Chapter 1
Health: A Community View
Community/Public Health Nursing
➢ is the synthesis of nursing practice and public health practice.
➢ has the major goal to preserve the health of the community and surrounding populations.
➢ focuses on health promotion and health maintenance.
➢ is associated with health and identification of populations at risk rather than an episodic
response to patient demand.
Public Health
● Is described as the art and science of:
➢ Preventing disease
➢ Prolonging life
➢ Promoting health through organized community efforts to benefit each citizen.
-Winslow (1920)
Definition of Community
● "a collection of people who interact with one another and whose common interests or
characteristics form the basis for a sense of unity and belonging".
-Rector (2017)
Health Care Reform
● "Costs of caring for the sick account for the majority of escalating health care dollars,
which increased from 5.7% of the gross domestic product in 1965 to 17.8% in 2015".
-National Center for Health Statistics (NCHS) (2017)
● Community/public health nurses are in a position to assist the U.S. health care system to
transition from being disease-oriented to a health-oriented system.
Public Health Mission
The mission of public health is social justice, which entitles all people to basic necessities such
as adequate income and health protection and accepts collective burdens to make this possible.
Definitions of Health
● "A state of complete well-being, physical, social, and mental, and not merely the
absence of disease or infirmity".
-World Health Organization (1958)
● "The extent to which an individual or group is able, on the one hand, to realize
aspirations and satisfy needs; and, on the other hand, to change or cope with the
environment. Health is, therefore, seen as a resource for everyday life, not the objective
of living; it is a positive concept emphasizing social and personal resources, and physical
capacities".
-World Health Organization (1986)
Definition and Focus of Public Health and Community Health
● Public health is the Science and Art of…
○ Prolonging life
○ Preventing disease
○ Promoting health and efficiency through organized community effort
● Community health extends the realm of public health to include organized health efforts
at the community level through both government and private efforts.
Core Public Health Functions
● Assessment: Regular collection, analysis, and information sharing about health
conditions, risks, and resources in a community
● Policy development: Use of information gathered during assessment to develop local
and state health policies and to direct resources toward those policies
● Assurance: Focuses on the availability of necessary health services throughout the
community. It includes maintaining the ability of both public health agencies and private
providers to manage day-to-day operations and the capacity to respond to critical
situations and emergencies
-Institute of Medicine (1988)
Essential Public Health Services
● Monitor health status to identify and solve community health problems
● Diagnose and investigate health problems and health. hazards in the community
● Inform, educate, and empower people about health issues
● Mobilize community partnerships and actions to identify and solve health problems
● Develop policies and plans that support individual and community health efforts
● Enforce laws and regulations that protect health and ensure safety
● Link people to needed personal health services and assure the provision of health care
when otherwise unavailable
● Assure a competent public health and personal health care workforce
● Evaluate effectiveness, accessibility, and quality of personal and population-based
health services
● Research for new insights and innovative solutions to health problems
The Three Levels of Prevention
● Primary prevention
○ Prevention of problems before they occur
○ Health promotion and health protection
● Secondary prevention
○ Early detection and intervention
○ Early diagnosis and treatment
● Tertiary prevention
○ Correction and prevention of deterioration of a disease state
○ Limitation of disability and rehabilitation
Level of Prevention-Individual
Table with 4 columns and 2 rows describing individual level of prevention
Definition of Primary (health Secondary (early Tertiary (limitation of
client served promotion and diagnosis and disability and
specific prevention) treatment) rehabilitation)
Individual Dietary teaching HIV testing Teaching new clients
during pregnancy with diabetes how to
Screening for cervical administer insulin
Immunizations cancer
Exercise therapy
after stroke
Skin care for
incontinent patient
Level of Prevention-Family
Table with 4 columns and 2 rows describing family level of prevention
Definition of Primary (health Secondary (early Tertiary (limitation of
client served promotion and diagnosis and disability and
specific prevention) treatment) rehabilitation)
Family (two or more Education regarding Dental examinations Mental health
individuals bound by smoking, dental care, counseling or referral
kinship, law, or living or nutritional Tuberculin testing for for family in crisis
arrangement and with counseling families at risk (e.g., grieving or
common emotional experiencing a
ties and obligations) Adequate housing divorce)
Dietary instructions
and monitoring for
family with
overweight members
Level of Prevention-Group
Table with 4 columns and 2 rows describing group level of prevention
Definition of Primary (health Secondary (early Tertiary (limitation of
client served promotion and diagnosis and disability and
specific prevention) treatment) rehabilitation)
Group or aggregate Birthing classes for Vision screening of Group counseling for
(interacting people pregnant teenage first grade class grade school children
with a common mothers with asthma
purpose or purposes) Mammography van
AIDS and other STD for screening of Swim therapy for
education for high women in a physically disabled
school students low-income elders at a senior
neighborhood
Alcoholics
Hearing tests at a anonymous and other
senior center self-help groups
Mental health
services for military
veterans
Level of Prevention-Community
Table with 4 columns and 2 rows describing community level of prevention
Definition of Primary (health Secondary (early Tertiary (limitation of
client served promotion and diagnosis and disability and
specific prevention) treatment) rehabilitation)
Community and Fluoride water Organized screening Shelter and
populations supplementation programs for relocation centers for
(aggregate of people communities such as fire or
sharing space over Environmental health fairs earthquake victims
time within a social sanitation
system; population VDRL screening for Emergency medical
groups or aggregates Removal of marriage license services
with power relations environmental applicants in a city
and common needs hazards Community mental
or purposes) Lead screening for health services for
children by school chronically mentally ill
district
Home care services
for chronically ill
Prevention Versus Cure
● Cure
○ Spending additional dollars for cure in the form of health care services does little
to improve the health of a population.
● Prevention
○ Spending money on prevention does a great deal to improve health and
decrease the dollars spent on cure.
-Getzen (2013)
Thinking Upstream
● Examining the origins of disease, nurses identify social, political, environmental,
and economic factors that often lead to poor health options for both individual
and populations.
● Refocus the efforts of nurses “upstream”, where the real problem lies.
-McKinlay (1979)
Healthy People 2020
● Vision:
➢ A society in which all people live long, healthy lives
● Overarching goals:
➢ Attain high-quality, longer lives free of preventable disease, disability, injury, and
premature death
➢ Achieve health equity, eliminate disparities, and improve the health of all groups
➢ Create social and physical environments that promote good health for all
➢ Promote quality of life, healthy development, and healthy behaviors across all life
stages
● Leading Health Indicators
➢ Access to Health Services
➢ Clinical Preventive Services
➢ Environmental Quality
➢ Injury and Violence
➢ Maternal, Infant, and Child Health
➢ Mental Health
➢ Nutrition, Physical Activity, and Obesity
➢ Oral Health
➢ Reproductive and Sexual Health
➢ Social Determinants
➢ Substance Abuse
● HP2020 has 42 focus areas
➢ The objectives and related information and materials can help guide health
promotion activities and can be used to aid in community-wide initiatives.
● All health care practitioners...
➢ Should focus on the relevant areas in their practice
➢ Incorporate objectives into programs, events, and publications whenever possible
➢ Use them as a framework to promote healthy cities and communities
Health People 2020
1. Access to Quality Health Services
2. Adolescent Health
3. Arthritis, Osteoporosis, and Chronic Back Conditions
4. Blood Disorders and Blood Safety
5. Cancer
6. Chronic Kidney Disease
7. Dementias, including Alzheimer's Disease
8. Diabetes
9. Disability and Health
10. Early and Middle Childhood
11. Educational and Community-based Programs
12. Environmental Health
13. Family Planning
14. Food Safety
15. Genomics
16. Global Health
17. Health Communication and Health Information Technology
18. Healthcare-Associated Infections
19. Health-Related Quality of Life and Well- Being
20. Hearing and Other Sensory or Communication Disorders
21. Heart Disease and Stroke
22. HIV
23. Immunization and Infectious Diseases
24. Injury and Violence Prevention
25. Lesbian, Gay, Bisexual, and Transgender Health
26. Maternal, Infant, and Child Health
27. Medical Product Safety
28. Mental Health and Mental Disorders
29. Nutrition and Weight Status
30. Occupational Safety and Health
31. Older Health New
32. Oral Health
33. Physical Activity
34. Preparedness New
35. Public Health Infrastructure
36 Respiratory Disease
37. Sexually Transmitted Diseases
38. Sleep Health New
39. Social Determinants of HealthNew
40. Substance Abuse
41. Tobacco Use
42. Vision
Public Health Nursing
● ANA definition (2013)
○ The practice of promoting and protecting the health of populations
○ Uses knowledge from nursing, as well as social and public health sciences, to
promote and protect the health of populations.
○ Is population focused, with the goals of promoting health and preventing disease
and disability for all people
Community Health Nursing
● ANA definition (1980)
○ Synthesis of nursing practice and public health to promote and preserve the
health of populations
○ Care is directed to individuals, families, groups.
○ Contributes to health of the total population
○ The terms Public Health Nursing and Community Health Nursing are used
interchangeably in Nies and McEwen, 7th edition.
Community-Based Nursing
● "Application of the nursing process in caring for individuals, families and groups where
they live, work or go to school or as they move through the health care system"
-McEwen and Pullis (2009)
● Setting-specific
● Emphasis is on acute and chronic care
Community and Public Health Nursing Practice
● Nurses practice disease prevention and health promotion.
● Practice is collaborative.
● Practice is based on research and theory.
● Applies the nursing process to the care of...
○ Individuals
○ Families
○ Aggregates
○ The community
Population-Focused Nursing
● Focuses on the entire population Is based on assessment of the population's health
status
● Considers the broad determinants of health
● Emphasizes all levels of prevention
● Intervenes with communities, systems, individuals, and families
-Minnesota Department of Health (2003)
PHN Intervention Wheel
● Population based
● Contains three levels of practice:
○ Community
○ System
○ Individual/family
● Identifies 17 public health interventions grouped into five wedges by color
PHN Intervention Wheel
● Surveillance: Describes and monitors health events through ongoing and systematic
collection, analysis, and interpretation of health data for the purpose of planning,
implementing, and evaluating public health interventions
● Disease and other health event investigation: Systematically gathers and analyzes data
regarding threats to the health of populations, ascertains the source of the threat,
identifies cases and others at risk, and determines control measures
● Outreach: Locates populations of interest or populations at risk and provides information
about the nature of the concern, what can be done about it, and how services can be
obtained
● Screening: Identifies individuals with unrecognized health risk factors or asymptomatic
disease conditions in populations
● Case finding: Locates individuals and families with identified risk factors and connects
them with resources
● Referral and follow-up: Helps individuals, families, groups, organizations, and/or
communities identify and access necessary resources to prevent or resolve problems or
concerns
● Case management: Optimizes self-care capabilities of individuals and families and the
capacity of systems and communities to coordinate and provide services
● Delegated functions: Direct care tasks a registered professional nurse carries out under
the authority of a health care practitioner as allowed by law
● Health teaching: Communicates facts, ideas, and skills that change knowledge,
attitudes, values, beliefs, behaviors, and practices of individuals, families, systems,
and/or communities
● Counseling: Establishes an interpersonal relationship intended to increase or enhance
capacity for self- care and coping with a community, system, and family or individual
● Consultation: Seeks information and generates optional solutions to perceived problems
or issues through interactive problem-solving with a community, system, and family or
individual
● Collaboration: Commits two or more persons or organizations to achieve a common goal
through enhancing the capacity of one or more of the members to promote and protect
health
● Coalition building: Promotes and develops alliances among organizations or
constituencies for a common purpose
● Community organizing: Helps community groups identify common problems or goals,
mobilize resources, and develop and implement strategies for reaching the goals they
collectively have set
● Advocacy. Plead someone's cause or act on someone's behalf, with focus on developing
the capacity of the community, system, and individual or family to plead their own cause
or act on their own behalf
● Social marketing: Uses commercial marketing principles and technologies for programs
designed to influence the knowledge, attitudes, values, beliefs, behaviors, and practices
of the population of interest.
● Policy development and enforcement. Places health issues on decision-makers'
agendas, acquires a plan of resolution, and determines needed resources, resulting in
laws, rules, regulations, ordinances, and policies. Policy enforcement compels others to
comply with laws, rules, regulations, ordinances, and policies
Providing Population-Based Care... A Shift in Thinking
1. Populations are not homogeneous; must address the needs of special subpopulations.
2. High-risk and vulnerable subpopulations must be identified early in the care delivery cycle.
3. Nonusers of services often become high-cost users; essential to develop outreach strategies.
4. Quality and cost of all health care services are linked together across the health care
continuum.
-Kaiser Family Foundation (2013)