oriented assessment
data analysis process
dimensions
location
population characteristics
social system
evaluation
community development theory
types of
health promotion
Minnesota wheel
nursing process
adaptable
client focused
cyclical
deliberative

2586
 forming partnerships and building coalitions interacting
interactive
need oriented
Omaha system
planning
goals and objectives
health planning process
priority setting
tools to assist with
public health nursing
practice model
principles
Salmon’s construct for
Community assets assessment
Community Care Transitions Program Community coalitions
strategic planning framework
Community data
community forums and social media descriptive epidemiologic
studies focus groups
geographic information system analysis international sources
national sources
primary and secondary sources
sources of
state and local sources
surveys
Community development theory
Community diagnosis
Community empowerment
Community First Choice Option
Community forum
Community health
asthma in
challenges of
definition of
practice of
public health nursing instructor on spread of disease

2587
Community health assessment. See also specific topics built
environment
land use
overview
Community health nursing. See also specific topics actively reaching
out in
clients as equal partners in
greatest good for greatest number in health conditions in
history of
interprofessional collaboration in nurse’s viewpoint
overview of
population focus in
prevention in
prevention pyramid
primary prevention priority in
research on
resource use optimization in
Community health practice
health assessment in
health promotion in
prevention in See also (Prevention pyramid, levels of) primary
secondary
tertiary
Community health services
financing of See (Financing, health care) health care economics
in See (Economics, health care) health care reform See
(Health care reform) history of
international health organizations in public health care system
development in Community health workers
Community needs assessment
community assets assessment
community subsystem assessment
comprehensive assessment
familiarization
problem-oriented assessment
Community nursing centers
Community of solution

2588
Community orientation
Community protective factors
Community risk factors
Community service learning (CSL), in NLHCs Community
subsystem assessment
Community trial
Community-and population-based interventions Community-based
agencies
Community-based long-term care system Community-based
participatory research (CBPR) Community-based primary health
care model Community-oriented
Community/public health nursing (C/PHN) application, ethical
decision-making in implications for
Online Resources for Accessing Programs and Services practice,
research on
nurse’s role
and patient outcomes
public policy and community/public health transcultural
nursing, role and preparation values and ethics in
Companionship, in elderly
Compassion fatigue
Competition
Complementary and alternative medicine (CAM) Compliance,
enforced
Comprehensive assessment
Comprehensive community-based primary health care model
Comprehensive Environmental Response, Compensation, and
Liability Act (Superfund) Comprehensive primary care centers
Comstock Act of 1873
Conceptual framework
Conceptual model
Conceptual skills
Confidentiality
Consistency
Consumer Product Safety Commission (CPSC) Consumption
Contact investigation
Contacting resources
Contagion theory

2589
Contemplation, in stages of change model Contemporary families
Continuing care retirement communities (CCRCs) Continuous needs
Continuum of care
Contract, in community/public health nursing characteristics of
concept and process of
levels of
nursing process and
principles of
value of
Coordinator/case manager, rural community health nurse role in Core
public health functions
Coronary heart disease
Correctional nursing
careers
challenges for
education for
functions of
future trends in
history of
patient-centered care for
perspectives in
Cost sharing
Cost shifting
Council of Public Health Nursing Organizations (CPHNO) County
Health Rankings Model
COVID-19, epidemiology and
Crack
Crime against elders
Crisis
developmental
dynamics and characteristics
intervention
situational
traumatic
Critical access hospitals (CAHs) Critical appraisal
Critical incident stress debriefing (CISD) Critical pathway
Cross immunity

2590
Cross subsidization
Cross-cultural guidelines
Cross-cultural sensitivity
Cross-sectional study
Cultivating cultural awareness
Cultural adaptation
Cultural assessment
Cultural assessment guide
Cultural brokering
Cultural diversity, transcultural nursing Cultural identity
Cultural plurality
Cultural relativism
Cultural self-awareness
Cultural sensitivity
Culturally derived health practices Culture
affecting neurobiology
characteristics of
cultural diversity
as dynamic
ethnocentrism
as generally tacit
as integrated
integrated nature, recognizing and respecting as learned
as shared
transcultural nursing
Culture shock
Current US health policy options ACA and C/PHN practice
accountable care organizations
policy competence
value-based purchasing
Custodial care
Cycle of violence
Cyclical, nursing process
Cystic fibrosis (CF)
D
Data collection categories

2591
Day care, for children
Dealing, with challenging situations Death. See also Mortality causes
of
Death certificate
DECIDE model
Decision making
ethical (See also Ethics) group
Decision-making behaviors
Decision-making frameworks
Deinstitutionalization
Delano, Jane
Deliberative, nursing process
Demand
Demand-side policies
Demographics
Demonstration method, teaching
Density, population
Dental health
in adolescents
in elderly
in infants, toddlers, and preschoolers in pregnancy
school nurse in
in school-age children
Denton Community Health Clinic
Department of Health and Human Services (DHHS) Department of
Homeland Security (DHS) Depression
in adolescents
in elderly
postpartum
Descriptive epidemiologic studies Descriptive epidemiology
counts in
prevalence in
rates in
Developmental disability, maternal Developmental framework
Developmental screening
Diabetes
in school-age children

2592
Diabetes medical management plan Diabetes mellitus
in adults
in rural populations
school nursing for
Diagnosis. See also specific disorders in teaching
Diagnosis-related groups (DRGs)
Diethylstilbestrol (DES)
Diets, fad
Differential vulnerability hypothesis Direct transmission
Directly impacted by disaster
Disability
in children, behavioral and emotional problems in
community/public health nurse
health
health care disparities
health promotion and prevention needs with misconceptions on
improvement in missed opportunities in
Healthy People 2030 on
international classification of
nursing process for
organizations serving needs, individuals with disabilities and
their families World Report on
Disability rights laws
Disability-adjusted life years (DALY) Disaster planning
Disasters
agencies and organizations
characteristics of
community/public health nurse
directly impacted by
factors contributing to
geographic distribution
indirectly impacted by
management phases of
persons impacted by
planning
preparation for
prevention

2593
 psychological consequences of
responding to
supporting recovery from
Discrimination
Disease control
Disease prevention. See also Health promotion Disease registries
Disparities, health care
on chronic illness and disabilities in urban health care
Displaced persons
Disproportionate Share Hospitals (DSH) Disseminator role
Distributive justice
for battered women and children
Distributive policy
District nurse
Disturbance handler
Divorce
behavioral and emotional problems with DME. See Durable
medical equipment (DME) Documentation home visit
Domestic violence. See also Violence homelessness and
Dominant values
Donabedian model
Doubling up
Drowning, childhood
Drug, prescription, abuse of
Drug Abuse Screening Test (DAST) Drug overdose deaths
Drug use
Duchenne muscular dystrophy
DUMBBELS
Durable medical equipment (DME)
E
Early childhood education
Eastern stream
Eating disorders. See also specific disorders in adolescents
school nursing and
in young adult women
Ebola disease virus (EDV)

2594
EBP. See Evidence-based practice (EBP) Eco-epidemiology
Eco-map
Economics, health care
on community health nursing
on community health practice
cost control in
definition of
disincentives for efficient use of resources in employer-
sponsored health insurance in financing of See (Financing,
health care) health insurance concepts in
high cost of health in
incentives for illness care in
macroeconomics in
of managed care See also (Managed care) of managed care,
public health values and medical bankruptcies in
microeconomics
supply and demand in
uninsured and underinsured in
Economic security, for elderly
Ecosystems
Ecstasy
Education. See also Health promotion; Teaching; specific topics on
children’s health
on communicable disease prevention for correctional nursing
early nursing
on health
of public health nurses
of school nurses
Educational environment
Educator role, community and public health nurses Egalitarian justice
Elder abuse
prevention of
Elderly, heart disease in
Electronic health literacy
Electronic health records
Emotional abuse
Emotional intelligence (EI)

2595
Emotional problems, in school-age children Employer-sponsored
health insurance Employing advocacy
Employment, homelessness and
Empowerment
Empowerment strategies
Enabling factors, in planning
Encephalitis, epidemiology of
Encouraging choice
Enculturation
Endemic
Endocrine disrupting chemicals (EDCs) Enforced compliance
Entrepreneur
Entrepreneurial nurse
Environment
in epidemiology
in health
Environmental epidemiology
Environmental exposure history
Environmental factors
Environmental health and safety
assessment
assurance
environmental justice
home
severe weather events
core functions of public health
ecosystems
definition
global environmental health
history of
and nursing
importance of
policy development
precautionary principle
prevention pyramid
sciences for
community assessment

2596
 home assessments
individual assessment
public health nursing assessments sustainability
toxic exposures See (Toxic exposures) vulnerabilities
Environmental health nurse. See Occupational and environmental
health nurse Environmental health regulatory agencies
Environmental justice
Environmental monitoring
Environmental Protection Agency (EPA) Environmental resources
Environmental tobacco smoke (ETS) Epidemic
Epidemiologic mortality rates
Epidemiologic triangle
Epidemiological research, conducting data collection in
developing conclusions and applications in disseminating
findings in
literature review in
problem identification in
study design in
Epidemiology
agent in
analytic
causal relationships in
causality in
characteristics of
chronic disease in
contagion theory in
and COVID-19
data in, existing
descriptive
eco-epidemiology in
environment in
eras in evolution of
experimental
Farr in
Florence Nightingale in
germ theory of disease in
historical roots of

2597
 early physician–epidemiologists
nurse epidemiologist
host in
immunity in
infectious disease in
informal observational studies in investigation
miasma theory in
natural history of disease health condition in physician–
epidemiologists and contributions public health services,
essentials of purposes of
research in, conducting
risk in
sanitary statistics
scientific studies in
of wellness
Epigenetics
Episodic needs
Equity, guide decision-making
Era of chronic diseases
Era of infectious diseases
Era of social health conditions
Erectile dysfunction (ED)
Essential services
Establish trust and rapport
Ethical decision-making
Ethical dilemma
Ethics
in community/ public health nursing decision-making
frameworks
ethical principles
autonomy
beneficence
fidelity
justice
nonmaleficence
respect
veracity

2598
 ethical standards and guidelines in global health
clinical service learning
motivations
volunteer
guide decision-making
equity
self-determination
well-being
identifying ethical situations
patient-centered care for
public health ethics
resolving moral conflicts and ethical dilemmas values,
application of
Ethnic disparities
Ethnic group. See also specific groups Ethnicity
Ethnocentrism
Ethnocultural health care practices. See also specific cultures
integrated health care and self-care practices world community
biomedical view
folk medicine and home remedies
herbalism
holistic view
magicoreligious view
prescription and OTC drugs
Ethnorelativism
Evaluation
of policy
in teaching
Evidence-based practice (EBP). See also specific topics in
compassion fatigue
family–nurse partnership
genomics and pharmacogenomics
on homeless youth
hospice care
implementation, quality improvement and research Institutional
Review Board/Human Subjects Committee Approval need
for

2599
 occupational and environmental health nursing patient-centered
care for
principles of
process, steps of
asking question
critical appraisal
disseminating outcomes
evaluating outcomes
finding evidence
spirit of inquiry, cultivation
on public health nursing
research basics to
on school nursing
Evolution
of epidemiology
of hospice care
public health nursing See also (Public health nursing)
Evolutionary change
Exclusive provider organizations (EPO) Exercise
school nursing and
in school-age children and adolescents Exercise professional
judgment
Expanded skills, community and public health nurses Expedited
partner treatment (EPT) Experiment
Experimental epidemiology
Experimental study
Explanation, coherence of
Exposure pathways
F
Faith communities, settings for community and public health nursing
practice Faith community nursing (FCN)
activities and interventions
as advocate
congregational health and wholeness faith and health, integrator
of
as health counselor
as health educator

2600
 historical background of
practice
as referral agent
roles of
as support group developer
as volunteer coordinator
Faith-based outreach
Falls
in elderly
in infants and toddlers
Familiarization
Family
Family and Medical Leave Act
Family as client
characteristics of
composition
contemporary
divorce
effect on behavior
family health and family health nursing family stage of
development
foster families
headed by a cohabitating couple
headed by an adolescent parent or parents with healthy family
functioning
active coping effort
effective structuring
enhancement, of family members’ development healthy
communication
healthy environment and lifestyle regular links, with
broader community home visit
components of
focus of
personal safety during
skills used during
implications, of family composition diversity LGBTQ families
nursing process

2601
 evaluation
family diagnosing process
family health assessment
planning and implementation
preliminary considerations
with older adults
remarriage and blending
roles
single-parent families
social class and economic status traditional
values
Family health
Family health nursing
Family life cycle
Family-centered care
Family-level problem-solving techniques Farming accidents
Farmworkers. See also Migrant health care migrant
seasonal
Farr, William
FastStats
Federal grants
Federal maternal-child health funding Federal Medical Assistance
Percentage (FMAP) Federal public health agencies
Federal Public Health Agency Reports Federally qualified health
center (FQHC) Feedback loop
Fee-for-service (FFS)
Fentanyl
Fertilizer
Fetal alcohol effects
Fetal alcohol spectrum disorders (FASD) Fetal alcohol syndrome
(FAS)
Fetal death
Fidelity
Figurehead role
Filicide
Financing, health care
capitation

2602
 Children’s Health Insurance Plan (CHIP) claims payment agents
direct consumer reimbursement
Medicare and Social Security Disability Insurance other
government programs
out-of-pocket payment
private and philanthropic support prospective payment
surprise medical billing
third-party payments See (Third-party payments) Flea-Borne
disease
FluNet
Fluoridation
Focus groups
Folk medicine
Fomites
Food
allergies
childhood
school-age children
microbial toxins
safety and cleanliness, methods for preserving vulnerable groups
Food and Drug Administration (FDA) Food-and water-related
transmission Formal contracting
Format, in contracting
Formative evaluation
Forming stage of group development For-profit agencies
For-profit health services
Foster families
Foundational Public Health Services (FPHS) Model Four Quadrant
Clinical Integration Model FQHC. See Federally Qualified
Health Center (FQHC) Friction, between family members
Frontier and remote area (FAR)
Frontier area
Frontier Nursing Service (FNS)
Full inclusion
Functioning. See also Disability definition of
international classification of
WHO model of

2603
Funding, for public health
G
Gamp, Sairey
Gang
Gang violence
Genital herpes, in pregnancy
Genogram
Geocoding
Geographic community
Geographic information system (GIS) Geriatrics
Germ theory of disease
Gerontology
Gestational diabetes mellitus (GDM) Global burden of disease (GBD)
Global environmental health
Global health
achievement
armed conflict
components
demographic transitions
epidemiologic transitions
ethics
clinical service learning
motivations
volunteer
global burden of disease
interdependence, of nations during migration intersection of
managing global diseases
patterns of care
policies
primary health care initiative
sustainable development goals
telehealth
trends
women’s health
Global health patterns

2604
Global Health Security Agenda (GHSA) Global Influenza
Surveillance and Response System (GISRS) program
Globalization
Goals, teaching
Gonorrhea
in adolescents
in pregnancy
Government health programs
Grand theories
Grant writing
Grants
applications
Federal grants
grant process
management
Grief in hospice care. See Hospice care Gross domestic product
(GDP)
Group development
Group process
Guiding letting go
Gun violence
H
Hallucinogens
Handicaps
Hantavirus
Head lice
Head Start
Health. See also specific topics community characteristics of
definition of
environment in
episodic needs
international classification of
national agenda for
subjective and objective dimensions of in U.S.
Health assessment
Health belief model (HBM)

2605
Health care
historical influences on
lack of affordable, homelessness and Health Care and Education
Affordability Reconciliation Act Health care expenditure
Health care financing. See also Financing, health care Health care
rationing
Health care reform. See also Policy changes
managed competition
universal coverage and single-payer system Health care service,
for elderly Health care system, development of CMS 2019b
commensurate value
comprehensive evaluation
health spending
significant legislation
the United Kingdom, Australia and the Netherlands Health
clinics, rural
Health continuum
Health delivery system transformation critical path Health disparities
definition of
Healthy People 2030
on older adults
in vulnerable populations
Health education. See also specific topics Health impact assessment
(HIA)
Health indicators, leading
Health insurance concepts
Health literacy
Health maintenance organization (HMO) Health Ministries
Association (HMA) Health organizations, U.S.
for-profit and not-for-profit health agencies health-related
professional associations levels and types of
private health sector organizations public health agencies
public sector health services in See (Public sector health
services) Health policy
Health policy analysis
legislative process at the National level local, state, and national
level policy policy and public health nursing practice

2606
 Health professional shortage areas (HPSAs) Health
promotion
in Healthy People 2030
access to health care
health disparities
quality of care
social determinants of health
socioeconomic gradient
implementation
learning domains in See (Learning domains) overview of
teaching-learning principles in See (Teaching learning
principles) theoretical propositions of
through change
domains of learning
effective teaching
health teaching models
learning theories
nature of change
planned change
teaching at three levels of prevention Health protection
Health reimbursement accounts (HRAs) Health risk assessment
Health savings accounts (HSAs)
Health teacher, rural community health nurse role in Health
technology
apps
big data
blogging and online support communities digital divide
electronic health literacy
electronic health records
geographic information system
mobile health
mobile phones
telehealth
video games and virtual reality games Health–income gradient
Health-related professional associations Healthy community
Healthy conditions
Healthy old age

2607
Healthy People
Healthy People 2030
on adolescent and young adults
communicable disease
community as client
on disabilities and chronic illness environmental health
on epidemiology
goals of
on health disparities
on health literacy and health communication on homelessness
on immunization
LGBTQ families
on maternal-child health
on men’s health
on mental health
primary health care
private settings
on public health priorities
rural health care
on substance abuse
violence
on women’s health
Heart disease
in adult men
in adult women
in elderly
Heat islands
Henry Street Settlement
Hepatitis B vaccine, in pregnancy Herbalism
Herd immunity
Heroin use
Hidden homeless
Hierarchical system, of values
High cost health plan (HCHP)
High-deductible health plan (HDHP) High-deductible health plans
with a savings option (HDHP/SOs) High-risk families
Hispanic population trend, in United States History and evolution

2608
district nursing in (mid-1800 s to 1900) early home nursing in
(before mid-1800 s) public health nursing in (1900-1970)

2609
20h century
HMA. See Health Ministries Association (HMA) Holistic practice,
community and public health nurses Holistic view
Home
Home environmental assessments
Home health agencies
Home health care (HHC)
care coordination
clients and their families
cost containment
fall risk in
future of
history of
home health agencies
vs. hospice care
hospice movement
infection control
laws and models governing home health coverage Medicare
home health eligibility criteria for medication safety
nurse safety
nursing practice
caregiving wheel
case management
collaborating and mobilizing in
during home visit
locating the client and getting through the door nursing
challenges in home
self-management promotion
solving problems in
overview
personnel
perspectives
providers
reimbursement for
services and benefits by payer
technology at home

2610
 value-based care
Home health nurse caregiving wheel Home health nursing
Home Health Value-Based Purchasing Model Home invasion
Home remedies
Home-bound
Homeless
children
contributing factors in
C/PHN, role of
advocacy
case management
primary prevention
secondary prevention
tertiary prevention
definition of
demographics of
age
ethnicity
families
gender
families
health care and
Healthy People 2030
lesbian, gay, bisexual, and transgender (LGBT) men
nursing process for
older
personal beliefs and values
prevention pyramid for
quality improvement for
resources for combating of
private sector
public sector
rural
scope of problem in
subpopulations of
tent cities and solutions for
veterans

2611
 women
youth
Homeless Emergency Assistance and Rapid Transition to Housing
(HEARTH) Act of 2009
Homelessness, school nursing and Homicide
Homogeneity
Hormone replacement therapy (HRT) Hospice and Palliative Nurses
Association (HPNA) Hospice care
caregiving tree
for children
compassion fatigue
for elderly
ethical challenges in
evidence-based practice
evolution of
future of
vs. home health
overview
palliative care nursing practice collaborating
comforting
connecting
encouraging choice
fundamentals of
speaking truth
spiritual practice and letting go strengthening the family
sustaining oneself
perspectives on
services and reimbursement
Hospice movement
Hospital-based agencies
Host
Host factors
Housing First
Human capital
Human immunodeficiency virus (HIV) in adolescents
education on
in migrant workers

2612
 in pregnancy
in rural populations
with tuberculosis
in young adult men
Human skills
Human Subjects Committee (HSC), evidence-based practice Human
trafficking
Hunger. See also Nutrition school nursing and
Hurricane Katrina aftermath, U.S. Public Health Service
Commissioned Corps in Hypertensive disease, in pregnancy I
Illicit drug use. See Substance use and abuse; specific drugs Illness.
See also specific illnesses Immigrant immunization
Immigration Reform and Control Act of 1986
Immortal cells
Immunity
active
cross
herd
passive
Immunization. See also Vaccines of adolescents
of adults
of children
by school nurse
community status of
contraindications and precautions with definition and overview
of
of elderly
in Healthy People 2030
herd immunity in
for immigrants
for international travelers
personal belief affidavit exemption personal belief exemption
for
planning and implementing programs of schedule of,
recommended
for vaccine-preventable diseases Impairments
Implicit bias

2613
Impotence. See Erectile dysfunction (ED) Improving Medicare Post-
Acute Care Transformation Act of 2014
Inactivity, in school-age children Incidence
Incidence rate
Incident command center (ICS)
Incident Command System (ICS)
Incubation period
Indemnity policy
Independence, of elderly
Independent health plans
Indian Health Services (IHS)
Indigenous
Indirect transmission
Indirectly impacted by disaster
Individual assessment
Individual protective factors
Individual risk factors
Individualized education plans (IEPs) Individualized health plans
(IHPs) Individuals with Disabilities Education Act (IDEA)
Industrial nursing
Infant
high-risk, flow sheet for
newborns
parentchild interactions and brain development of prenatal and
birth age See (Pregnant women and infants) Infant death
Infant mortality rate
Infanticide
Infants, toddlers, and preschoolers health care in
accidents and injuries
chronic diseases
communicable diseases
definitions
history, global
lead poisoning
maltreatment
nutrition, poor
oral health

2614
 weight gain
health promotion programs for See also (Health promotion)
children with disabilities
developmental screening
infant brain development and parentchild interactions
nutritional programs
health services for
child abuse and neglect protection day care and preschool,
quality
health promotion programs
health protection programs
immunization
parent training
preventive health programs
safety and injury protection
prevention pyramid for
Infection control, home health care Infectious agent
Infectious disease
Infectious waste
Infectivity
Influenza, seasonal
Influenza vaccine, contraindications and precautions to Informal
contracting
Informal observational studies
Information behaviors, transfer of Inhalant
Inhalant abuse
Inherent resistance
Injuries
in infants, toddlers, and preschoolers in school-age children
unintentional, in adults
Injury prevention
in infants, toddlers, and preschoolers in school-age children and
adolescents In-migration
Innovative community
Institute of Medicine (IOM)
Institutional Review Board (IRB), evidence-based practice
Instrumental values

2615
Insurance, health
Children’s Health Insurance Plan employer-sponsored
Medicare and Social Security Disability Insurance private
insurance companies
in rural areas
Integrated behavioral health models of clinical integration Integrated
health care
Integrated pest management (IPM) Integration of Behavioral Health
Services Integrative reviews
Integrative strategies
Intensity
Interaction
infant, parentchild
social, in elderly
Interactional framework
Interactive, nursing process
International Classification of Functioning, Disability, and Health
(ICF) International health organizations World Health
Organization (WHO)
International Health Regulations (IHR) International Labour
Organization (ILO) International travelers, immunization for
Interpersonal behaviors
Interpersonal skills
Interprofessional collaboration
Intimate partner violence (IPV)
Intoxication
Intraethnic variations
Iowa Department of Public Health substance abuse program Isolation
J
Jenner, Edward
Judicial action, of policy
Justice
distributive
egalitarian
environmental
restorative
social

2616
K
Kansas Prevention Coalition
Katz Index of Activities of Daily Living Kernicterus
Key informants
Knowledge. See also Education L
Land use-related health issues
Latency period
Lead poisoning, of infants, toddlers, and preschoolers Leader
Leadership role
Leading health indicators 2030, private settings Learning disabilities
Learning disorders
Learning domains
affective
cognitive
psychomotor
Learning theory
HBM
Pender’s HPM
transtheoretical model
Legalization of Marijuana/Cannabis Legislation, landmark. See also
specific legislation Legislative process
Leprosy
Lesbian, gay, bisexual, and transgender (LGBT) Letter of inquiry
LGBTQ families
Liaison role
Lice, head
Life expectancy
at birth
U.S.
worldwide
of older adults
Lind , James
Literacy
health
of adults
on health outcomes

2617
 low, in client communication
Literally homeless
Living wills
Lobbying
Local health departments (LHDs)
Local knowledge
Local policy
Logic models
Long-term care
Long-term health conditions
Low birth weight (LBW)
Lower respiratory diseases, chronic Low-risk alcohol consumption
limits Lung cancer
M
Maass, Clara
Macroeconomic
Macroeconomic theory
Magicoreligious view
Mainstreaming
Maintenance, in stages of change model Major depressive episode
Majority–minority nation
Making referrals
Malaria
Malnutrition. See Nutrition, in World Health Report 2002
Managed care. See also specific types competition and regulation
drivers of costs
exclusive provider organizations Health Maintenance
Organizations high-deductible health plan
point-of-service plans
preferred provider organization
Managed care organizations (MCOs) Managed competition
Management skills, manager role
Manager role, community and public health nurses case management
management behaviors
management skills
nurse as controller and evaluator nurse as leader

2618
 nurse as organizer
nurse as planner
Mandated reporters
Man-made disaster
Marginalized populations
Marijuana/Cannabis
Marine Hospital Service
Marketing, planning
social marketing
value of
Mass casualty
Mass media, for health education Mass-casualty incident
Maternal developmental disability Maternal mortality rate
Maternal-child health
children’s health care in
children’s health services in
history of
infants, toddlers, and preschoolers in See (Infants, toddlers, and
preschoolers) preconception care in
pregnant women and infants in See (Pregnant women and
infants) McKinney-Vento Homeless Assistance Act Titles
I-IX
MDMA
Medicaid
Medical bankruptcies
Medical errors
Medical home
Medical loss ratio
Medically underserved areas (MUAs) Medically underserved
population (MUP) Medicare
criteria and reimbursement
home health benefit
home health eligibility criteria for hospice benefit
prospective payment system
Medicare advantage
Medicare home health benefit
Medicare hospice benefit

2619
Medicare Modernization Act
Medicare plans
Medicare prospective payment system Medication administration, by
school nurse Medication safety, home health care Medication-
Assisted Treatment Programs in CriminalJustice Settings, 727
Menopausal hormone therapy (MHT) Menopause
Men’s health
in adults
heart disease in
overview of
prostate cancer in
prostate health in
reproductive health in
Healthy People 2030 goals for in homeless
overview of factors in
testicular self-examination in
in young adult men
HIV in
overview of
testicular cancer in
Mental disorders
cost
Healthy People 2030
incidence and prevalence of
indicated strategies
prevention strategies
recovery
selective strategies
substance use and community health nurse treatment, referral to
Mental health
in corrections nursing
definition
Healthy People 2030
major depressive episode
suicide
Mental illness. See also specific illnesses in adolescents
homelessness and

2620
Mentor, rural community health nurse role in Meta-analysis
Methamphetamine
Methicillin-resistant Staphylococcus aureus (MRSA) Miasma theory
Microcultures
Microeconomics
Microeconomic theory
Micropolitan statistical areas
Middle-range theories
Midlife crisis
Midwestern stream
Migrant farmworkers
demographics
health risks
hero
historical background
lifestyle
migrant streams and patterns
overview
profile
Migrant health care
agricultural labor
environmental exposure history in health risks of
community health nursing
health care delivery
infectious diseases
information tracking systems
occupational hazards
pesticide exposure
poor sanitation
primary prevention
social, emotional and behavioral health substandard
housing
immigration policies
migrant farmworkers
demographics
health risks
hero

2621
 historical background
lifestyle
migrant streams and patterns
overview
profile
Migrant streams
Migration patterns, changing
Military service, nurses in
Minnesota wheel
Minority group
Mitigation phase
Mobile apps
Mobile health (mHealth)
Monitor role
Monogamy
Moral
Moral evaluations
Moral hazard
Morbidity, measures of
Morbidity rates
Mortality rate
infant
maternal
neonatal
Mosquito-Borne diseases
Mothers. See also Pregnant women and infants; Teenage pregnancy
Mothers Against Drunk Driving (MADD) Motor vehicle crashes
in infants, toddlers, and preschoolers in school-age children and
adolescents Moulage
Multidrug-resistant tuberculosis Multiple causation
Multiple-casualty incident
Multivoting
Munchausen syndrome by proxy
Muscular dystrophy (MD)
Mutual company
Mutual participation, in collaboration Mutuality, in contracting
Myalgic encephalomyelitis (ME)

2622
N
Naloxone
National Amyotrophic Lateral Sclerosis (ALS) Registry National
Association of City and County Health Officials (NACCHO)
National Center for Health Statistics Health Surveys National
Council for Community Behavioral Healthcare National Council
on Disability (NCD) National Depression Screening Day
National Health and Nutrition Examination Survey National
Health Service Corp (NHSC) Program National Hospice and
Palliative Care Organization (NHPCO) National Institute for
Occupational Safety and Health (NIOSH) National Institute of
Environmental Health Sciences (NIEHS) National Institutes of
Health (NIH) National League for Nursing (NLN) National
Library of Medicine (NLM) National Nurse-Led Care
Consortium (NNCC) National Nursing Home Survey
National Organization for Public Health Nursing (NOPHN) National
Organization on Disability (NOD) National policy
National Quality Forum
National Survey of Family Growth National Survey on Drug Use and
Health (NSDUH) National Violent Death Reporting System
Natural disaster
Natural history, of disease/health condition clinical disease stage
resolution/advanced disease stage subclinical disease stage
susceptibility stage
Need oriented, nursing process
Neglect
Negotiation, in contracting
Negotiator role
Neonaticide
Neurobiology, culture affecting
Never events
New York State Department of Health (NYSDH) Transitional Care
Model Nicotine replacement therapy (NRT) Nightingale,
Florence
epidemiological work of
Nightingale model
Nomadic migrant workers
Nominal group technique

2623
Noncertified agencies
Nongovernmental organizations (NGOs) Noninfectious
(noncommunicable) disease, causation in Nonmaleficence
Nonprofit agencies
Norming stage of group development Nosology
Not-for-Profit health services
Novel
Novel influenza virus
Nurse entrepreneur in community public health nursing in community
opportunities
steps to becoming
Nurse practitioner (NP)
Nurse safety, home health care
Nurse-family partnership (NFP)
Nurse-led clinics (NLCs)
Nurse-led health centers/clinics (NLHCs) community service learning
(CSL) in definition and overview
Denton Community Health Clinic
family-centered care
funding for
future directions for
history of
models
nursing research and
perspectives on
students role in
wellness screening
Nurse-managed health clinic
definition of
sustainability of
Nurses’ Health Study (NHS) I
Nurses’ Health Study (NHS) II Nursing centers
Nursing home
Nursing process
community as client
adaptable
client focused

2624
 cyclical
deliberative
forming partnerships and building coalitions interacting
interactive
need oriented
C/PHN use of
Nutrition
in adolescents
in elderly
in infants, toddlers, and preschoolers migrant and seasonal
farmworkers in pregnancy
in school nursing
in school-age children
in World Health Report 2002
Nutting, Adelaide
O
OASIS. See Outcome and Assessment Information Set (OASIS)
Obesity
in adults
childhood See also (Overweight) migrant and seasonal
farmworkers prevention pyramid for
school nursing and
in World Health Report 2002
Objectives, teaching
Observational studies, informal
Occupational and environmental health nursing educational
preparation
evidence-based practice
future trends
health promotion and wellness
history of
occupational health team
roles and career opportunities of safety culture creation
settings for
work on health, effects of
Occupational hazard

2625
Occupational health settings, settings for community and public
health nursing practice Occupational health team
OHNs work in a team environment with Occupational safety
for adolescents
for migrant workers
Occupational Safety and Health Administration (OSHA) Older adults
advance directives
ageism and
care for caregiver
case management and needs assessment in chronic diseases of
chronic illness
community health nurse role in
definition of
demographics
global
U.S.
elder abuse
family caregiving
functional disabilities
geriatrics
gerontology
health costs for
health needs of
health risks
health services for
criteria for effective service in level of care
health status of
homeless
homelessness, health complications hospice
Medicaid
Medicare
palliative care
primary prevention
coping with multiple losses and suicide economic security
needs
exercise needs
maintaining independence

2626
 nutrition needs
oral health needs
poverty
psychosocial needs
purpose
safety and health needs
sleep
social interaction and companionship spiritual needs
safety needs See (Safety and health needs of elderly) secondary
prevention
Alzheimer’s disease
arthritis
cancer
cardiovascular disease
depression
diabetes
obesity
osteoporosis
sensory loss
tertiary prevention
Older Americans Resources and Services Information System
(OARS) Older homeless
Omaha system
One Health
Online counseling and remote counseling Operational planning
Opioid, in America
Opioid crisis
Opioid epidemic
Oral health
in adolescents
in elderly
in infants, toddlers, and preschoolers in pregnancy
school nurse in
in school-age children
OSHA. See Occupational Safety and Health Administration (OSHA)
Osteoporosis
OTC drugs

2627
Outcome. See also specific topics health literacy and
program evaluation
Outcome and Assessment Information Set (OASIS) Outcome criteria
Outcome evaluation
for community programs/services
accreditation
benchmarking
logic models
program evaluation
quality assurance and improvement quality indicators
setting measurable goals and objectives Out-migration
Out-of- pocket payment
Ovarian cancer
Overweight
migrant and seasonal farmworkers in World Health Report 2002
Ozone levels
P
Pain relief, components of
Palliative care
definition of
for elderly
fundamentals of
in hospice
Palliative intervention
Pandemic
Parent training, of infants, toddlers, and preschoolers Parentchild
interactions, in infant brain development Parish nurse
Participation
restrictions
Partner notification
Partnership
in contracting
Passive immunity
Pathogenicity
Patient Protection and Affordable Care Act Patient-centered care
for correctional nurses

2628
 for EBP and ethics
Patient-Centered Outcomes Research Institute (PCORI) Patient-
delivered partner treatment Patterns
global health
migration
Patterns of migrant
Patterns of migration
Payment
prospective
retrospective
Pediculicide
Pediculosis
Peer-based support
Pender’s health promotion model
People with disabilities
Performing stage of group development Perimenopause
Period prevalence counts
Period prevalence rate
Personal factors
Personal Responsibility and Work Opportunity Reconciliation Act
Perspectives
community
for cervical cancer
on chronic illness
community health nursing
on correctional nursing
hearing loss
on Medicare
on migrant health care
on school nursing
on urban health
student
families in disabilities
on maternal-child health
Pesticide exposure, migrant worker Phases of disasters
Philadelphia study
Physical abuse

2629
Physical activity
Plague
Planetary health
Planned change
applying to larger aggregates
change and health promotion within characteristics
effecting positive change
process
Planning. See also specific topics community as client
goals and objectives
health planning process
priority setting
tools to assist with
grants
applications
Federal grants
grant process
management
group identification
advisory groups
collaborating with
community action model
delineating the problem(s)
enabling factors
engaging, target population
importance and changeability
local health priorities and initiatives national and state
health objectives and initiatives predisposing factors
reinforcing factors
target groups and neighborhoods
understanding, target population using data to confirm
using evidence to guide interventions marketing
social marketing
value of
outcome evaluation in
accreditation
benchmarking

2630
 logic models
program evaluation
quality assurance and improvement quality indicators
setting measurable goals and objectives program planning
in
evaluating outcomes
overview of
steps and sources of information in in teaching
Plausibility
Pneumonia
Point-in-time counts
Point-of-Service Plans
Poisoning, of children
Polarization
Policy
analysis
for activism
Kingdon’s framework
rational framework
definition
global health
solution
Policy competence
Policy development
Policy primeval soup
Polio
Political action
committees
nursing’s role, in health care reform professional advocacy
public health and social justice public health nursing advocacy
Political action committee (PAC) Politics
Pollution
air
biologic
Polypharmacy, in older adults
Poor nutrition, migrant and seasonal farmworkers Population
density

2631
 infectious diseases, era of See (Infectious disease) statistics
Population characteristics
composition/demographics
cultural characteristics
density
mobility
rate of growth
size
social determinants of health
Population density
Population focus
Population health
Population-based interventions
Population-focused care
Postacute care
postgraduation employment
Postpartum depression
Posttraumatic stress disorder (PTSD) Potential years of life lost
(PYLL) Poverty
on children’s health
on health
in homelessness
Power
Precautionary principle
PRECEDE model
Preconception care
Precontemplation, in stages of change model Predictive value
Predisposing factors, in planning Preferred provider organization
Pregnancy
teenage, school nursing and
violence during
Pregnancy Risk Assessment Monitoring System (PRAMS) Pregnant
women and infants
cesarean section deliveries in
complications of childbearing in fetal or infant death
gestational diabetes
hypertensive disease

2632
 postpartum depression
global overview of
HIV/AIDS
infant mortality rate
Healthy People 2030 on
maternal mortality rates in
risk factors for
adolescent pregnancy
alcohol use
HIV and AIDS
intimate partner violence
maternal developmental disability oral health
poor nutrition and weight gain
sexually transmitted diseases
socioeconomic status and social inequality substance use
teenage pregnancy, epidemiology
tobacco use
U.S. overview of
birth weight and preterm birth
breast-feeding
substance use and abuse
violence
Preparation, in stages of change model Preparedness phase
Preschool
Preschoolers. See also Infants, toddlers, and preschoolers Prescription
Prescription drug
Prescription drug abuse, in adolescents Preterm birth
Prevalence
Prevalence rate
Prevalence studies
Preventing disasters
Prevention. See also Prevention pyramid, levels of for healthy full-
term infant
primary
secondary
tertiary
Prevention pyramid, levels of

2633
 for adult health
for breast cancer
for cervical cancer
community health nursing
for diabetes type 2, childhood
for domestic violence in migrant worker population
environmental health and safety
epidemiology
for homeless addict health
for obesity in school setting
for school nursing
for transition into retirement, healthy Previsit preparation
Primary health care (PHC)
Primary prevention. See also Prevention pyramid, levels of Primary
Stroke Center (PSC)
Principles. See also specific topics Priority setting
Privacy
Private agencies
Private health sector organizations Private insurance companies
Private settings
faith community nursing
activities and interventions
as advocate
congregational health and wholeness faith and health,
integrator of
as health counselor
as health educator
historical background of
practice
as referral agent
roles of
as support group developer
as volunteer coordinator
nurse entrepreneur in community public health nursing in
community
opportunities
steps to becoming

2634
 nurse-led health centers/clinics community service learning in
definition and overview
family-centered care
funding for
future directions for
history of
models
nursing research and
perspectives on
students role in
wellness screening
occupational and environmental health nursing educational
preparation
evidence-based practice
future trends
health promotion and wellness
history of
occupational health team
roles and career opportunities of safety culture creation
settings for
work on health, effects of
Problem-oriented assessment
Procedural policy
PROCEED model
Professional advocacy
Program planning, community programs/services evaluating
outcomes
overview of
steps and sources of information in Promotoras, 772
Prospective payment
Prospective study
Prostate
Prostate cancer
Prostate health
Protective factors
Psychomotor domains
Psychosocial needs, of elderly

2635
Public agencies
Public health
definition and scope of
elements of
goal of
managed care and the future of
in urban areas See also (Urban health care) Public health care
(PHC). See Primary health care (PHC) Public health care
system development, U.S.
early health insurance
health-related professional associations recent calls to action
Public health departments, in rural areas Public Health Emergencies
of International Concern (PHEIC) Public health ethics
Public health functions
assessment
assurance
within the core public health functions model essential services
policy development
Public Health Functions Steering Committee Public health
interventions
Public health nursing (PHN)
and 10 essential public health services and 1918 influenza
pandemic
assessment
community settings for
definition of
development of
education in
funding and governmental structures for local public health
national policy
state agencies
Healthy People 2030 on
history and evolution of (1900-1970) community health nursing
(1970-present) in district nurse
early home care nursing
professionalization and education Sanger
visiting nurse associations

2636
 Wald
key functions in
nursing roles in
assess
diagnosis
evaluation
Indian Health Service
overview
plan and implement
school nursing
uniformed public health nursing
U.S. Public Health Service Commissioned Corps
(USPHSCC) practice model
principles
public health functions
assessment
assurance
within the core public health functions model essential
services
policy development
Salmon’s construct for
school nursing See (School nursing and nurses) school-based
health centers
settings for community and public health nursing practice
ambulatory service settings
community at large
faith communities
homes
occupational health settings
residential institutions
schools
Standards of Practice
tuberculosis
Public health nursing practice
ambulatory service settings
community at large
faith communities

2637
 homes
occupational health settings
residential institutions
schools
Public health services, ten essential Public policy
Public policy and community, research, on community/public health
and nursing practice Public sector health services
budgets and funding for
core public health functions
Department of Health and Human Services federal public health
agencies
local public health agencies
state public health agencies
Purpose, for elderly
Q
Quad Council Coalition
Quad Council of Public Health Nursing Organizations Quality and
Safety Education for Nurses (QSEN) Quality improvement (QI)
for homeless
Quality indicators, outcome evaluation in Quality of care, in
vulnerable populations Quality of life
Quality-adjusted years of life (QALYs) Quarantine

R
Race. See also Ethnic group Racial and Ethnic Approaches to
Community Health (REACH) Racial disparities
Racial/ethnic disparities
Racism
Radiation
Randomized controlled trials (RCTs) Rapid Response Registry
Rates
computing
definition of
types of
Rationing
Rationing in health care
Reaching out

2638
Recovery
Recovery phase
Red Cross
Referral. See also specific health care areas Referral agent, rural
community health nurse role in Reform
Refreezing
Refugee
immunization of
vulnerable individuals
Regulation
Regulatory policy
Rehabilitation Act
Reinforcing factors, in planning Relapse
Relationship
causal
protective factors
risk factors
trusting
Relative risk
Reliability
Remarriage
Reportable diseases
Reproductive health
in adult men
in young adult women
Request for proposal (RFP)
Research
on community health nursing
on community/public health and nursing practice
community/public health nurse’s role and patient outcomes
public policy and community/public health conducting
epidemiological See also (Epidemiology) definition of
evidence-based practice
family–nurse partnership
implementation, quality improvement and research
Institutional Review Board/Human Subjects
Committee Approval need for

2639
 patient-centered care for
principles of
process, steps of
research basics to
to evidence-based practice
participatory action
on women’s health
Researcher role, community and public health nurses Reservoir
Residential institutions, settings for community and public health
nursing practice Resilience
Resistance, inherent
Resolution/advanced disease stage Resource
environmental
optimizing use of
socioeconomic
Resource allocator
Resource directory
Respect
Respite care
Respite care services
Response phase
Restorative justice
Rethinking drinking
Retrospective payment
Retrospective study
Review
integrative
scoping
systematic
Revolutionary change
RFP. See Request for proposal (RFP) Rights of inmates
Ring vaccination
Risk assessment
Risk averse
Risk factor
Risk management
R-nought/R-zero

2640
Robb, Isabel Hampton
Rogers, Lina
Rural
Rural health care
access to health care in
barriers to
insurance, managed care, and health care services in new
approaches to
community health nursing in
definitions of
demographics of
health issues in
access to acute care
agriculture and health
built environment and health
locating rural home health clients self, home and
community care
Healthy People 2030, 766–768
major health problems in
cardiovascular disease
chronic obstructive pulmonary disease diabetes
HIV
population characteristics in
age and gender
race and ethnicity
Rural health clinics
Rural homeless
Rural nursing
S
Safe consumption sites
Safety
in illness and injury prevention for infants, toddlers, and
preschoolers medication
nurse
occupational, for migrant workers school nursing in

2641
 for school-age children and adolescents Safety and health needs
of elderly assessment guidelines for
in community
falls in
immunizations
medications
as pedestrians and drivers
polypharmacy in, sb0007
Safety-net health care provider
Safety-net programs
Sanger, Margaret
Sanitary statistics
Sanitation
SARS-CoV2 (COVID-19)
Sate Children’s Health Insurance Programs (S-CHIPs) Satisfaction,
client
School age child health
behavioral and learning problems of attention deficit
hyperactivity disorder behavioral problems
disabilities
divorce
emotional problems
learning disorders
school refusal
communicable diseases in
dental health in
economic status-related problems in health problems of, chronic
diseases asthma
autism spectrum disorder
cancer
diabetes
seizure disorders
health problems of, overview
inactivity in
injury-related deaths in
nutrition in, inadequate
obesity and overweight in See (Overweight) poverty

2642
 seizure disorders
School nurse
School nursing and nurses
careers
definition and overview of
education of
evidence-based practice of
history of
key roles of
nursing practice of, chronic conditions anaphylaxis
asthma
behavioral problems
diabetes
food allergies
individualized education plans
individualized health plans
learning disabilities
medication administration
Section 504 plans
seizure disorders
nursing practice of, health education and promotion in nursing
practice of, illness and injury prevention immunization
safety
prevention pyramid for
promotion of healthful environment in abuse
adolescent high-risk behaviors
eating disorders
homelessness and hunger
maltreatment
mental health issues and suicide nutrition and exercise
obesity
substance abuse
teen pregnancy and STDs
responsibilities of
school-based health clinics in
screenings
health

2643
 hearing
oral and dental health
vision
seizure disorders
School refusal
School, settings for community and public health nursing practice
School violence
School-age child health services health promotion programs in
health protection programs in
preventive health programs in
School-based clinics
School-based health center (SBHC) Scientific studies
Scope
Scope and Standards of Practice for Home Health Nursing Scoping
reviews
Screening
communicable disease
Department of Homeland Security (DHS) in developmental
of older adults
by school nurse
health
hearing
oral and dental health
vision
Seacole, Mary
Seasonal farmworkers
Secondary conditions
Secondary prevention
Section 504 plans
Security, economic, for elderly
Seizure disorders
child
Self-care
Self-care deficit
Self-care practices
Self-determination
Self-directed violence (SDV)

2644
Self-evaluation
Self-injury
Self-insured health plans
Semmelweis, Ignaz
Senility
Sensorineural hearing loss
Settings, private. See Private settings Severe weather events
Sexual abuse
Sexual assault
Sexuality, teen
Sexually transmitted diseases (STDs). See also N
Chlamydia
genital herpes
gonorrhea
in pregnancy
prevention and control
school nursing and
smallpox
syphilis
viral warts
Shaken baby syndrome
Shared goals, in collaboration
Sheppard–Towner Maternity and Infancy Act Sickle cell anemia
Sign language
Single-nurse unit
Single-parent families
Single-payer system
Single-room occupancy (SRO) housing S-I-R model
Situation-specific theories
Skilled home health care
Skilled nursing facilities
Sleet, Jessie
Smallpox
Smokeless tobacco use
in adolescents
Smoking
in adolescents

2645
 in adults
chronic lower respiratory diseases from in pregnancy
Snow, John
Social capital
Social determinants of health
Social inequality, in pregnancy
Social interaction, in elderly
Social justice
Social marketing
concepts of
definition
ethical issues in
nursing students and
Social media
Social Security Disability Insurance (SSDI) Social Security’s
Supplemental Security Income (SSI) Social stressors
Social system
Societal risk factors
Socioeconomic gradient
Socioeconomic resources
Socioeconomic status, pregnancy and Speaking truth
Special interest groups
Specialized physical health care procedures Specificity
Spectrum of prevention
Spiritual needs, of elderly
Spokesperson role
Stages of change
Stalking
Standards for behavior, values
Standards of Practice
State Children’s Health Insurance Program (SCHIP) State health
department (SHD)
State policy
State public health agencies
Statistical area
metropolitan
micropolitan

2646
Statistics, vital
Status
health
on school-age child health
socioeconomic, pregnancy and
Statutory model
Stigma
Stillbirth
Storming stage of group development Strategic planning
Strength of association
Stress, in adolescents
Stroke
Structural–functional framework
Structure, program evaluation
Structure–process evaluation
Student study teams (SSTs)
Subclinical disease stage
Subcultures
Subject relevance
Substance use and abuse
in adolescents
in adults
cocaine
community health nurse
cost
Healthy People 2030, 720
homelessness and
incidence and prevalence
indicated strategies
marijuana
in pregnancy
prevention strategies
recovery
school nursing and
selective strategies
tobacco See also (Tobacco use) Substance use disorder (SUD)
Substantive policy

2647
Sudden infant death syndrome (SIDS) Suffocation, infant
Suicide
in adolescents
in elderly
mental and substance use disorders rates in rural areas
school nursing and
in school-age children
Summative evaluation
Sun exposure, in elderly
Superfund
Supervised injection sites
Supplemental Security Income (SSI) Supply
Supply-side policies
Surprise medical billing
Surveillance
Surveillance systems
Survival sex
Susceptibility
Susceptibility stage
Sustainability
of nurse-managed health clinics
Sustainable communities
Sustainable Development Goals (SDGs) Sustaining oneself
Sydenham, Thomas
Syphilis
in adolescents
in pregnancy
Systematic reviews
Systems theory
T
Tacit
Target population
Tau proteins
Teaching, effective. See also Teaching-learning principles clients with
special learning
definition of

2648
 materials
methods
teaching process
Teaching–learning principles
client application
client environment
client participation
client perceptions
client readiness
client satisfaction
subject relevance
Technical skills
Technology at home, home health care Teen dating violence
Teen fathers. See also Pregnant women and infants Teen mothers. See
Pregnant women and infants Teen sexuality
Teenage pregnancy
epidemiology
school nursing and
Telehealth
Temporality
Temporary Assistance for Needy Families (TANF) Ten essential
public health services. See Essential services Ten essentials of
public health services Tenement
Terminal values
Termination, in stages of change model Terrorism
biologic warfare
bioterrorism
chemical warfare
community/public health nurse role primary prevention
secondary and tertiary prevention current and future
opportunities factors contributing to
history of
trauma
Tertiary prevention
Testicular cancer
Third-party payments
government health programs

2649
 independent or self-insured plans private insurance companies
Tick-Borne diseases
Tobacco industry, in U.S.
Tobacco use
in adolescents
in adults
epidemiology of
in pregnancy
Toddlers. See Infants, toddlers, and preschoolers Total Worker Health
(TWH)
Toxic exposures
air
food
microbial toxins
vulnerable groups
toxic waste
and communities
radiation
waste management
water
Toxicology
Toxigenicity
Traditional families
Transcultural nursing
community/public health nurse, role and preparation of culture
See also (Culture) characteristics of
cultural diversity
as dynamic
ethnocentrism
as generally tacit
as integrated
as learned
as shared
ethnocultural health care practices biomedical view
folk medicine and home remedies
herbalism
holistic view

2650
 integrated health care and self-care practices
magicoreligious view
prescription and OTC drugs
ethnocultural health care practices in See (Ethnocultural health
care) transcultural community/public health nursing
principles client group’s culture assessment cultural self-
awareness
cultural sensitivity
culturally derived health practices respect and patience in
Transgender
Transitional care
Transmission
airborne
direct
food-and water-related
indirect
vector
Transtheoretical model (TTM)
Trauma Informed Care (TIC)
Traveling, personal safety during the home visit Triage
Trusting relationships
Tuberculosis (TB)
case management
classification system for
diagnosis of
with HIV
incidence and prevalence of
in migrant workers
multidrug-resistant
pathophysiology and transmission of prevention and
intervention
in public health nursing setting screening
surveillance of
tuberculin skin test reactions for TWH. See Total Worker Health
(TWH) Twitter
Two-phase cultural assessment process U
Unaccompanied youth

2651
Underinsured
Unfreezing
Uniformed public health nursing
Uninsured
Unintentional injuries
United Nations Convention on the Rights of Persons With Disabilities
Universal coverage
Universal design
Universal precaution
Universal prevention
Unmarried parents, adolescent. See also Teenage pregnancy
Unsheltered homeless
Urban
Urban health
Urban health care
access to health services
community health nursing in
definition and overview of
health disparities in
history of
social justice and community health nurse urban populations in
Urban planning
Urban sprawl
Urbanized area (UA)
U.S. Department of Health and Human Services (USDHHS) U.S.
Public Health Service (USPHS) U.S. Public Health Service
Commissioned Corps (USPHSCC) U.S. Zika Pregnancy and
Infant Registry Utilitarianism
V
Vaccine
Vaccine hesitancy
conceptual model of
matrix
Vaccine-preventable diseases (VPDs) Vaccines and vaccination, ring
Validity
predictive
Value(s). See also Ethical decision-making application of

2652
 in community/ public health nursing clarification
conflict
dominant
hierarchical system of
standards for behavior
terminal
value systems
Value systems
Value-based care
Values clarification
Vector
Vector transmission
Vector-borne diseases
Veracity
Very low birth weight (VLBW)
Veterans, homeless
Vicarious
Video games
Violence
in adolescents
batterer characteristics
child abuse in See also (Child abuse) against children
commercial sexual exploitation
emotional abuse
neglect
physical abuse
specific abusive situations
cycle of violence
effects, on children
elder abuse
gang violence
gun violence
history
myths and truths
public laws
homelessness and
homicide

2653
 human trafficking
intimate partner
life cycle
neurobiology of trauma
protective factors and risk factors nursing process
assessment and nursing diagnosis evaluation
implementation
planning interventions
from outside home
during pregnancy
primary prevention
secondary prevention
self-directed violence
sexual assault
stalking
teen dating violence
tertiary prevention
victim characteristics
vulnerability factors
workplace violence
Viral warts
Virtual reality games
Visiting nurse associations (VANs) Vital statistics
Volunteering
Vulnerability
Vulnerable populations
access to nursing services
behavioral model
causative factors in
poverty
race and ethnicity
uninsured and underinsured
conceptual model
definition and overview of
health literacy
improving health and public policy inequality in health care in
access to care

2654
 health disparities
social determinants of health
socioeconomic gradient of health models and theories of
prevalence of
public health nurse role in
empowerment
evidence to reduce
facilitating external support
participatory action research
quality of care in
W
Wald, Lillian
Wall-less concept
Waste, infectious
Waste management
Water contamination
Web of causation
Weight gain, in pregnancy
Well-being
Wellness
community and public health nurses in elderly
epidemiology of
Wellness center
Wellness-illness
West Nile virus
Western culture
Western stream
Whitman, Walt
Whole School, Whole Community, Whole Child (WSCC) model
Windshield
Windshield survey
Women, homeless
Women’s health
in adults
cancer in
chronic fatigue syndrome in

2655
 heart disease in
menopause and hormone replacement therapy in
factors in
Healthy People 2030 goals for research on
in young adults
eating disorders in
nursing care plan matrix for promotion of overview of
reproductive health in
sexually transmitted diseases in Working poor
Workplace violence
Works Progress Administration (WPA) World community,
ethnocultural health care practices biomedical view
folk medicine and home remedies
herbalism
holistic view
magicoreligious view
prescription and OTC drugs
World Health Organization (WHO)
World Health Report 2002, on chronic illness and disabilities World
Trade Center Health Registry Y
Years lived with disability (YLD) Years of life lost (YLL)
Yield
Young adults
men See (Men’s health)
women See (Women’s health) Youth, homeless
Youth Risk Behavior Surveillance System Youth Risk Behavior
Survey (YRBS)

2656