POPULATION AND COMMUNITY HEALTH

NURSING

Mary Jo Clark

Sixth Edition

Boston Columbus Indianapolis New York San Francisco Hoboken Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montreal Toronto

Delhi Mexico City São Paulo Sydney Hong Kong Seoul Singapore Taipei Tokyo

A01_MARY9591_06_SE_FM.indd 1 09/09/14 5:22 PM

Publisher: Julie Alexander Product Manager/Executive Editor: Pamela Fuller Development Editor: Elisabeth Garofalo Program Manager: Erin Rafferty Editorial Assistant: Erin Sullivan Director of Marketing: David Gesell Senior Product Marketing Manager: Phoenix Harvey Field Marketing Manager: Debi Doyle Marketing Specialist: Michael Sirinides Director, Product Management Services: Etain O’Dea

Project Management Team Lead: Cynthia Zonneveld Project Managers: Maria Reyes, Jonathan Cheung Manufacturing Manager: Maura Zaldivar-Garcia Art Director: Maria Guglielmo Cover and Interior Design: Wanda Espana Cover Art: Getty Images by Iconeer Full-Service Project Management: Revathi Viswanathan Composition: Lumina Datamatics, Inc. Printer/Binder: RR Donnelley / Willard Cover Printer: Phoenix Color/Hagerstown

Copyright © 2015, 2008, by Pearson Education, Inc. All rights reserved. Manufactured in the United States of America. This publication is protected by Copyright, and permission should be obtained from the publisher prior to any prohibited reproduction, storage in a retrieval system, or transmission in any form or by any means, electronic, mechanical, photocopy- ing, recording, or likewise. To obtain permission(s) to use material from this work, please submit a written request to Pearson Education, Inc., Permissions Department, 221 River Street, Hoboken, New Jersey 07030.

Many of the designations by manufacturers and sellers to distinguish their products are claimed as trademarks. Where those designations appear in this book, and the publisher was aware of a trademark claim, the designations have been printed in initial caps or all caps.

Library of Congress Cataloging-in-Publication Data Clark, Mary Jo Dummer, author. [Community health nursing] Population and Community Health Nursing / Mary Jo Clark. — Sixth edition. p. ; cm. Preceded by: Community health nursing / Mary Jo Clark. 5th edition. 2008. Includes bibliographical references and index. ISBN 978-0-13-385959-1 ISBN 0-13-385959-2 I. Title. [DNLM: 1. Community Health Nursing. 2. Nursing Process. WY 106] RT98 610.73’43—dc23 2014024175

ISBN-10: 0-13-385959-2 ISBN-13: 978-0-13-385959-1

10 9 8 7 6 5 4 3 2 1

A01_MARY9591_06_SE_FM.indd 2 09/09/14 5:22 PM

Mary Jo Clark, PhD, RN, PHN, has been practicing and teaching population health nursing for 50 years. After completing her BSN degree at the University of San Francisco, she received her in- troduction to global population health nursing as a U.S. Peace Corps Volunteer in Vita, India, a ru- ral town with a population of about 3,000. Returning to the United States, Dr. Clark employed her cross-cultural expertise as a Public Health Nurse in the Los Angeles County Department of Health Services. In 1973, she became a pediatric nurse practitioner, and later began teaching population health nursing at East Tennessee State University. She completed a master’s degree as a com- munity health clinical nurse specialist at Texas Women’s University and a PhD in nursing at the University of Texas at Austin. Moving with her army nurse husband to Augusta, Georgia, she taught graduate and undergraduate population health at the Medical College of Georgia. For the past 29 years, Dr. Clark has taught at baccalaureate, master’s, and doctoral levels at the University of San Diego, Hahn School of Nursing and Health Science. In addition to her full-time teaching and writing, Dr. Clark has maintained an active population health nursing practice. She is well known in the population health nursing field and has provided consultation and made presentations across the country and overseas. Her many and varied experiences in population health nursing in the United States and abroad form the core of the material presented in this book.

About the Author

This book is lovingly dedicated to Phil the elder, Phil the younger, and Heather, who are the wind beneath my wings, and to my fellow population health nurses and faculty across the country and around the globe. Little by little we are improving the health status of the world’s population.

Dedication

A01_MARY9591_06_SE_FM.indd 3 09/09/14 5:22 PM

Reviewers Our heartfelt thanks go to our colleagues from schools of nursing across the country and others who have given time generously to help create this exciting new edition of our text. These individuals helped us plan and shape our book and resources by reviewing chapters, art, design and more. Population and Community Health Nursing has reaped the benefit of your collective knowledge and experience as nurses and teachers, and we have improved the materials due to your efforts, suggestions, objections, endorsements and inspira- tion. Among those who gave their time to help us are the following:

Thank You!

Dr. Sue Bhati, PhD,FNP-BC,NP-C,MSN,RN Northern Virginia Community College Springfield, Virginia Terese Blakeslee, MSN, RN, Ed University of Wisconsin Oshkosh, Wisconsin Anne Watson Bongiorno, Ph.D., APHN-BC, CNE SUNY Plattsburgh Plattsburgh, New York Angeline Bushy, PhD, RN, FAAN, PHC University of Central Florida Daytona Beach, Florida Kim Clevenger, EdDc, MSN, RN, BC Morehead State University Morehead, Kentucky Angela Cox, RN, MS Ball State University—School of Nursing Muncie, Indiana Mary P. Curtis, RN, PhD, ANP-BC, PHCNS-BC Barnes-Jewish College, Goldfarb School of Nursing St. Louis, Missouri Pamela Davis, MSN, RN, ANP, CPHQ Northern Kentucky University Highland Heights, Kentucky Julia K. Donegan, MS, APHN-BC, RN The Ohio State University—College of Nursing Columbus, Ohio Charlene Douglas, PhD, MPH, RN George Mason University Fairfax, Georgia Janice Edelstein, RN, EdD University of Wisconsin Oshkosh, Wisconsin Susan England, PhD, RN Texas State University Round Rock, Texas Melissa Garno, EdD, RN Georgia Southern University—School of Nursing Statesboro, Georgia Camille Groom, RN,MS Miami-Dade College School of Nursing Miami, Florida

Tammy Haley, PhD, CRNP University of Pittsburgh at Bradford Bradford, Pennsylvania Linda James, MSc, RN Sam Houston State University Huntsville, Texas Nancy Jones, MSN, RN Kent State University Kent, Ohio Toshua Kennedy, MSN/MPH, BSN, ADN The University of South Carolina Upstate Greenville, South Carolina Nancy Laplante, PhD, RN Neumann University Aston, Pennsylvania Sherry Lovan, PhD, RN Western Kentucky University Bowling Green, Kentucky Paula McNiel, DNP, RN, APHN-BC University of Wisconsin Oshkosh—College of Nursing Oshkosh, Wisconsin Richard Ralls, RN, BSN Florida International University Miami, Florida Kate Shade, PhD, RN Samuel Merritt University Oakland, California Ashley Shroyer, MSN, RN, CNE Fairmont State University Fairmont, West Virginia Virginia Teel, DHSc, RN Georgia Southern University Statesboro, Georgia Anne Watson Bongiorno, Ph.D., APHN-BC, CNE SUNY Plattsburgh Plattsburgh, New York Kim White, PhD, MS, CNS-BC Southern Illinois University Edwardsville—School of Nursing Edwardsville, Illinois

Lisa Rae Dummer, Transgender Law Center San Francisco, California

A01_MARY9591_06_SE_FM.indd 4 09/09/14 5:22 PM

Preface

This book represents the lessons learned and the prog-ress made in more than 100 years of population health nursing in the United States. The year 1993 marked the 100th anniversary of the founding of the Henry Street Settlement, the acknowledged beginning of modern American population health nursing. Since then, the work of population health nurses and others has led to better health for individuals, families, and population groups. In this book, I have tried to dis- till the wisdom of early pioneers and present-day practitioners to guide and direct future generations toward nursing excellence.

Locally, nationally, and globally, society is in greater need of population health nursing services than at any time since our be- ginning. Although expected longevity has increased significantly in the last century, quality of life has not kept pace for a large por- tion of the world’s population. Previously controlled communi- cable diseases are resurfacing, and new diseases are emerging to threaten the public’s health. Malnutrition is a fact of life for many people. Chronic physical and emotional diseases are taking their toll on the lives of large numbers of people. Substance abuse and violence are rampant, and more and more frequently, environ- mental conditions do not support health. All of these are problems that population health nurses can and do help to solve.

Population health nurses must have the depth and breadth of knowledge that allows them to work independently and in conjunction with clients and others to improve the health of the world’s populations. In part, this improvement occurs through care provided to individuals and families, but it must also occur on a larger scale through care provided to communi- ties and population groups. Population and Community Health Nursing, Sixth Edition, provides population health nurses with the knowledge needed to intervene at these levels. This knowl- edge is theoretically and scientifically sound, yet practical and applicable to society’s changing demands.

Nursing Excellence Through Advocacy Like prior editions, this edition focuses on the central facet of population health nursing—advocating for the health of the public. The theoretical concept of advocacy is introduced in Chapter 1 and is based on qualitative research by the author that examines the process of advocacy as it is performed by population health nurses. Practical application of the concept occurs in each of the subsequent chapters.

Advocacy Then and Advocacy Now The Advocacy Then and Advocacy Now vignettes that open each chapter showcase the efforts of population health nurses,

other health professionals, and members of the lay public to advocate for the health of populations. Some of the Advocacy Now vignettes were contributed by population health nurses and are gratefully acknowledged. Other vignettes celebrate the past and present contributions of population health nurses and others to promoting health and addressing health needs in the United States and the world. We offer our appreciation to these contributors for their heartfelt descriptions of nursing in the population and for their generosity in permitting us to tell their stories. The Advocacy Now vignette that opens Chapter 2 de- scribes the work of Susie Walking Bear Yellowtail, the first Na- tive American registered nurse and an exemplary population health nurse advocate. The other stories, past and present, are equally inspiring for the population health nurses of today and those in the ages to come.

Population and Community Health Nursing, Sixth Edition, provides students with a strong, balanced foundation for pop- ulation health nursing practice. The book is designed to help students first achieve excellence in the classroom through the many features and exercises that accompany the narrative. The additional tools and supplemental information will help stu- dents succeed at applying those concepts in clinical settings with families, communities, and population groups, with the ultimate goal of preparing nurse generalists who will exhibit nursing excellence in any setting.

The underlying intent of this book is to convey to nurs- ing students at the beginning of the 21st century the excite- ment and challenge of providing nursing care to populations. As we begin a new era of population health nursing, I believe that well-educated population health nurses can provide a fo- cal point for resolution of the global health problems presented throughout the book. Early population health nurses changed the face of society; we can be a strong force in molding the so- ciety of the future by striving for nursing excellence through advocacy.

Organization This textbook is designed to present general principles of population health nursing and to assist students to apply those principles in practice. It is organized in five units. The first three units address general concepts and strategies of popula- tion health nursing practice, and the last two examine the ap- plication of those concepts to specific populations, settings, and population health problems.

UNIT I sets the stage for practice by describing popula- tion health nursing and the context in which it occurs. Read- ers are introduced to population health nursing as an area of

v

A01_MARY9591_06_SE_FM.indd 5 09/09/14 5:22 PM

vi Preface

specialized practice and to its emphasis on advocacy for the health of individuals, families, and population groups. The attributes and features that make population health nursing unique, standards for practice, and typical roles and func- tions of population health nurses are addressed. Then, the concept of populations as recipients of nursing care and the historical and theoretical underpinnings and development of population health nursing are presented followed by a discus- sion of epidemiology as a core content area for population health care.

A unique feature of this book is the consistent use of the Population Health Nursing model to structure the discussion of principles of practice. The model is introduced in Chapter 1. Further Information about other theoretical models that may be useful in population health nursing practice is provided in ancillary materials found at www.nursing.pearsonhighered .com. Other relevant models dealing with epidemiology, family nursing, health promotion, and so on, are included in specific chapters.

The population health nursing (PHN) model is used as the organizing framework for most of the chapters in the book, providing students with a systematic approach to determining factors that influence health and relevant strategies designed to promote health, prevent illness and injury, resolve existing health problems, and restore health in individuals, families, communities, and populations. The consistent use of the PHN model permits students to readily identify commonalities and differences among processes, populations, settings, and health problems.

UNIT II examines influences on population health and ad- dresses environmental, cultural, economic, healthcare delivery system, and global influences on population health. Knowledge of the influence of these factors on population health leads to the application of specific strategies to improve population health addressed in UNIT III. Strategies addressed include po- litical, empowerment, health promotion and health education, case management, and home visiting approaches to population health nursing as a specialized area of practice. Other aspects of population health nursing practice (e.g., community engage- ment, referral, delegation, social marketing, group dynamics, and leadership) are integrated into these and other chapters as appropriate.

UNIT Iv addresses health care provided to special popu- lation groups. In each chapter, students are assisted to apply principles of care to individuals and families, as well as to these populations as aggregates. For example, Chapter 16 emphasizes population health nursing care for children and adolescents as population groups, as well as strategies for improving the health of individual children and adolescents. Similar approaches are taken to other population groups in the unit: families, com- munities, men, women, the elderly, the GLBT population, and people experiencing poverty and homelessness.

UNIT Iv also addresses population health nursing in spe- cialized settings such as the school, work, correctional, and di- saster settings. For example, Chapter 22 examines the role of the

population health nurse in school settings, whereas Chapter 23 addresses employee health in the work setting. In each chapter in the unit, students are guided in the use of the nursing pro- cess and application of the PHN model in the special practice setting. Consideration is given to factors influencing determi- nants of health in each setting, and population health nursing interventions related to health promotion, illness and injury prevention, resolution of existing health problems, and health restoration are discussed.

UNIT v focuses on population health nursing practice re- lated to the control of common population health problems such as communicable diseases, chronic physical and men- tal health conditions, substance abuse, and societal violence. Again, students are assisted to apply the nursing process and the PHN model to identify factors contributing to problems in each of these areas and in designing nursing interventions at each of the four levels of health care. Consideration is given to the care of individuals and families with these problems as well as to resolving common health problems at the population level.

How to use this book to foster success in POPULATION HEALTH advocacy

The various features in the sixth edition of Population and Community Health Nursing provide tools to help you succeed in the classroom and in practice. They offer opportunities to apply the principles presented in the book in real and virtual practice settings, promoting your ability to be an advocate for health at multiple levels.

Learning Outcomes Learning outcomes at the beginning of each chapter help you to focus on the outcomes expected of you in relation to your knowledge and application of principles of population health nursing. They highlight the important content for each chapter and assist you in applying the PHN model to specific circum- stances and settings.

Key Terms The list of key terms at the beginning of each chapter alerts you to significant concepts to be addressed in the chapter, concepts with which an effective population health nurse needs to be fa- miliar. At the point of definition within the chapter, each term is set in boldface type.

Healthy People 2020: Objectives for Population Health These boxes present relevant objectives from Healthy People 2020 to familiarize you with these important population health goals. You also learn about the current status of objectives here

A01_MARY9591_06_SE_FM.indd 6 09/09/14 5:22 PM

Preface vii

and sources of further information on the objectives on the Nursing Portal for students at www.nursing.pearsonhighered .com.

Focused Assessments These boxes present a series of questions that assist you in conducting health assessments focused on a particular client, specific population groups, or particular aspects of care. They are framed in the context of determinants of health included in the PHN model and help you to tailor your nursing assessment to the specific needs of the client population, setting, or health problem addressed in the chapter.

Global Perspectives This feature presents an international view of population health nursing practice, examining issues that affect health throughout the world. The feature also addresses differences in population health nursing as practiced outside the United States and highlights global solutions to health problems facing mankind.

Evidence-Based Practice These boxes discuss the evidence base (and sometimes the lack of evidence) that underlies specific aspects of population health nursing practice. They also pose questions that stimulate think- ing about the development or critical review of the evidence base for practice.

Client Education These boxes identify important content for educating clients and the public regarding particular health issues and topics, equipping you for successful clinical encounters as you begin your career.

Highlights A feature intended to aid your review of content from the chap- ter; these bulleted summaries of main points or special foci ap- pear periodically in the text.

Case Studies Each chapter concludes with a case study designed to assist you to apply the principles addressed in the chapter to the real world of population health nursing practice. Many of the case studies foster application of the PHN model in clinical prac- tice with individual, families, and/or population groups. Each case study is followed by questions designed to promote critical thinking in practice.

References References contained in each chapter present an up-to-date pic- ture of principles and concepts related to the topic presented. References provide a balanced view of population health nurs- ing, exploring a variety of issues from several perspectives, and

provide a wide range of supplemental materials, including re- search reports, for the interested reader.

Additional Student Resources A variety of supplemental information and assessment tools are provided on the Nursing Portal for students at www.nursing .pearsonhighered.com. The site includes the following features:

• Testing Your Understanding: This feature assists you in evaluating your comprehension of concepts and principles presented in each chapter and assessing your achievement of the chapter learning outcomes. Questions are open-ended to facilitate thought and discussion.

• Clinical Reasoning Questions: Additional short answer questions are provided to assist readers in applying content from the chapters and to promote clinical reasoning. These questions maintain a balance between application of prac- tice concepts to individuals/families and population groups.

• Exam Review Questions: Multiple-choice review questions are provided for each chapter to assist readers in evaluating their comprehension of chapter content.

• Assessment Guidelines: The Nursing Portal for students also contains a wide variety of assessment tools and guide- lines to assess the health needs of individuals, families, and population groups in a variety of settings. Formerly included in a separate companion text, these tools and guidelines are made available to assist you with the practical aspects of as- sessing the health needs of various populations as well as in- dividual clients and their families. Most of the guidelines are organized around the elements of the PHN model, making it even easier to apply the model to a variety of client popu- lations, settings, and population health issues. Tools range from comprehensive assessment and intervention guides for care of specific population groups (e.g., children and ado- lescents, prisoners) or in specific settings (e.g., schools) to more specialized assessments (e.g., fall risk assessment in the elderly or client suitability for case management services). The tools and guidelines can be downloaded for immediate use in practice.

• Cultural Considerations: Relevant cultural considerations are provided for each chapter of the book to assist you in developing expertise in caring for a wide variety of culturally and ethnically diverse populations.

• Further Information: For some chapters, the Nursing Portal for students contains additional information related to chap- ter topics that may be of interest to readers. As noted earlier, additional information about other theoretical models for population health nursing is provided in this feature. Simi- larly, detailed cultural information tables are provided for a wide variety of cultural groups, including ethnic groups, healthcare professionals, and the dominant U.S. culture.

• Resource Exchange: This section of the Nursing Portal for students provides resources for further information on a va- riety of topics addressed in the book.

A01_MARY9591_06_SE_FM.indd 7 09/09/14 5:22 PM

viii Preface

Instructor Resources • Test Bank: An electronic test generator with questions for

each chapter is available for instructors to download from the Instructor Resource Center via the Nursing Portal.

• Instructor’s Resource Manual: This guide, available in the Instructor Resource Center, provides a wealth of helpful in- formation for planning learning opportunities for students.

Included are learning objectives that provide instructors with student goals for each chapter. Suggested classroom ac- tivities promote student participation in learning and help bring community health nursing practice to life.

• Lecture Note PowerPoints: PowerPoint slides for each chapter are available to instructors in the Instructor Re- source Center to help convey key points to students in class and facilitate discussion.

A01_MARY9591_06_SE_FM.indd 8 09/09/14 5:22 PM

Contents

Preface v

Unit 1 Population Health Nursing: An Overview 1

Chapter 1 Population Health and Nursing 2 Defining Populations as a Focus for Care 3 Defining Population Health 4 Population Health Practice 5

Core Public Health Functions 5 Essential Public Health Services 5

Objectives for Population Health 6 Nursing and Population Health: Labeling the Specialty 10 Population Health Nursing as Advocacy 10

Defining Advocacy 10 Advocacy by Population Health Nurses 11 The Advocacy Process 11 Population Health Nursing Functions in the Advocacy Role 12

Population Health Nursing Standards and Competencies 13 Population Health Nursing Education 14 A Population Health Nursing Model 14

Determinants of Population Health 15 Population Health Nursing Interventions 20 Levels of Health Care 24

Chapter 2 Population Health Nursing: Yesterday, Today, and Tomorrow 29

Historical Roots 31 The Influence of Christianity 32

The Early Christian Church 32 The Middle Ages 32

Other Religious Influences 33 The European Renaissance 33 A New World 33

The Colonial Period 33 Early Public Health Efforts 34

The Industrial Revolution 34 Nursing in War 37 District Nursing in England 37 Visiting Nurses in America and the World 38 Nursing and the Settlement Houses 38 Expanding the Focus on Prevention 39 Standardizing Practice 42 Educating Population Health Nurses 42 Federal Involvement in Health Care 44

The Latter Half of the 20th Century 45 The Present and Beyond 47

Chapter 3 Epidemiology and Population Health Nursing 53

Basic Epidemiologic Concepts 55 Causality 56 Risk 57 Rates of Occurrence 58

The Epidemiologic Process 60 Defining the Condition 60 Determining the Natural History of the Condition 60 Identifying Strategic Points of Control 61 Designing, Implementing, and Evaluating Control Strategies 62

Epidemiologic Investigation 62 Descriptive Epidemiology 62 Analytic Epidemiology 63 Experimental Epidemiology 63

Epidemiologic Models 64 The Epidemiologic Triad Model 64 The Web of Causation Model 67 Determinants-of-Health Models 67

Unit 2 Influences on Population Health 71 Chapter 4 Environmental Influences on Population

Health 72 Environment and Health 73 Components of the Human Environment 78

The Natural Environment 78 The Built Environment 85 The Social Environment 87 Interactions Among Environmental Components 90

Population Health Nursing and Environmental Influences on Health 91

Assessing Environmental Health Influences 91 Planning to Address Environmental Health Issues 94 Evaluating Environmental Health Measures 98

Chapter 5 Cultural Influences on Population Health 102

Basic Concepts Related to Culture and Health 104 Culture and Health 106

Ethnic/Societal Culture and Health 107 Biomedical Culture and Health 107

Ethnic Diversity in the United States 108

ix

A01_MARY9591_06_SE_FM.indd 9 09/09/14 5:22 PM

x Contents

Assessing Cultural Influences on Health and Health Care 109 Principles of Cultural Assessment 109 Obtaining Cultural Information 109

Cultural Assessment Data 111 Biological Determinants 111 Psychological Determinants 113 Environmental Determinants 115 Sociocultural Determinants 116 Behavioral Determinants 126 Health System Determinants 127

Planning Culturally Congruent Care and Delivery Systems 135 Cultural Competence 136

Evaluating Cultural Competence 140

Chapter 6 Economic Influences on Population Health 144

Economics and Health—The Interrelationships 146 Societal Productivity and Stability 146 Health Care Spending 146 Socioeconomic Factors and Health Status 148

Health Care Reimbursement Systems 150 Retrospective Reimbursement 150 Prospective Reimbursement 152 Capitation 152 Pay-for-Performance 152

Health Care Funding Sources 153 Personal Payment 153 Commercial Insurance 153 Government-Funded Care 157 Charity Care 161

Health Insurance and Reform 161 Health Care Reform and Population Health 162

Chapter 7 Health System Influences on Population Health 167

The U.S. Health Care System 169 Forces Influencing the Health Care System 169 Components of the U.S. Health Care System 170 U.S. Health System Reform 176

Other National Health Care Systems 179 Public Health Functions: An International Perspective 179 Features of Selected National Health Systems 179 Comparing Health System Outcomes 183

Chapter 8 Global Influences on Population Health 187 Globalization 189

Dimensions of Globalization 189 Health Effects of Globalization 190

International and Global Health Perspectives 191 Trends in Global Health Collaboration 191 U.S. Involvement and Global Health 193 Global Health Initiatives 193 Global Health Governance 194

Health Care Organization at Global and International Levels 196 Bilateral Agencies 196 Multilateral Agencies 197 Civil Society Organizations 198

Global Health Issues 199 Health Status Issues 199 Social Determinants of Health 203

Population Health Nursing and Global Health 206 Service Delivery 206 Framing Global Policy Issues 207 International Nursing Organizations 208

Unit 3 Population Health Nursing Strategies 213

Chapter 9 Political Strategies 214 Policy and Politics 216 Relationships Between Public Policy and Health 216 Types of Policies 217 Avenues for Public Policy Development 218

Legislation 218 Regulation 223 Administrative and Judicial Decisions 223 State Health Plans 224

Nursing and Policy Development 224 Spheres of Nursing Influence in Policy Development 225 Principles of Policy Development 225 The Policy Development Process 225 Population Health Nursing Roles and Policy Development 226 Applying the Population Health Nursing Model to Policy Development 226

The Patient Protection and Affordable Care Act—PL 111–148 235

Chapter 10 Community Empowerment Strategies 239 Empowerment and Related Concepts 241 Levels of Empowerment 242 Models for Community Empowerment 243 Population Health Nursing and Community Empowerment 244

The Population Health Nurse’s Role in Fostering Empowerment 244 Assessing Community Strengths and Needs 245 Planning and Implementing Empowerment Strategies 245 Evaluating Community Empowerment 251

Chapter 11 Health Promotion and Education Strategies 256

Defining Health Promotion 258 The Need for Health Promotion 259 Models for Health Promotion 259

The Precaution Adoption Process Model 260 The Theories of Reasoned Action and Planned Behavior 261 The Health Belief Model 261 Pender’s Health Promotion Model 262

A01_MARY9591_06_SE_FM.indd 10 09/09/14 5:22 PM

Contents xi

Population Health Nursing and Health Promotion 263 Factors Influencing Health Promotion 263 Strategies for Health Promotion 265 Evaluating Health Promotion Programs 279

Chapter 12 Case Management Strategies 285 Defining Case Management 287 Case Management Models 288 Standards and Principles of Case Management 288 Competencies and Functions of Case Managers 289 The Case Management Process 290 Ethical and Legal Issues in Case Management 291 Case Management and Health Care Reform 292 Population Health Nursing and Case Management 292

Assessing the Need for Case Management 293 Assessing the Case Management Situation 293 Planning and Implementing Case Management Strategies 294 Evaluating the Process and Outcomes of Case Management 298

Chapter 13 Home Visits as a Population Health Nursing Strategy 303

Defining a Home Visit and Types of Home Visits 305 Advantages and Disadvantages of Home Visits 305 Home Visiting Programs 306 The Home Visit Process 307

Initiating the Home Visit 307 Conducting a Preliminary Health Assessment 308 Deriving Nursing Diagnoses 309 Planning the Home Visit 309 Implementing the Planned Visit 312 Evaluating the Home Visit 314 Documenting Home Visits 315 Termination 315

Home Visits in the Home Health and Hospice Contexts 316 Collaboration in Home Health and Hospice Care 317 Technology and Home Care Services 317 Funding Home Health and Hospice Services 318 Licensing of Home Health and Hospice Services 318 Standards for Home Health and Hospice Nursing 319 Evaluating Home Health and Hospice Services 319

Unit 4 Nursing Care of Special Populations 325

Chapter 14 Care of Families 326 Theoretical Perspectives on Family 328

Systems Models 328 Family Life Cycle Theory 329 Symbolic Interactionism 330

The Family as a Unit of Care 331 Defining Family 331 Family Types 331

Population Health Nursing and Care of Families 332 Assessing Family Health Status 333 Diagnostic Reasoning and Care of Families 347 Planning and Implementing Health Care for Families 347 Evaluating Family Care 349

Chapter 15 Care of Communities and Target Populations 352

Community Engagement and Population-Based Health Initiatives 354

Benefits of Engagement 355 Models for Engagement 355 Principles of Engagement 356 Developing a Comprehensive Community Engagement Strategy 356

Nursing Care of Populations 356 Assessing Population Health Status 357 Deriving Population-Level Nursing Diagnoses 370 Planning Population-Based Health Initiatives 370 Implementing Population-Based Health Initiatives 377 Evaluating Population-Based Health Initiatives 378

Chapter 16 Care of Child and Adolescent Populations 388

Health Issues for Children and Adolescents 390 Child and Adolescent Mortality 390 Preterm Births 390 Injury 390 Communicable Diseases 391 Chronic Conditions 392 Psychological and Behavioral Health Problems 392 Developmental Disorders 393 Violence 394

Population Health Nursing Care of Child and Adolescent Populations 394

Assessing the Health of Child and Adolescent Populations 394 Diagnostic Reasoning and the Health of Child and Adolescent Populations 403 Planning and Implementing Health Care for Child and Adolescent Populations 404 Evaluating Health Care for Child and Adolescent Populations 417

Chapter 17 Care of Men 424 Population Health Nursing and Care of Men 426

Assessing the Health Status of Men 426 Diagnostic Reasoning and Men’s Health 436 Planning to Meet the Health Needs of Men 436 Evaluating Health Care for Men 440

Chapter 18 Care of Women 446 Population Health Nursing and Women’s Health 448

Assessing the Health Status of Women 448 Diagnostic Reasoning and Women’s Health 462

A01_MARY9591_06_SE_FM.indd 11 09/09/14 5:22 PM

xii Contents

Planning to Meet the Health Needs of Women 463 Evaluating Health Care for Women 468

Chapter 19 Care of the Older Population 475 Theoretical Perspectives on Aging 478 Population Health Nursing and Care of Older Populations 479

Assessing the Health Status and Needs of Older Populations 479 Diagnostic Reasoning and Care of Older Populations 499 Planning to Meet the Health Needs of Older Populations 500 Implementing Care for Older Populations 514 Evaluating Health Care for Older Populations 516

Chapter 20 Care of Gay, Lesbian, Bisexual, and Transgender Populations 525

Sexual Orientation and Gender Identity 526 Determining the Size of the GLBT Population 528 Population Health Nursing and Care of GLBT Populations 529

Assessing the Health of GLBT Populations 529 Planning and Implementing Health Care for the GLBT Population 543 Evaluating Health Care for the GLBT Population 545

Chapter 21 Care of Poor and Homeless Populations 551 Overview of Poverty and Homelessness 553

Defining Poverty and Homelessness 553 The Magnitude of Poverty and Homelessness 555

Population Health Nursing and Care of Poor and Homeless Populations 556

Assessing the Health of Poor and Homeless Populations 556 Diagnostic Reasoning and Care of Poor and Homeless Populations 570 Planning and Implementing Health Care for Poor and Home- less Populations 571 Evaluating Care for Poor and Homeless Populations 577

Chapter 22 Care of School Populations 582 Historical Perspectives 584 The School Health Team 585

The School Nurse 585 Other Team Members 586

Population Health Nursing and Care of School Populations 588 Assessing the Health of School Populations 588 Diagnostic Reasoning and Care of School Populations 604 Planning and Implementing Services to Meet the Health Needs of School Populations 605 Evaluating Health Care for School Populations 616

Chapter 23 Care of Employee Populations 624 Occupational Health Nursing 626

Educational Preparation for Occupational Health Nursing 627 Standards and Competencies for Occupational Health Nursing 627 Occupational Health Nursing Roles 627

Population Health Nursing and Care of the Working Population 628 Assessing the Health Status of the Working Population 628 Diagnostic Reasoning and Care of Working Populations 646 Planning and Implementing Care for Working Populations 647 Evaluating Health Care in Work Settings 657

Chapter 24 Care of Correctional Populations 663 The Correctional Population 665 The Need for Correctional Health Services 666 Population Health Nursing and Correctional Health 667

Assessing the Health Status of Correctional Populations 667 Diagnostic Reasoning and Care of Correctional Populations 680 Planning and Implementing Health Care for Correctional Populations 680 Evaluating Health Care for Correctional Populations 692

Chapter 25 Care of Populations Affected by Disaster 696

Defining and Categorizing Disasters 697 Disaster Trends 700 Characteristics of Disasters 701 The Disaster Role of the Public Health System 703 Elements of a Disaster Event 703

The Temporal Element: Stages of Disaster Response 703 The Spatial Element 706 The Role Element 711 The Effects Element 711

Population Health Nursing and Disaster Care 711 Disaster-related Assessment 712 Diagnostic Reasoning and Care of Populations in Disaster Settings 720 Planning: Disaster Preparedness 722 Implementing Disaster Care 733 Evaluating Disaster Preparedness and Response 734

Unit 5 Population Health Issues 739 Chapter 26 Communicable Diseases 740 General Concepts Related to Communicable Diseases 743

Chain of Infection 743 Modes of Transmission 743 Portals of Entry and Exit 744 Incubation and Prodromal Periods 745 Immunity 745 Other Communicable Disease Concepts 745

Trends in Communicable Diseases 746 Vaccine-preventable Diseases 746 Sexually Transmitted Infections 749 Viral Hepatitis 749 Tuberculosis 750 Food and Waterborne Diseases 750

A01_MARY9591_06_SE_FM.indd 12 09/09/14 5:22 PM

Contents xiii

Bloodborne Diseases 751 Arthropodborne (Arboviral) Diseases 751 Emerging Diseases 752

Population Health Nursing and Communicable Disease Control 752 Assessing Determinants of Health in Communicable Disease 752 Diagnostic Reasoning and Control of Communicable Diseases 763 Planning and Implementing Control Strategies for Communi- cable Diseases 764 Evaluating Communicable Disease Control Strategies 779

Chapter 27 Chronic Physical Health Problems 791 Individual, Family, and Societal Effects of Chronic Physical Health Problems 793

Individual Effects 793 Family Effects 794 Societal Effects 795

Population Health Nursing and Chronic Physical Health Problems 797

Assessing Risks for and Effects of Chronic Physical Health Problems 797 Diagnostic Reasoning and Control of Chronic Physical Health Problems 812 Planning and Implementing Control Strategies for Chronic Physical Health Problems 812 Evaluating Control Strategies for Chronic Physical Health Problems 826

Chapter 28 Mental Health and Mental Illness 836 Individual, Family, and Societal Effects of Chronic Mental Health Problems 838

Personal Effects 838 Family Effects 838 Societal Effects 838

Trends in Mental Health Problems 839 Population Health Nursing and Mental Health and Illness 842

Assessing Mental Health Status 842 Diagnostic Reasoning and Mental Health and Illness 853 Planning and Implementing Strategies Related to Mental Health and Illness 853 Evaluating Interventions for Mental Health and Illness 859

Chapter 29 Substance Abuse 866 Individual, Family, and Societal Effects of Substance Abuse 868

Individual Effects 868 Family Effects 870 Societal Effects 871

Trends in Substance Use and Abuse 872 Population Health Nursing and Substance Abuse 876

Assessing Risks for and Effects of Substance Abuse 876 Diagnostic Reasoning and Control of Substance Abuse 890 Planning and Implementing Control Strategies for Substance Abuse 890 Evaluating Control Strategies for Substance Abuse 899

Chapter 30 Societal Violence 907 Trends in Societal Violence 910

Self-Directed Violence 910 Interpersonal Violence 911

Population Health Nursing and Societal Violence 916 Assessing Risks for and Effects of Societal Violence 916 Diagnostic Reasoning and Societal Violence 927 Planning and Implementing Control Strategies for Societal Violence 927 Evaluating Control Strategies for Societal Violence 933

Index 939

A01_MARY9591_06_SE_FM.indd 13 09/09/14 5:22 PM

A01_MARY9591_06_SE_FM.indd 14 09/09/14 5:22 PM

This page intentionally left blank

1 — Population Health and Nursing

2 — Population Health Nursing: Yesterday, Today, and Tomorrow

3 — Epidemiology and Population Health Nursing

1 unit

C h

a p

te rs

Population Health Nursing: An Overview

M01_MARY9591_06_SE_C01.indd 1 06/09/14 5:51 PM

chaPter

Population Health and Nursing

Key Terms

Learning Outcomes

After reading this chapter, you should be able to:

1. Define population health and population health nursing.

2. Describe the Healthy People 2020 national objectives for population health.

3. Describe advocacy as a critical function of population health nurses.

4. Summarize the standards for population health nursing practice.

5. Identify the eight domains of competency for population health nursing.

6. Describe the components of the population health nursing (PHN) model.

7. Describe a systematic process for implementing evidence-based population health nursing practice.

advocacy

aggregates

assessment

assurance

case finding

case manager

clinical practice guidelines

coalition building

collaboration

community

community mobilization

coordination

counseling

education

evidence-based practice

geopolitical community

health determinants

health promotion

liaison

neighborhood

policy advocate

policy development

population health

population health management

population health nursing

populations

prevention

primary prevention

referral

resolution

restoration

role model

secondary prevention

social capital

social marketing

surveillance

tertiary prevention

1

M01_MARY9591_06_SE_C01.indd 2 06/09/14 5:52 PM

3

A Picture Is Worth a Thousand Words

Residents of a small community and staff members of local health and social service agencies in a small southern California community were involved in an assessment of community health status and health needs. One of the concerns voiced most often by community members were discrimina- tory practices by absentee landlords in which tenants, many of whom were newly arrived immigrants, were evicted if they complained about needed repairs and safety hazards. Because many of them had arrived in the United States from countries with repressive regimes, the residents were reluc- tant to present their concerns to the local housing authority. The local public health nurse, who was well respected in the community and knowledgeable about many housing code violations, took pictures of violations in the homes of many of her clients. Her pictures depicted stoves situated immediately next to walls without adequate ventilation, stairs in poor repair, stairs without hand- rails, and bars on windows that prevented escape in the event of fire. Armed with her pictures, the Community Collaborative held a town forum to which they invited members of the local housing authority. The pictures graphically reinforced the concerns voiced by community members at the meeting. As a result, the housing authority acted on a number of code violations, which encour- aged community members to report other safety issues. In addition, the efforts of the Collaborative resulted in the creation of a city-funded position of housing ombudsman to assist residents in deal- ing with a variety of housing issues.

Florence Nightingale and Population Health

Florence Nightingale, considered the founder of modern nursing practice, was also a consummate advocate for population health. In her work in the Crimean War, she was a strong advocate for both the use of statistics to provide a population level of health and of environmental sanitation to improve the conditions of the ill and injured (Lewis, 2010). Ms. Nightingale used her influential media con- tacts with The Times of London to force the British government to support women’s involvement in care of the sick and injured soldiers (Simkin, n.d.). Throughout her career, she continued to advocate for social conditions that promoted health and was influential in creating the system of district nurs- ing that was the British version of public health nursing. She also was instrumental in workhouse reform in England (Workhouse, n.d.) and in the establishment of the Indian Sanitary Department to deal with environmental sanitation in India (Bloy, 2010). In a letter to a friend, Nightingale wrote of the need for nursing advocacy, stating “One’s feelings waste themselves in words; they ought all to be distilled into actions . . . which bring results” (cited in Hallett, 2010, p. 50).

A d

vo ca

cy T

h en

A d

vo ca

cy N

ow

Emphasis on the health of populations as a focus for care arose out of growing evidence that individual-oriented health care has only limited effects on improving the health of the general pub- lic. A population health focus may occur at a variety of levels, and populations may encompass smaller or larger groups of people.

Defining Populations as a Focus for Care Populations are groups of people, who may or may not inter- act with each other, but who have common health concerns and needs. According to the second edition of the American Nurses Association (ANA) Public Health Nursing: Scope and

M01_MARY9591_06_SE_C01.indd 3 06/09/14 5:52 PM

4 unit 1 Population health nursing: an Overview

Standards of Practice, a population, in the population health nursing context, refers to the residents of a specific geographic area, but the population health nurse’s focus may include spe- cific targeted groups of people with some trait or attribute in common (e.g., a minority group, employees, the elderly) or who “may be at risk for, experience, a disproportionate bur- den of poor health outcomes” (ANA, 2013, p. 3). Three other commonly used, similar, but different terms for these smaller subgroups are neighborhood, community, and aggregate.

A neighborhood is a smaller, frequently more homoge- neous group than a community that involves an interface with others living nearby and some level of identification with those others. Neighborhoods are self-defined, and although they may be constrained by natural or man-made factors, they often do not have specifically demarcated boundaries. For example, a major highway may limit interactions between residents on either side, thus creating separate neighborhoods. Or a neigh- borhood may be defined by a common language or cultural heritage. Thus, non-Hispanic residents of a “Hispanic neigh- borhood” are not usually considered, nor do they consider themselves, part of the neighborhood.

A community may be composed of several neighbor- hoods. Some people define communities in terms of specific geographic locations or settings, but most definitions of com- munity go beyond locale as a primary defining characteris- tic. In addition to location, other potential defining aspects of communities include a social system or social institutions designed to carry out specific functions; identity, commit- ment, or emotional connection; common norms and val- ues; common history or interests; common symbols; social interaction; and intentional action to meet common needs. A community is described as an “interactional whole” differ- ent from the people who comprise it (ANA, 2013, p.65). For our purposes, then, a community is defined as a group of people who share common interests, who interact with each other, and who function collectively within a defined social structure to address common concerns. By this definition, geopolitical entities, such as the city of San Diego, a school of nursing, and a religious congregation can be considered communities. A geopolitical community is one character- ized by geographic and jurisdictional boundaries, such as a city.

Aggregates are subpopulations within the larger popula- tion who possess some common characteristics, often related to high risk for specific health problems. School-aged children, persons with human immunodeficiency virus (HIV) infection, and the elderly are all examples of aggregates.

Population health nurses may work with any or all of these population groups—aggregates, neighborhoods, and communities—in their efforts to enhance the health sta- tus of the general public or overall population. Population health addresses the health needs of entire groups, and those health needs are affected by factors influencing indi- viduals, families, neighborhoods and communities, as well as the society at large. Issel and Bekemeier (2010) used the

population-patient to reflect this focus on providing care at the population level.

Defining Population Health The health of a population goes beyond the health status of the individuals or subgroups that comprise it, but involves the collective health of the group. Several authors have noted the lack of a precise definition of population health, but note that definitions range from health outcomes affecting total popula- tions defined by geography (e.g., a county or state) to “account- ability for health outcomes in populations defined by health care delivery systems such as health plans or Accountable Care Organizations” (Stoto, 2013, p. 2). This latter perspective re- quires health care systems to address “upstream” factors such as health promotion and illness and injury prevention as well management of disease. Both of these perspectives embody a “population health perspective” characterized by conceptual- ization of the population as a unit separate from its members, incorporation of upstream factors in measures of population health, and the goal of reducing disparities within the popu- lation. Other characteristics of a population health perspective include consideration of a broad array of determinants or fac- tors that influence health and recognition that responsibility for population health is shared by many segments of society that must work collaboratively to achieve health, because none of them can do so alone (Stoto, 2013).

Thirty years ago, the World Health Organization conceptu- alized population health as both a measure of the health sta- tus of a given population and “a resource for everyday life, not the object of living. Health is a positive concept, emphasizing social and personal resources as well as physical capacities.” (World Health Organization, 1984, p. 1).

The Public Health Agency of Canada (2012) combined these perspectives to describe population health as “the health of a population as measured by health status indica- tors and as influenced by social, economic and physical envi- ronments, personal health practices, individual capacity, and coping skills, human biology, early childhood development, and health services” (para 2). The Institute of Medicine (IOM) adopted Kindig and Stoddart’s (2003) definition of popula- tion health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (p. 380) as the working definition of population health for its Roundtable on Population Health Improvement (IOM, 2013). The Institute also noted the distinction between population health as the health status of residents in a geopolitical area ver- sus the clinical health outcomes of a subpopulation served by a given health care system. Notice was also given to Jacobsen and Teutsch’s (2012) recommendation that the term “total popu- lation health” be used to denote the health status of people within a geopolitical jurisdiction, but the Institute anticipated further refinement of the definition of population health in the work of the Roundtable (2013). The outcome of that work is yet to be realized.

M01_MARY9591_06_SE_C01.indd 4 06/09/14 5:52 PM

chaPter 1 Population health and nursing 5

In the interim, for purposes of this book, population health, as an outcome of care, can be defined as the attainment of the greatest possible biologic, psychological, and social well-being of the total population as an entity and of its individual members. Population health can also be viewed as a capability or resource that allows members of the population to pursue goals, develop skills, and grow. A population health approach to care focuses on improving the health of the population and decreasing inequities in health status among subgroups within the population. Key elements of a population health approach include the following:

• A focus on the health of the overall population • Attention to determinants of health and their interactions • Decision making based on scientific evidence of health

status, health determinants, and the effectiveness of interventions

• “Upstream” investment in strategies that maintain and pro- mote health and address root causes of health and illness

• Application of multiple strategies • Collaboration across sectors and levels of society • Mechanisms for public participation in health improvement • Demonstrated accountability for health outcomes (Public

Health Agency of Canada, 2013)

Population Health Practice In the United States, the terms “public health” and “population health” are often used interchangeably, but have the same focus on the health of the overall population. Elements of public or popula- tion health practice include core functions and essential services.

Core Public Health Functions In 1988, the Institute of Medicine (IOM) released a report enti- tled “The Future of Public Health,” which identified three core functions related to public or population health. These core functions of assessment, policy development, and assurance form the foundation for population health practice and popu- lation health nursing activities (ANA, 2013). These functions

were reinforced in a 2002 revision of the report. The revised report also recommended adoption of a population health approach similar to that described above to address multiple determinants of health (IOM, 2002).

In their assessment function, public health agencies are expected to identify the health needs of the population. The National Public Health Performance Standards Program (n.d.) defined assessment as “the systematic collection and analysis of data in order to provide a basis for decision-making” (p. 3).

The policy development function of public health practice involves advocacy and political action to develop local, state, and national policies conducive to population health. Policy development has been described as the process of making in- formed decisions about issues related to the public’s health (National Public Health Performance Standards Program, n.d.). The third core function, assurance, reflects the respon- sibility of the public health care system to see that needed ser- vices are available to the population through other entities, regulatory processes, or direct provision of care (National Public Health Performance Standards Program, n.d.).

Essential Public Health Services In 1994, the core public health functions were operationalized in 10 essential public health services delineated by the Pub- lic Health Functions Steering Committee (American Public Health Association, 2014). These services and their relation- ship to the core functions are presented in Table 1-1•.

The statement of the essential functions of public health agencies led in 2001 to the development of core competencies for public health professionals performing these functions. Revised in 2010, the core competencies reflect eight domains of public health practice: analytic assessment skills, knowledge of basic public health sciences (e.g., epidemiology), cultural com- petence, communication skills, capacity for community-level practice, financial planning and management skills, leadership and systems thinking capabilities, and policy development and program planning skills (Council on Linkages Between Aca- demia and Public Health Practice, 2010). Based on feedback

Core Function Essential Services

Assessment • Monitor health status to identify health problems • Diagnose and investigate health problems and hazards in the community • Evaluate the effectiveness, accessibility, and quality of personal and population-based health services

Policy Development • Develop policies and plans that support individual and community health efforts • Enforce laws and regulations that protect health and ensure safety • Inform, educate, and empower people with respect to health issues

Assurance • Link people to needed personal health services and assure the provision of health care when otherwise unavailable

• Assure a competent public and personal health care workforce • Inform, educate, and empower people about health issues • Mobilize community partnerships to identify and solve health problems • Conduct research into innovative solutions for health problems

TAbLE 1-1 Core Public Health Functions and Related Essential Services

M01_MARY9591_06_SE_C01.indd 5 06/09/14 5:52 PM

6 unit 1 Population health nursing: an Overview

from the community of public professionals, the competencies are currently undergoing another revision. The revised com- petencies will continue to include the same eight domains and three tiers of practice (entry level practice, program manage- ment/supervisory practice, and senior management/execu- tive level practice). The revised competencies are expected to be completed by June 2014 (Public Health Foundation, n.d., 2014a, 2014b). The development of these general competencies led, in turn, to the development of specific competencies for population health nursing practice, which are discussed later in this chapter.

Objectives for Population Health The goals and desired outcomes for population health in the United States have been operationalized in several sets of na- tional objectives. The Healthy People initiative began in 1979 with the publication of the Healthy People: Surgeon General’s Report on Health Promotion and Disease Prevention (Of- fice of Disease Prevention and Health Promotion [ODPHP], n.d.a). A subsequent set of more detailed national objectives was established in 1980 in the publication Promoting Health/ Preventing Disease: Objectives for the Nation (U.S. Department of Health and Human Services [USDHHS], 1980). Later sets of objectives were published in 1990 and 2000. See the materi- als provided on the student resources site for a discussion of the changes in the objectives over time.

In 2007, work commenced on a two-phase process for de- veloping the Healthy People 2020 objectives. Phase I involved the development of the framework and format to be used in the revision and culminated in a report from the Secretary’s Ad- visory Committee on National Health Promotion and Disease Prevention Objectives for 2020 in October of 2008 (Advisory Committee, 2008). The committee recommended an interac- tive, searchable, web-based format for the document rather than the prior print format. The framework consists of a vision, mission statement, overarching goals, four foundation health measures, and a graphic model. The vision is one of a “society in which all people live long, healthy lives” (ODPHP, n.d.b), and the mission statement is as follows:

Healthy People 2020 strives to: • Identify nationwide health improvement priorities • Increase public awareness and understanding of the deter-

minants of health, disease, and disability and the opportuni- ties for progress

• Provide measurable objectives and goals that are applicable at the national, state, and local levels

• Engage multiple sectors to take actions to strengthen poli- cies and improve practices that are driven by the best avail- able evidence and knowledge

• Identify critical research, evaluation, and data collection needs (ODPHP, n.d.b)

The primary emphasis for Healthy People 2020 is on achieving health equity and eliminating disparities among

segments of the population by addressing the determinants that influence health. Actual delivery of health care services is a secondary emphasis (ODPHP, n.d.a; USDHHS, n.d.). Health determinants as defined in Healthy People 2020 are “the range of personal, social, economic, and environmental factors that influence health status” (USDHHS, 2012a, para 3). Determinants of health addressed by Healthy People 2020 include policy making, social factors, health services, individual behavior, and biology and genetics (USDHHS, 2012a).

The overarching goals for the Healthy People 2020 are to: • Attain high-quality, longer lives free of preventable disease,

disability, injury, and premature death. • Achieve health equity, eliminate disparities, and improve the

health of all groups. • Create social and physical environments that promote good

health for all. • Promote quality of life, healthy development, and healthy

behaviors across all life stages (ODPHP, n.d.b).

The final element of the framework was the development of a graphic model for Healthy People 2020. The model is de- picted in Figure 1-1•. Within the model, actions, consisting of policies, programs, and interventions, influence determinants of health to achieve the overarching goals. The feedback cycle indicated by the two-way arrow in the model relies on assess- ment, monitoring, evaluation, and dissemination of best prac- tices to inform action (ODPHP, n.d.b).

Healthy People 2020, released in December 2010, incorpo- rates nearly 600 objectives across the 42 topical areas depicted in Table 1-2•. Objectives were developed by experts from lead federal agencies and then reviewed for comment by multiple constituencies including the Federal Interagency Workgroup as well as the general and professional population. Some ob- jectives focus on specific health conditions, whereas others ad- dress broader issues such as health disparities, access to care, dissemination of health-related information, strengthening of public health services, and addressing social determinants of health (USDHHS, n.d.). Figure 1-2• depicts the stakeholders who influenced the development of the 2020 objectives.

Generally, objectives are of two kinds: measurable and de- velopmental. Measurable objectives include the current na- tional baseline status of a health issue derived from existing reliable data sources, as well as the target for achievement by 2020. Developmental objectives do not have available base- line data and are targeted for the development of national data collection systems and processes. Objectives for some of the topical areas are still in development, but each topical area will include an overview of the topic, a list of related objectives to be achieved by 2020, and information on interventions and resources. The interventions and resources information will include clinical recommendations for evidence-based inter- ventions and links to relevant consumer health information (USDHHS, n.d.).

Monitoring progress toward achieving the objectives will be the primary responsibility of a designated lead federal

M01_MARY9591_06_SE_C01.indd 6 06/09/14 5:52 PM

chaPter 1 Population health and nursing 7

agency for each topical area. Overall progress will be as- sessed in terms of four foundation health measures: general health status, health-related quality of life and well-being, determinants of health, and disparities. Specific measures included within each of the general measures are sum- marized in Table 1-3•. In addition, a revised set of leading health indicators, first established for Healthy People 2010,

have been established as a focus for assessing goal attainment (USDHHS, 2012b, 2012c). The health indicators consist of 26 objectives addressing 12 topical areas that have been selected as high-priority health issues. The 26 indicator objectives are included in Table 1-4•.

You can access data related to the health indicators through the Healthy People 2020 website. For further information

Figure 1-1 Model for Healthy People 2020 Source: Office of Disease Prevention and Health Promotion. (n.d.a). Healthy People 2020: A resource for promoting health and preventing disease throughout the nation.

Retrieved from http://www.healthypeople.gov/2020/consortium/HealthyPeoplePresentation_2_24_11.ppt

Healthy People 2020 A society in which all people live long, healthy lives

Health Outcomes

Determinants eDetteermrmiinants

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.

Health Services

Physical Environment

Social Environment

Individual Behavior

Biology & Genetics

• Access to health services • Adolescent health* • Arthritis, osteoporosis, and chronic back

conditions • Blood disorders and blood safety* • Cancer • Chronic kidney disease • Dementias, including Alzheimer’s disease* • Diabetes • Disability and health • Early and middle childhood* • Educational and community-based programs • Environmental health • Family planning • Food safety • Genomics*

• Global health* • Health communication and health informa- tion technology*

• Health care–associated infections* • Health-related quality of life and well-being* • Hearing and other sensory or communication

disorders • Heart disease and stroke • HIV • Immunization and infectious diseases • Injury and violence prevention • Lesbian, gay, bisexual, and transgender

health • Maternal, infant, and child health

• Medical product safety • Mental health and mental disorders • Nutrition and weight status • Occupational safety and health • Older adults* • Oral health • Physical activity • Preparedness* • Public health infrastructure • Respiratory diseases • Sexually transmitted diseases • Sleep health* • Social determinants of health* • Substance abuse • Tobacco use • Vision

* Indicates new focus area for 2020, not included in prior sets of objectives. Based on: U.S. Department of Health and Human Services. (2014). About Healthy People. Retrieved from http://www.healthypeople.gov/2020/about/default.aspx

TAbLE 1-2 Healthy People 2020 Topical Areas

M01_MARY9591_06_SE_C01.indd 7 06/09/14 5:52 PM

8 unit 1 Population health nursing: an Overview

about the Healthy People 2020 objectives, see the External Resources section of the student resources site.

Population health care is designed to improve the overall health status of the public through modification of factors that

influence health either positively or negatively. National health objectives, as exemplified in Healthy People 2020 and its precur- sors, guide the design of care delivery systems and serve as a means for evaluating the effectiveness of population health care.

Figure 1-2 Stakeholders in the Healthy People 2020 Development Process Source: Office of Disease Prevention and Health Promotion. (n.d.a). Healthy People 2020: A resource for promoting

health and preventing disease throughout the nation. Retrieved from http://www.healthypeople.gov/2020/consortium/

HealthyPeoplePresentation_2_24_11.ppt

State and Local Governments (50 State Coordinators)

National-Level Stakeholders, Including Members of the Healthy

People Consortium (2,200+Volunteers)

Community-Based Organizations, Community Health Clinics, Social Service Organizations, etc.

HHS Secretary’s Advisory Committee

Individuals, Families, and Neighborhoods Across America

HHS

ODPHP

Federal Interagency Workgroup (28 Federal

Agencies)

Foundation Measure Specific Measures

General health status • Life expectancy • Healthy life expectancy • Years of potential life lost • Physically and mentally unhealthy days • Self-assessed health status • Limitation of activity • Chronic disease prevalence

Health-related quality of life and well-being

• Physical, mental, and social health-related quality of life • Well-being/satisfaction • Participation in common activities

Determinants of health • A range of personal, social, and environmental factors including biology, genetics, individual behavior, access to health services, and environment

Disparities Differences in health status based on: • Race/ethnicity • Gender • Physical and mental ability • Geography

Based on: U.S. Department of Health and Human Services. (2014). About Healthy People. Retrieved from http://www.healthypeople.gov/2020/about/default.aspx

TAbLE 1-3 Foundation Health Measures for Healthy People 2020 and Related Specific Measures

M01_MARY9591_06_SE_C01.indd 8 06/09/14 5:52 PM

chaPter 1 Population health and nursing 9

Topical Area Leading Health Indicator Objectives Target

Access to health services AHS 1.1 Increase the proportion of persons with medical insurance. 100%

AHS 3 Increase the proportion of persons with a usual primary care provider.

83.9%

Clinical preventive services C-16 Increase the proportion of adults who receive a colorectal cancer screening based on the most recent guidelines.

70.5%

HDS-12 Increase the proportion of adults with hypertension whose blood pressure is under control.

61.2%

D-5.1 Reduce the proportion of the diabetic population with an A1c value greater than 9%.

14.6%

IID-8 Increase the proportion of children aged 19 to 35 months who receive the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, and PCV vaccines.

80%

Environmental quality EH-1 Reduce the number of days the Air Quality Index (AQI) exceeds 100.

10 days

TU-11.1 Reduce tobacco use by adults. 12%

Injury and violence IVP-1.1 Reduce fatal injuries. 53.3/100,000 pop

IVP-29 Reduce homicides. 5.5/100,000 pop

Maternal, infant, and child health MICH-1.3 Reduce infant deaths (within 1 year). 6/1,000 live births

MICH-9.1 Reduce preterm births. 11.4%

Mental health MHMD-1 Reduce the suicide rate. 10.2/100,000

MHMD-4.1 Reduce the proportion of adolescents who experience major depressive episodes.

7.4%

Nutrition, physical activity, and obesity

PA-2.4 Increase the proportion of adults who meet the objectives for aero- bic physical activity and for muscle-strengthening activity.

20.1%

NWS-9 Reduce the proportion of adults who are obese. 30.6%

NWS-10.4 Reduce the proportion of children and adolescents aged 2 to 19 years who are obese.

14.6%

NWS-15.1 Increase the contribution of total vegetables to the diets of the population aged 2 years and older.

1.1 cup equivalents per 1,000 calories

Oral health OH-7 Increase the proportion of children, adolescents, and adults who used the oral health care system in the past 12 months.

49%

Reproductive and sexual health FP-7.1 Increase the proportion of sexually active females aged 15 to 44 years who received reproductive health services in the past 12 months.

86.7%

HIV-13 Increase the proportion of persons living with HIV who know their serostatus.

90%

Social determinants AH-5.1 Increase the proportion of students who graduate with a regular diploma 4 years after starting 9th grade.

82.4%

Substance abuse SA-13.1 Reduce the proportion of adolescents reporting use of alcohol or any illicit drugs during the past 30 days.

16.5%

SA-14.3 Reduce the proportion of persons engaging in binge drinking during the past 30 days—Adults aged 18 years and older.

24.3%

Tobacco TU-1.1 Reduce cigarette smoking by adults. 12%

TU-2.2 Reduce cigarette smoking by adolescents. 16%

Based on: U.S. Department of Health and Human Services. (2013). 2020 LHI topics. Retrieved from http://www.healthypeople.gov/2020/ LHI/2020indicators.aspx

TAbLE 1-4 Leading Health Indicators for Healthy People 2020

M01_MARY9591_06_SE_C01.indd 9 06/09/14 5:52 PM

10 unit 1 Population health nursing: an Overview

Nursing and Population Health: Labeling the Specialty As noted in the description of historical advocacy by Florence Nightingale at the beginning of this chapter, nursing has long had a focus on the health of population groups. The spe- cialty area that has had this primary focus has been variously known as public health nursing, community health nurs- ing, population-based nursing, community-based nursing, community-focused nursing, community-driven nursing, and community-focused health care. Each of these terms, how- ever, has slightly different connotations and may give rise to misconceptions.

The original term for the specialty, public health nursing, was coined by its U.S. founder Lillian Wald (Fee & Bu, 2010). At the time, Wald used the term to describe a nursing focus on the myriad ills of populations, particularly poor immigrants. These first nurses in the specialty were not associated with any official government agency, but functioned independently, often relying on charitable donations to fund their services. Subsequently, however, the term was most often used to de- scribe nurses working for official local, state, or national pub- lic health departments or agencies. Current critics of the term public health nursing note that it implies the clientele of these official public health agencies, who are often the underserved sick poor, as the primary recipients of care. In fact, however, the specialty addresses the needs of whole populations, includ- ing those who are well and affluent as well as those who are poor and sick.

Community health nursing, as a name for the specialty, also has the potential for inappropriate connotations. The term community health nursing was coined by the American Nurses Association (ANA) as a general term for all nurses who worked outside of institutional settings such as hospitals. Work out- side of an institutional setting, however, may not be focused on the health of the population. These nurses might be more appropriately described as engaged in “community-based” nursing (Levin, Swider, Breakwell, Cowell, & Reising, 2013). “ Community-focused” care involves “consideration of health across a whole population; working with communities and other agencies to plan interventions based on local need, valid evidence, and national health priorities” (Poulton, 2009, p. 74).

“Community-driven” care focuses on the needs of the com- munity as a whole and emphasizes community participation in determining those needs. This terminology, however, has the potential for limiting the focus of practice to those health needs identified by members of the community or population group. Although community involvement in the identification and resolution of health needs and issues is important, it is also true that part of community health nursing practice is raising community consciousness levels to the point where commu- nity members recognize the existence of health needs they may have previously ignored. Similarly, “community-oriented” care can be somewhat limiting, focusing program development on

small aggregates while potentially ignoring health issues that affect larger population groups.

The Public Health Nursing Section of the American Pub- lic Health Association (APHA) has traditionally labeled the specialty as “public health nursing.” According to the section, public health nursing incorporates nursing, public health, and social science concepts to foster the health of population groups (APHA, Public Health Nursing Section, 2013).

The American Nurses Association (1986) used the term community health nurse, in the introduction to Standards of Community Health Nursing Practice. The 1999 definition by the Quad Council of Public Health Nursing Organizations (Quad Council) reinstated the term public health nursing, and the current Public Health Nursing: Scope and Standards of Practice defined the specialty as nursing practice “focused on population health through continuous surveillance and assess- ment 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” (ANA, 2013).

Despite the disagreement regarding labels and definitions, there is basic agreement that the defining characteristic of the specialty is population-focused nursing care directed toward the overall health of communities or population groups. For this reason, in this book, we will use the term population health nursing to describe the specialty. Population health nursing is a synthesis of nursing knowledge and practice and the science and practice of public health to affect determinants that influ- ence the health of population groups.

Population Health Nursing as Advocacy Improving the overall health of populations requires advo- cacy, usually at multiple levels. As noted in one article related to population health practice, action to modify determinants of health at the societal level is not for the faint of heart. Public health proponents, including population health nurses, must be actively involved in advocacy within and outside the health care delivery system to create conditions that promote health and prevent illness and injury as well as provide access to care for existing conditions (Baum, Bégin, Houweling, & Taylor, 2009).

Defining Advocacy Dictionary definitions of advocacy involve adoption of a cause or pleading in favor of a cause (Advocacy, n.d.a, n.d.b). Wikipe- dia distinguishes health advocacy as a specific form of advocacy and notes that health advocacy “encompasses direct service to the individual or family as well as activities that promote health and access to health care in communities and the larger public. Advocates support and promote the rights of the patient in the health care arena, help build capacity to improve community

M01_MARY9591_06_SE_C01.indd 10 06/09/14 5:52 PM

chaPter 1 Population health and nursing 11

health and enhance policy initiatives focused on available, safe and quality care” (Health Advocacy, 2014).

In nursing, advocacy was originally defined by the Amer- ican Nurses Association in its 1976 Code for Nurses with In- terpretive Statements as protecting clients from “incompetent, unethical, or illegal practice of any person” (p. 8). The Public Health Nursing Scope and Standards of Practice (ANA, 2013) defined advocacy as “the act of pleading or arguing in favor of a cause, idea, or policy on someone else’s behalf, with a focus on developing the community, system, individual, or family’s capacity to plead their own cause or act on their own behalf” (p. 65). Nursing authors have noted that social advocacy is a legal and moral imperative, particularly for population health nurses who need to return to their commitment to caring for the most vulnerable. Advocacy can be defined from a popula- tion health nursing perspective, as action taken on behalf of, or in concert with individuals, families, or populations to create or support an environment that promotes health.

Advocacy by Population Health Nurses Advocacy in the acute care setting has been described as focus- ing on informing and educating patients, protecting patients, and promoting access to care (Young, 2009). These latter ac- tivities, however, primarily support the interests and welfare of individual clients. For population health nurses, on the other hand, advocacy for the health of populations, as well as indi- viduals and families, has historically been a large part of their practice. As we will see in Chapter 2 , community or public health nursing was synonymous with political activism and population advocacy for early nurse leaders such as Florence Nightingale, Clara Barton, Lillian Wald, Lavinia Dock, and Margaret Sanger. Florence Nightingale was a consumate advo- cate for human rights and population health, although she never used the term advocacy (Selanders & Crane, 2012). Margaret Sanger, an early advocate of contraceptive rights for women, highlighted the need for continuing advocacy by population health nurses: “Though many disputed barricades have been leaped, you can never sit back smugly content, believing that victory is forever yours; there is always the threat of its being snatched from you” (quoted in Drevdahl, Kneipp, Canales, & Dorcy, 2001, p. 28).

Advocacy for social justice is an essential aspect of the core mission of population health nursing, yet the last century has witnessed a decline in the social activist efforts of these nurses. In part, this decline has been attributed to a shift in control of population health nursing practice. In the early days of public health nursing, the practice of population health nurses was outside the control of the medical profession. After World War II, medicine began to dominate public health, and pop- ulation health nurses were less autonomous (Drevdahl et al., 2001). Another contributing factor, as we will see later, was the shift from a focus on health promotion and illness prevention to provision of direct care to individuals and families (Barnum,

2011). Recently, however, population health nurses have begun to reclaim their population advocacy function, while still maintaining advocacy activities for individual clients and families.

The Advocacy Process How does one engage in advocacy, particularly at the popula- tion level? There is a great deal in the literature about the need for advocacy and its importance as an element of nursing prac- tice. There is very little discussion, however, of how advocacy occurs. Two qualitative research studies provide some informa- tion on the process involved in advocacy. One study examined advocacy events in general and the other focused primarily on advocacy in a population health nursing context (Clark, 2001, 2008).

In the studies, advocacy arose out of a precipitating situation that resulted in vulnerability. Vulnerability may be experienced by clients at any level—individual, family, community, or pop- ulation. Carel (2009) noted that at the individual level, vulner- ability stems from a loss of ability to do something for oneself that one is accustomed to doing without assistance from oth- ers. This may be the result of actual physical inability or be- cause one is prohibited from doing something by the rules of the setting (e.g., getting up without assistance). At the popula- tion level, vulnerability may stem from a variety of physical and social conditions that prohibit group members from taking ac- tion for themselves. Situations that contribute to vulnerability may relate to health status (e.g., mentally retarded individuals or persons with HIV/AIDS), behavior (e.g., substance abuse), culture, social status (e.g., unemployment or poverty), envi- ronment, or other social factors that lessen people’s abilities to promote and protect their health. Vulnerability is reflected in a loss of control over factors that impinge on health and that result in some kind of unmet need. Vulnerability prevents the person or group affected from acting on their own behalf and requires the efforts of an outside agent (the population health nurse) to act for or support action by the vulnerable person or group.

The advocacy situations described in the studies involved three essential categories of participants: a recipient of the ad- vocacy, an advocate, and an “adversary.” The recipient of ad- vocacy was the vulnerable individual, family, or population group who could not act for themselves for a variety of reasons (e.g., fear, lack of knowledge, poverty). The advocate was the person or persons who acted for or enabled action by the re- cipient. Not all of the advocates in the situations reviewed were nurses. Family, friends, and other health care providers also functioned as advocates in some situations.

Adversaries were persons, institutions, or societal systems that impeded action to address unmet needs. Individual clients may need advocacy with family members or health care profes- sionals to meet their needs. For example, a nurse may have to intervene with overly protective parents who are not allowing a

M01_MARY9591_06_SE_C01.indd 11 06/09/14 5:52 PM

12 unit 1 Population health nursing: an Overview

handicapped child to achieve his or her full potential. Similarly, advocacy may be needed with a physician who ignores a client’s request for information about treatment options for breast cancer. A health department that charges fees for immuniza- tions may be a health system adversary prohibiting access to preventive care for indigent segments of the population. Simi- larly, legislation prohibiting access to care for undocumented immigrants is a societal adversary impeding health promotion for this population.

An additional participant, an “intermediary,” was also pres- ent in many advocacy situations. Intermediaries were of two types: adversarial or supportive. Adversarial intermediaries interpreted and supported the adversary’s position. For exam- ple, a nurse case manager may merely inform clients that their health insurance does not support a specific intervention rather than searching for a way to provide the desired intervention or discover an acceptable alternative. Unfortunately, adversarial intermediaries were often other nurses (Clark, 2001). Support- ive intermediaries, on the other hand, supported the efforts of the advocate to meet client needs. A legislator interested in changing eviction practices to protect vulnerable groups, such as non-English-speaking residents, would be an example of a supportive intermediary.

The research identified three major factors influencing participants in an advocacy situation: knowledge, conviction, and emotion. Knowledge influenced all of the participants. For example, knowledge of current eviction regulations (or lack thereof) may lead unscrupulous landlords to evict tenants for complaints about unsafe housing conditions; conversely, lack of knowledge of appropriate channels to report housing viola- tions may make tenants more vulnerable to coercion. Knowl- edge also influences the actions of the advocate when he or she knows what is allowable under the law.

Conviction was a factor that primarily influenced the advo- cates in the study situations. Advocates frequently voiced their conviction that their action was warranted. Often this convic- tion was upheld in the face of knowledge about possible conse- quences and even in the event of negative consequences for the advocate. Advocates repeatedly spoke of knowing they were doing “the right thing.”

Emotion also played a role in advocacy situations. Emotions such as fear and anxiety may contribute to the vulnerability of the advocacy recipient. For example, fear of eviction may pre- vent tenants from filing complaints about unsafe housing con- ditions. The effect of both conviction and emotion can be seen in recent debates regarding gay marriage and granting spou- sal rights (e.g., to insurance coverage) to members of same-sex marriages.

In each advocacy situation, effective advocacy required ac- tion on the part of the advocate. The type of action taken de- pended on the situation as well as on the personality of the advocate. Some actions were collaborative, with the advocate attempting to work cooperatively with the adversary to meet clients’ needs. Other actions were more adversarial in nature. Types of actions taken by advocates included adjusting (e.g.,

changing a therapeutic regimen or adjusting clinic hours to accommodate clients’ schedules), connecting or “hooking up” clients with outside resources, supporting clients’ decisions, helping (e.g., helping a sexually active adolescent to obtain con- traceptives), and assuring (e.g., promoting access to care, assur- ing informed consent). Other approaches to advocacy included educating the advocacy recipient or adversary, confronting the adversary, requesting a change, showing (e.g., providing legis- lators with photographs of housing violations to promote ef- fective legislation), explaining (e.g., explaining the effects of unprotected intercourse to sexually active adolescents), and enlisting the help of others (e.g., forming coalitions to promote legislation to enhance access to care for underserved segments of the population).

The last element of the advocacy process was its conse- quences. Advocacy had consequences for multiple partici- pants in the advocacy situations. Generally the consequences were positive ones, but that was not always the case. Advocacy always entails an element of risk and may never be completely politically safe. Some authors see exposure to client vulnerabili- ties and the stress involved in addressing them as contributing to vulnerability of the part of the nurse advocate (Carel, 2009).

Population Health Nursing Functions in the Advocacy Role As an advocate, the population health nurse engages in a num- ber of activities or functions. The first function is determining the need for advocacy and factors that prevent clients from acting on their own behalf. A second function involves deter- mining the point at which advocacy will be most effective. For example, should the nurse raise concerns of safety violations in rental housing with the landlord, with the housing authority, or with the media? Answers to such questions might be derived from knowledge of what has been tried previously and the effects of prior action. Related questions involve how the case should be presented. Should one, for example, ask for a meet- ing with interested parties, or stage a demonstration?

Collecting facts related to the problem is another advocacy- related function. An advocate is considerably less effective when he or she does not have all the facts about a situation. A population health nurse advocate should get a detailed chrono- logical account of events related to the problem for which ad- vocacy is needed. The nurse should also try to validate or verify the information obtained to support the claim that a problem exists and action is needed.

The fourth task in advocacy is presenting the case to the appropriate decision makers. This function requires tact and interpersonal skill. Threatening or confrontational behavior should be avoided whenever possible, as both can set up an adversarial relationship rather than a collaborative one, which may be detrimental to the cause. When other avenues fail, threats may have to be employed, but nurse and client popula- tion must be committed to acting on them. For example, if the nurse threatens to report a landlord for safety code violations

M01_MARY9591_06_SE_C01.indd 12 06/09/14 5:52 PM

chaPter 1 Population health and nursing 13

unless action is taken to remove hazards, he or she should actu- ally be prepared to make the report.

The final function of the nurse as an advocate is to prepare clients to speak for themselves. The activities and functions of advocacy should not be carried out by the nurse alone, but should be a collaborative effort between nurse and client popu- lation. In this way, clients learn how to develop and present a forceful argument for their own needs and may, in the future, be able to act without nursing intervention.

Population health nurses must speak for those who can- not speak for themselves and articulate their needs to those in power. Nurses must also assist members of the population to learn how to speak for themselves rather than remain depen- dent on the nurse. Advocacy is a twofold obligation to take the part of others and, in time, to prepare them to stand alone.

A final comment is necessary with respect to advocacy. Be- cause advocacy promotes clients’ right to self-determination, population health nurses must be prepared to support clients’ decisions even when they run counter to health interests. For instance, the nurse may need to accept a community’s deci- sion not to act on an issue that the nurse believes to be impor- tant in favor of focusing on other issues of greater community concern.

Population Health Nursing Standards and Competencies One of the hallmarks of a profession is the establishment of standards of practice. Nursing, like other health-related pro- fessions, has set up standards for nursing practice and nursing service. The standards for nursing practice are further delin- eated in standards established for each of several specialty

areas in nursing. Among these, and of particular interest to population health nurses, is the American Nurses Associa- tion’s Public Health Nursing: Scope and Standards of Practice (2013) which addresses 16 standards for population-focused nursing care.

The standards of care for population health nursing prac- tice have been developed within the framework of the nursing process and the core functions of public health. They relate to the areas of assessment, population diagnosis and priority set- ting, outcomes identification, planning, implementation, and evaluation. Additional standards address expected levels of professional performance and deal with ethics, education, ev- idence-based practice and research, quality of practice, com- munication, leadership, collaboration, professional practice evaluation, resource utilization, environmental health, and advocacy. The first standard addresses assessment. Under this standard, the population health nurse collects data needed to assess the health status of the population and to identify fac- tors contributing to health and illness in the population. Un- der Standard 2, the nurse analyzes health assessment data to derive population health diagnoses which are then prioritized to promote effective action. Standard 3 addresses determina- tion of expected outcomes of population-based care for the diagnoses and priorities identified. Standard 4 focuses on planning to address population health diagnoses; planning is based on best practices derived from available evidence (ANA, 2013).

Under Standard 5, the population health nurse implements the plan of care, partnering with others as appropriate. Com- petencies related to this standard include the abilities to coor- dinate efforts, promote health and prevent illness, and engage in health teaching. Skill in consultation, prescriptive author- ity, and identification, interpretation, and implementation of health-related laws, regulations, and policies are also addressed in this standard. Standard 6 focuses on evaluating the health status of the population and the effectiveness of population- based interventions (ANA, 2013).

Standards 7 through 17 address standards of professional performance in the public health nursing role. Under Stan- dard 7, the population health nurse promotes ethical practice, whereas under Standard 8, he or she attains knowledge and maintains competency in nursing and public health practice. Standard 9 addresses the nurse’s responsibility to integrate evidence and research into practice. Standard 10 requires the nurse to promote the quality of practice in the specialty (ANA, 2013).

The focus of Standard 11 is on effective communication with a variety of audiences including the public, policy mak- ers, and interprofessional colleagues, whereas Standard 12 ad- dresses the requirements for leadership in the practice setting and the profession. Standard 13 focuses on the nurse’s ability to collaborate with others in addressing the health needs of the population, and Standard 14 addresses the nurse’s ability to evaluate his or her own practice in light of professional stan- dards and guidelines, laws, rules, and regulations (ANA, 2013).

Population health nurses collaborate with people from widely varied segments of the population. (MindStudio/Pearson Education. Inc)

M01_MARY9591_06_SE_C01.indd 13 06/09/14 5:52 PM

14 unit 1 Population health nursing: an Overview

Standard 15 focuses on the population health nurse’s re- sponsibility to use resources wisely and to consider factors related to safety, effectiveness, and cost in planning systems of care. Standard 16 addresses the expectation that the popula- tion health nurse will promote environments that are condu- cive to health and will support environmental justice for all segments of the population. Finally, under Standard 17, the population health nurse functions as an advocate to protect the health, safety, and rights of members of the population (ANA, 2013).

As noted earlier, the Council on Linkages between Aca- demia and Public Health Practice (COL) (2010) has devel- oped a set of competencies reflecting the skills, knowledge, and attitudes required for effective public or population health practice. In 2003, the Quad Council developed a set of related competencies for public/population health nurs- ing at two levels of practice, the staff nurse/generalist and the manager/specialist/consultant. The Quad Council ini- tially examined the applicability of the COL competencies specifically to public health nursing practice and developed performance expectations related to each competency for two levels of practice, generalist and specialist. The general- ist competencies were intended to reflect baccalaureate-level educational preparation, and the specialist competencies re- flected master’s-level preparation (Swider, Krothe, Reyes, & Cravetz, 2013).

The nursing competencies incorporate expectations for care of individuals and families within an overall context of population-focused practice, a unique feature compared to the COL competencies that deal only with population- focused practice (Quad Council of Public Health Nursing Organizations, 2011). The competencies address eight do- mains of practice: (a) analytic and assessment skills, (b) policy development and program planning, (c) communication, (d) cultural competence, (e) community dimensions of prac- tice, (f) public health science, (g) financial planning and management, and (h) leadership and systems thinking. The competencies were intended to reflect the practice of ex- perienced population health nurses at both generalist and specialist levels, not novices, and expectations ranged from awareness through knowledge to proficiency on any given item. In 2011, the Quad Council undertook a revision of the competencies to address three tiers of practice. Tier 1 compe- tencies are skills to be possessed by public health nurses who engaged in day-to-day care in official state and local public health agencies. Tier 2 competencies address the practice of program managers or supervisors. Tier 3 competencies are intended for public health nurses in senior management and leadership positions with responsibility for major programs and strategy development (Quad Council of Public Health Nursing Organizations, 2011). Any particular population health nursing position may incorporate components from some or all domains. For further information about the com- petencies, see the External Resources section of the student resources site.

Population Health Nursing Education Because of the autonomy and breadth of knowledge required in population health nursing at the generalist level, the mini- mum level of educational preparation should be a bacca- laureate degree. Even in the early days of district nursing in England, Florence Lee, a former student of Nightingale’s, pro- posed that district nurses be educated beyond the basic nursing preparation. In the United States, the first postgraduate course in public health nursing was offered by the Instructive District Nursing Association of Boston in 1906 (Howse, 2009).

As noted above, specialist level population health nursing competencies were predicated on master’s level educational preparation, and many nurses in the specialty were prepared in master’s programs as community health clinical nurse spe- cialists. More recently, however, the nursing professional has established the Doctor of Nursing Practice (DNP) degree. Based on the Essentials for Doctoral Education for Advanced Nursing Practice (American Association of Colleges of Nurs- ing [AACN], 2006), the guiding document for DNP programs, the DNP may have one of two foci, advanced practice directed toward individuals (e.g., nurse practitioners, nurse midwives, etc.) or population or aggregate-focused practice. AACN data for 2009 indicated that 14% of the existing DNP programs had a population or public health option. A survey of leaders in community/public health settings indicated that the competen- cies included in the Essentials document would be appropriate for population health nursing, but that their organizations did not have positions designated for DNPs (Swider et al., 2009). It remains to be seen whether or not DNP level education will be required for specialist level population health nursing in the future.

The current shortage of nurses prepared for population health nursing practice has led many public health agencies to hire nurses prepared at the Associate Degree level despite the fact that Associate Degree program curricula do not in- clude content on population-level nursing. Issel and Bekemeier (2010) cautioned that employment of unprepared nurses may jeopardize the safety of whole populations and advance the concept of population-patient safety comparable to safety con- cerns in acute care settings.

A Population Health Nursing Model Effective nursing practice is facilitated when nurses use a sys- tematic approach to clients, their health status, and the nursing interventions needed to promote, maintain, or restore health. Conceptual or theoretical models provide such an approach. A conceptual model is usually “a diagram that defines theoretical entities, objects, or conditions of a system and the relationships between them” (Conceptual model, n.d.). In nursing, concep- tual models describe the relationships between health care

M01_MARY9591_06_SE_C01.indd 14 06/09/14 5:52 PM

chaPter 1 Population health and nursing 15

needs and nursing interventions to meet those needs. Con- ceptual models can assist population health nurses to evaluate health status and to plan, implement, and evaluate effective nursing care to improve the health of populations. The model directs attention to relevant aspects of a client situation and to interventions that are apt to be most effective in that situ- ation. The Population Health Nursing (PHN) model used in this text has been developed specifically for use in population health nursing and consists of three components: determinants of population health, population health nursing interventions, and levels of health care. The model is depicted in Figure 1-3•.

Determinants of Population Health Determinants of health are factors that determine whether people are healthy or unhealthy. The World Health Organi- zation (WHO, 2014) has categorized determinants of health as reflecting social and economic environments, the physical environment, and personal characteristics and behaviors. The Canadian government has identified a number of determinants of health to include biology and genetics, physical environ- ment, early childhood development, education, employment and working conditions, culture, gender, housing, the social environment, personal health practices, income and social sta- tus, social support networks, and the health care system (Senate Subcommittee on Population and Health, 2009). As indicated

in Figure 1-1, Healthy People 2020 has conceptualized deter- minants of health as arising from human biology and genet- ics, individual behavior, social and physical environments, and health service systems.

Emphasis on broad determinants of health and illness marks a change from individually focused explanations of dis- ease to a focus on social and environmental contributions to health and illness. A focus on broad determinants of health ac- knowledges that individual behaviors are shaped by interaction with the environment (WHO, 2014) and that contextual vari- ables found in the environment probably interact in complex ways with individual variables to determine health and illness. In the PHN model, the determinants that influence health have been grouped into six categories of determinants: biological, psychological, environmental, sociocultural, behavioral, and health system determinants. Factors in each of the six catego- ries influence the health of individuals as well as the overall health status of a population.

bIOLOgICAL DETERMINANTS. Biological determinants of health are factors related to human biology that influence health and illness. These factors may be related to age and developmental level, genetic inheritance, and physiologic function. Age can affect one’s susceptibility to illness or the potential for exposure to other risk factors. Genetic inheritance encompasses gender and racial/ethnic characteristics as well as

Figure 1-3 elements of the Population Health Nursing Model

Determinants of Health

Biological Psychological

Environmental Sociocultural

Behavioral Health System

Assessment Planning Implementation Evaluation

Population health status

Levels of Health Care Health promotion

Illness and injury prevention Resolution Restoration

Education Counseling

Referral Role modeling

Case management Coordination Collaboration

Liaison Case �nding Surveillance

Policy formulation Community mobilization

Coalition building Social marketing

Promoting evidence- based practice

Population Health Nursing Interventions

M01_MARY9591_06_SE_C01.indd 15 06/09/14 5:52 PM

16 unit 1 Population health nursing: an Overview

the specific gene pattern transferred by one’s parents. Certain health problems (e.g., hemophilia and sickle cell disease) are more frequently associated with some gender or racial/ethnic groups than with others. The presence of certain genetically transmitted traits also increases one’s risk of developing some health problems, such as heart disease and some forms of cancer. Concern for genetic influences on health is evident in the increased focus on genetics and genomics in baccalaureate nursing education (AACN, 2008).

Factors related to physiologic function include one’s basic state of health as it affects the probability of developing other health problems. Considerations in this area would include the presence or absence of other disease states. For example, obe- sity is a physiologic factor that contributes to a variety of health problems, including heart disease, diabetes, and stroke. Immu- nity, discussed in more detail in Chapter 26 , is another aspect of physiologic function that affects susceptibility to disease.

When assessing populations, rather than individuals, the age, gender, and racial/ethnic composition of the groups would be determined. Other information related to biological determinants include the prevalence of genetic traits for spe- cific health conditions, the prevalence of specific physiologic conditions in the population (e.g., pregnancy, diabetes), and population levels of immunity. The Focused Assessment below includes questions that address biological determinants related to the population-level problem of increased incidence and prevalence of childhood obesity.

PSyCHOLOgICAL DETERMINANTS. Psychological de- terminants of health include both internal and external psy- chological environments. Depression and low self-esteem are two factors in one’s internal psychological environment that contribute to a variety of health problems, including suicide, substance abuse, family violence, and obesity. External psycho- logical factors can also influence the development of health prob- lems. For example, a person who has a great deal of emotional

support in a crisis is less likely to attempt suicide than a per- son who faces a crisis without such support. Stress is another factor in the external psychological environment that is associ- ated with a variety of health problems. The ability to cope with stress, on the other hand, is a factor in one’s internal psycho- logical environment.

Psychological determinants at the population level would include the incidence and prevalence of psychiatric disorders, the amount of stress experienced by members of the popula- tion, and the coping abilities of the population as a whole. For example, some populations or communities are better able to cope with increased numbers of homeless individuals or with increasing unemployment than others. Questions to guide as- sessment of psychological determinants contributing to child- hood obesity in the population are presented in the Focused Assessment on the next page.

ENvIRONMENTAL DETERMINANTS. Although psycho- logical determinants address aspects of one’s psychological envi- ronment, the environmental dimension encompasses the health effects of factors in the physical environment. The physical envi- ronment consists of weather, geographic locale, soil composition, terrain, temperature and humidity, and hazards posed by poor housing and unsafe working conditions. Additional elements of the physical environment that affect health include light and heat, exposure to pathogens and allergens, radiation, pollution, and noise. Similarly, elements of the built environment, such as areas to congregate or obtain exercise, have been shown to affect both physical and psychological health in general.

The health effects of environmental factors will be ad- dressed in greater detail in Chapter 4 . Using the PHN model, the population health nurse would assess the overall popula- tion, as well as individual clients, for the presence of environ- mental conditions detrimental to health. For example, poorly constructed highways may contribute to high rates of motor vehicle accidents for the population. At the individual level,

FOCuSED ASSESSMENT biological Determinants Influencing Childhood Obesity

• Are there gender or ethnic group differences in the prevalence of overweight and obesity in the child population?

Physiologic function

• What physical conditions or disabilities are present in the population that might contribute to lack of physical activity and obesity? What is the incidence and prevalence of such conditions?

• What physiologic effects has obesity had on the child population? For example, what are the incidence and prevalence of type 2 diabetes or hypertension among children in the population?

Age and developmental level

• What age groups within the child and adolescent population are most affected by overweight and obesity?

• Are there infant feeding practices common in the population that contribute to obesity?

• To what extent are infants breastfed in the population?

• To what extent do parents supervise the eating habits of children of different ages?

Genetics

• Is there a genetic predisposition to obesity in the population?

M01_MARY9591_06_SE_C01.indd 16 06/09/14 5:52 PM

chaPter 1 Population health and nursing 17

poor lighting, stairs, and other hazards may increase the poten- tial for falls in an elderly client. The Focused Assessment below includes questions that address environmental determinants related to the population-level problem of childhood obesity.

SOCIOCuLTuRAL DETERMINANTS. Sociocultural de- terminants of health include those factors within the social environment that influence health, either positively or negatively. Elements of the social structure such as employment, econom- ics, politics, ethics, and legal influences all fall within this dimen- sion of health. The sociocultural dimension also includes societal norms and culturally accepted modes of behavior.

Another important sociocultural determinant is prevailing attitudes toward specific health problems. For example, the fear and stigma attached to HIV infection may seriously hamper ef- forts to control the spread of disease. Substance abuse, mental illness, family violence, and adolescent pregnancy are other ex- amples of health problems in which social attitudes contribute to the problem or hinder the solution.

Societal action with respect to health behaviors also falls within this category. For example, legislation requiring im- munization of preschool children may significantly decrease rates of illness in the population. Legislative action can have both positive and negative effects on population health. For example, increases in cigarette taxes in New York City led to

decreased levels of smoking, but also increased black market sales and decreased tax revenues targeted for smoking cessa- tion programs (Shelley, Cantrell, Moon-Howard, Ramjohn, & VanDevanter, 2007).

Social capital is another sociocultural determinant of health that has been receiving increased attention in public health are- nas. Social capital is the extent of one’s access to and participa- tion in relationships that can provide one with the necessities for life. Social capital is comprised of two components: social relationships that permit claims to available resources and the actual resources received. Social capital, at the population level, is akin to the concept of social support networks avail- able to individuals and families. As an example, the existence of and access to educational opportunities afforded a popula- tion group is one element of social capital that can affect health status in a number of ways.

Sociocultural determinants can also influence health in other ways. Media portrayals of a variety of healthy and un- healthy behaviors are an example of the influence of social mo- res on health and illness. Occupation is another sociocultural determinant that may influence health. Conversely, unem- ployment may have adverse effects on physical and emotional health. Several sociocultural determinants will be addressed further in the chapters related to culture, economics, and poli- tics (Chapters 5, 6, and 9 , respectively ).

FOCuSED ASSESSMENT Psychological Determinants Influencing Childhood Obesity

• What value do members of the population place on physical activity by children?

Internal psychological environment

• What is the effect of overweight and obesity on the self- image and psychological health of children affected?

External psychological environment

• Is food used by members of the population as a reward for children’s good behavior?

• Is food seen as a symbol of love and affection in the population?

• What attitudes do members of the population hold toward childhood overweight and obesity?

FOCuSED ASSESSMENT Environmental Determinants Influencing Childhood Obesity

• What is the extent of access to healthy foods in the environment?

• What is the extent of fast food establishments in the environment? How often are they frequented by members of the population?

• What are the opportunities and environment for physical activity among children? For example, do traffic patterns or personal safety issues prohibit physical activity?

• Are there parks, sports fields, and other environmental features that promote physical activity?

M01_MARY9591_06_SE_C01.indd 17 06/09/14 5:52 PM

18 unit 1 Population health nursing: an Overview

Population health nurses using the PHN model would assess the effects of sociocultural determinants on the health of the public. For example, the nurse might examine the un- employment rate in the population and the consequent effects on access to health care services. Sample assessment ques- tions related to childhood obesity are presented in the focused assessment above.

bEHAvIORAL DETERMINANTS. Behavioral determi- nants involve personal behaviors that either promote or impair health. Behavioral factors are often those most amenable to change in efforts to prevent disease and promote health and, so, are of particular importance in population health nursing practice. Health-related behaviors include dietary patterns, rec- reation and exercise, substance use and abuse, sexual activity, and use of protective measures.

Dietary habits can either enhance or undermine health, and both leanness and obesity can predispose one to other health problems. Exercise patterns also influence health status, as do smoking, drinking, and drug use. Recreational activities are another behavioral factor that may pose health risks, but may also improve both physical and emotional health. Sexual activ- ity poses risks related to pregnancy and sexually transmitted diseases. Failure to use protective measures such as contracep- tives or barrier devices during intercourse can also increase one’s chances of health problems. Similarly, not wearing seat belts or motorcycle helmets increases the potential for serious injury. Population health nurses can assess the extent of these and other health-related behaviors in individuals and in popu- lation groups and use this information to design appropriate interventions. Examples of assessment questions that might be

used to assess the population health problem of childhood obe- sity are presented in the focused assessment on the next page.

HEALTH SySTEM DETERMINANTS. The final category of health determinants included in the PHN model is related to the health care system. The way in which health care services are organized and their availability, accessibility, affordability, appropriateness, adequacy, acceptability, and use influence the health of individual clients and population groups. Availability refers to the type and number of health services present in a community, and accessibility reflects the ability of clients to make use of those services. Affordability, the ability to pay for services, also influences health outcomes. Service appropriateness refers to a health care system’s ability to provide those services needed and desired by its clientele. The adequacy of health services refers to the quality and amount of service provided relative to need, and acceptability reflects the level of congruence between services provided and the expectations, values, and beliefs of the target population. Acceptability of services is also related to the level of trust that people have in health care providers and may differ significantly from one population group to another (Abel & Elfird, 2013). Finally, the extent to which members of the population actually make use of available health care services will influence health status.

Health system factors can influence health status either pos- itively or negatively. For example, immunization services that are available and easily accessible to all community members promote control of communicable diseases such as measles, polio, and tetanus. Conversely, the failure of health profession- als to take advantage of opportunities to immunize people con- tributes to increased incidence of these diseases.

FOCuSED ASSESSMENT Sociocultural Determinants Influencing Childhood Obesity

and candy perceived as a way to generate funds for school activities?

• What are school policies related to physical activity among children? Are regular physical education activities that involve vigorous physical activity incorporated into school curricula at all levels?

• Are there sports teams available to promote physical activity among children? Do all children have access to them, or are some barred from participation due to expense?

• What is the level of funding provided by policy makers for programs related to nutrition and physical activity? Does funding for these programs receive priority within the community?

• What is the employment status of parents in the population? Do many parents work making it more difficult to find time to prepare healthful meals?

• To what extent do children prepare their own meals in parents’ absence?

• What is the socioeconomic level of members of the population? How does socioeconomic status influence the ability to obtain and consume healthy or unhealthy foods?

• What are the cultural influences on food preferences and modes of preparation? Do they contribute to the development of overweight and obesity among children?

• What are the typical attitudes of members of the population to food, nutrition, and physical activity? Is physical activity among children valued, or are other activities (e.g., school work) given higher priority?

• What is the educational level of the population? Are they aware of factors contributing to obesity? Do they understand the long-term consequences of obesity for physical, emotional, and social health?

• What policies in the social environment contribute to or prevent obesity? For example, do local schools have “no junk food on campus” policies, or is the sale of sodas, fast food,

M01_MARY9591_06_SE_C01.indd 18 06/09/14 5:52 PM

chaPter 1 Population health and nursing 19

As we will see in Chapter 6 , some health care system contributions to health problems stem from the economics of health care delivery. The high cost of health services limits the ability of many individuals to take advantage of them. Continu- ity of care may also affect health outcomes for individuals and population groups. In other instances, inappropriate actions on the part of health care providers may actually contribute to health problems. For example, inappropriate use of antibiot- ics has contributed to the development of antibiotic-resistant strains of gonorrhea and syphilis. Other health system activi- ties may also contribute to disease. For example, blood transfu- sion has been associated with transmission of diseases such as HIV and hepatitis B and C. The focused assessment below pro- vides questions addressing health system determinants related to childhood obesity in the population.

Elements of the determinants of health component of the PHN model are summarized below. Health determinants re- lated to specific kinds of community health problems will also be addressed in relevant chapters of this book.

The population health nurse collects and organizes data regarding determinants of health. Factors in each of the six categories may apply to clients at multiple levels, including individuals, families, groups, communities, and populations. From the data, the population health nurse derives commu- nity health diagnoses that guide the planning of nursing inter- ventions. Table 1-5• summarizes the contribution of various determinants of health to the problem of high incidence and prevalence of obesity in a university population.

FOCuSED ASSESSMENT behavioral Determinants Influencing Childhood Obesity

• What is the extent of physical activity among children in the population?

• What types of physical activity are preferred? Do these types of physical activity require specialized training or equipment that might make them unaffordable for lower income children?

• To what extent do children walk or bicycle to school?

• What kinds of after-school activities do children engage in?

• How many hours per week are spent in vigorous physical activity by children?

• How many hours per week are spent in sedentary activities like watching television or playing video games?

• What household chores do children engage in? Do these chores promote physical activity (e.g., vacuuming the house)?

• What is the typical daily calorie consumption among children in the population? What is the source of these calories?

• What is the average daily consumption of fruits and vegetables among children in the population?

• How many empty calories are consumed by children on a daily or weekly basis (e.g., sodas, unhealthy snacks, sweets)?

• What are the food preferences of children in the population?

• To what extent do families consume extensive fast food? How often do families eat meals prepared at home?

• Do children eat breakfast every day?

• Do children take lunches to school, or do they purchase lunch or eat in the cafeteria at school? How healthful are school meal menus?

FOCuSED ASSESSMENT Health System Determinants Influencing Childhood Obesity

for new parents that emphasize healthy diet? Are there educational programs for parents and children of other ages?

• What health care programs are available for weight management for overweight or obese children? What is the level of accessibility of these programs to all children in need of services?

• What is the level of funding available for programs to promote healthy eating and physical activity among children or to provide weight management services when needed?

• To what extent are programs to promote healthy diets and physical activity among children culturally sensitive and appropriate to various segments of the population?

• To what extent do health care providers focus on healthy weight, nutrition, and physical activity? Does this focus extend to children with physical conditions that necessitate physical activities specifically tailored to their abilities?

• What percentage of children in the population has access to a regular health care provider who can promote healthy eating and physical activity?

• What population-based programs are available in the community to promote good nutrition and physical fitness? For example, are there educational programs available

M01_MARY9591_06_SE_C01.indd 19 06/09/14 5:52 PM

20 unit 1 Population health nursing: an Overview

Population Health Nursing Interventions The second component of the PHN model reflects interven- tions taken by population health nurses to address health problems within a population. Several categories of popula- tion health nursing intervention have been identified and are summarized below. Each type of intervention will be discussed briefly and examples of particular interventions will be in- cluded throughout this book.

Education is the process of facilitating learning that leads to positive health behavior. In the educator role, the popula- tion health nurse provides clients and others with information and insights that allow them to make informed decisions on health matters. Population health nurses often provide educa- tional services to individuals, families, and groups, and they are frequently involved in the development of population-based health education programs. Population health nurses, for ex- ample, educate individuals and their families about adequate nutrition. At the same time, they may educate the general pub- lic regarding the harmful effects, say, of a high-cholesterol, low-fiber diet. Similarly, population health nurses may educate legislators and other policy makers regarding societal factors that impede population health. Educational interventions are discussed in greater detail in Chapter 11 .

Although many people do not distinguish between coun- seling and education, they are different. Counseling is the process of helping a client to choose viable solutions to health problems. In educating, one is presenting facts and develop- ing attitudes and skills. In counseling, one is not telling people what to do but helping them to employ the problem-solving process and decide on the most appropriate course of action. In the role of counselor, population health nurses explain the problem-solving process and guide clients/populations through each step. In this way, the nurse is not only helping the individual, family, or population to solve the immediate problem but also assisting in the development of problem- solving abilities.

Counseling involves several steps on the part of the commu- nity health nurse. The first step is helping to clarify the prob- lem to be solved. The nurse and client/population together examine the factors that contribute to a problem and those

Determinants of Health

biological Determinants

• Age and developmental level

• Genetics

• Physiologic function

Psychological Determinants

• Internal psychological environment

• External psychological environment

Environmental Determinants

• Physical environment

• Environmental hazards

Sociocultural Determinants

• Social structure

• Societal norms

• Societal attitudes

• Social action

behavioral Determinants

• Dietary practices

• Recreation and exercise

• Substance use and abuse

• Sexual activity

• Use of protective measures

Health System Determinants

• Availability

• Accessibility

• Affordability

• Appropriateness

• Adequacy

• Acceptability

• Use

Highlights

Model Concept Application

Biological determinants Age composition of the population; prevalence of obesity in the population Psychological determinants Stress of college life; extent of use of food as stress reliever; extent of exposure to stressful circumstances; prevalence of

eating disorders on campus Environmental determinants Weather conducive to outdoor exercise; facilities available for obese members of the population (e.g., size of classroom chairs) Sociocultural determinants Use of eating and drinking as social activities; population attitudes toward obesity; extent of peer support for healthy

lifestyles; availability of education for healthy lifestyles Behavioral determinants Dietary practices in campus population; availability of healthy foods in campus dining facilities; availability of recreational ac-

tivities and equipment; extent of participation in physical activity among campus population; sedentary nature of university life Health system determinants Health center staff attention to weight problems among campus community members; availability of weight/diet counseling

programs; availability of stress-reduction/counseling programs

TAbLE 1-5 Determinants of Health and Their Influence on the Problem of Obesity in a university Population

M01_MARY9591_06_SE_C01.indd 20 06/09/14 5:52 PM

chaPter 1 Population health and nursing 21

that may enhance or impede problem resolution. The second step involves identifying alternative solutions to the problem. If, for example, a large proportion of pregnant women in the population do not receive prenatal care, one could suggest an educational campaign, outreach efforts by lay health promot- ers, financial subsidies for care by available providers, or the use of nurse midwives.

Assisting the client or population group to develop criteria for an acceptable solution to the problem is the third step in counseling. For example, an acceptable solution to the prob- lem of poor nutrition among family members would need to fit the family’s budget and might need to conform to cul- tural dietary preferences. A program to address nutritional needs at the population level would need to address the same constraints.

Next, the population health nurse would assist the client to evaluate each of the alternative solutions in terms of criteria established for an acceptable solution. The most appropriate alternative is one that best meets the acceptability criteria. This alternative is then implemented. Evaluation is the fifth step of the problem-solving process. If the alternative selected solves the problem, fine! If not, the process begins again.

Referral is one of the key functions of population health nurses. Referral is the process of directing clients to resources required to meet their needs. These resources may be other agencies that can provide necessary services or sources of in- formation, equipment, or supplies that the client needs and the population health nurse cannot supply. A distinction must be made between the functions of referral and consultation. In a referral, the client is directed toward another source of services. In consultation, on the other hand, the nurse may seek assis- tance or information needed to help the client from another source, but the client does not receive services directly from the consultant. Population health nurses also provide consultation to other professionals and to policy-making bodies. The refer- ral process is discussed in more detail in Chapter 12 .

A role model is someone who consciously or unconsciously demonstrates behavior to others who will perform a similar role. Population health nurses serve as role models for a variety of people with whom they come in contact. Through their own behavior, nurses influence the behavior of others. For instance, the population health nurse’s ability to engage in systematic planning may promote similar skills in community planning groups.

Although case management is a new concept for many nurses, it has long been an integral component of population health nursing. A case manager is a health professional who coordinates and directs the selection and use of health care services to meet client needs, maximize resource utilization, and minimize the expense of care. The aims of case manage- ment include identifying high-risk clients or those with the potential for high-cost service needs, making appropriate choices among available services and providers, controlling costs, and coordinating care to achieve optimal client out- comes. The process of case management will be addressed in more detail in Chapter 12 .

Population Health Nursing Interventions Education: Providing clients/populations with information to make informed health-related decisions

Counseling: Assisting clients/populations to choose viable solu- tions to health problems

Referral: Directing clients to resources needed to meet their needs

Role modeling: Demonstrating desired behaviors to promote learn- ing and change

Case management: Coordinating and selecting health care services to meet identified client needs

Coordination/care management: Organizing and integrating health care delivery services to best meet population health care needs

Collaboration: Engaging in joint decision making with clients/ populations, other health care providers, and non-health sectors of society to resolve client/population health problems

Liaison: Facilitating relationships between clients/populations and other health care providers or policy makers

Case Finding/screening: Identifying individual cases of health problems or the incidence and prevalence of conditions in the population

Surveillance: Monitoring occurrence and trends in specific health problems within the population

Policy formulation: Promoting and assisting in the development of social and health care policies that support the health of the population

Community mobilization: Assisting populations to identify goals and implement strategies to improve health and promote conditions that support health

Coalition building: Assisting in the creation of alliances of individu- als or groups to achieve health-related goals

Social marketing: Using commercial marketing strategies to change public attitudes or behaviors

Promoting evidence-based practice: Critically examining scientific evidence to identify and effectively implement strategies that improve population health

Highlights

Population health nurses frequently care for clients who are receiving services from a variety of sources. Because of their awareness of the needs of the client as a whole being, popula- tion health nurses are in an ideal position to serve as coordi- nators of care. Coordination is the process of organizing and integrating services to best meet client needs in the most effi- cient manner possible. Unlike the case manager, the coordina- tor does not plan the care to be carried out by other health care professionals, but organizes that care to meet clients’ needs as effectively as possible. At the population level, coordination may be referred to as population health management, or the “coordination of care across a population to improve clinical and financial outcomes” (Population Health Management, 2010, p. 1).

M01_MARY9591_06_SE_C01.indd 21 06/09/14 5:52 PM

22 unit 1 Population health nursing: an Overview

Collaboration involves joint decision making regarding action to be taken to resolve health problems. Collaboration is frequently confused with the nurse’s coordination role. Co- ordination is essentially a management function and involves making sure that efforts to provide services are consistent and occur without gaps or overlaps. Collaboration, on the other hand, entails joint decision making. Both collaboration and co- ordination, of course, necessitate working with members of the population and other professionals (and nonprofessionals) to address population health problems.

Collaboration is not a matter of each health care provider or agency designing and providing a program in his or her area of expertise with a certain amount of coordination be- tween efforts. Rather, it is a joint effort on the part of health care providers, members of the population, and representa- tives from other sectors of society to set mutual goals and to arrive at a mutually acceptable plan to achieve them. A liai- son is a person who provides a connection, relationship, or intercommunication. The population health nurse working with clients dealing with multiple health and social agencies may serve as that connection or liaison. In referral, the nurse may function as the initial point of contact between client and agency. The liaison’s role might involve continued communi- cation between client and other providers via the nurse. Some- times this communication includes the additional function of interpretation and reinforcement of provider recommenda- tions to the client or advocacy for the client with the provider agency. At the population level, the population health nurse may serve as a liaison between community residents and policy makers.

Case finding has been described as basic to population health nursing. Case finding involves identifying individual cases or occurrences of specific diseases or other health-related conditions requiring services. As we will see in Chapter 26 , case finding is an important strategy in preventing the spread

of communicable diseases in large population groups. Case finding may involve screening or conducting tests to identify the presence of a particular disease or condition. Population health nurses may screen individual clients or assist in plan- ning and implementing population-based screening efforts.

Case finding is closely related to the public health nursing intervention of surveillance, which is defined as “the system- atic collection, analysis, interpretation, and dissemination of data to assist in the planning, implementation, and evaluation of public health interventions and programs” (ANA, 2013, p. 68). For example, identifying more instances of child abuse may be an indication of a community health problem.

As noted earlier in this chapter, policy development is one of the core functions of public health practice, and popula- tion health nurses have a definite role as policy advocates in the execution of this function. A policy advocate is a person or group of people who work for and argue on behalf of policy formation or changes in policy that influence population health. Policy advocacy may occur at institutional, community, state, national, or international levels. Population health nurses may assist in determining the need for policy formation or change, developing policy goals, analyzing factors influencing the policy situation, identifying key decision makers involved in policy for- mation, assisting in the formulation of proposed policies, com- municating the proposed policy to the general public and to policy makers, and monitoring the progress of policy formation. These functions will be discussed in more detail in Chapter 9 .

Community mobilization is assisting populations to iden- tify areas of concern and to develop and implement strategies to address them. Community mobilization promotes the par- ticipation of members of population groups in the control of their own lives and gives them the power to enact changes in circumstances that affect their health. Community mobiliza- tion will be discussed in more detail in Chapter 10 .

As we will see in Chapter 9 , coalition building is a strat- egy often used in political activism. Coalition building is the process of creating temporary or permanent alliances of indi- viduals or groups to achieve a specific purpose. Coalitions have the advantage of fostering community-wide problem solving and collaborative policy and program development bringing to bear the assets and resources and perspectives of multiple seg- ments of the population. Population health nurses may initiate coalition building activities among members of the population and between both health-related and other sectors of society to influence the determinants of health.

Social marketing is another population health nursing in- tervention. The most frequently quoted definition of social marketing in the literature is that provided by Andreasen (1995): “the application of commercial marketing technolo- gies to the analysis, planning, execution, and evaluation of programs designed to influence the voluntary behavior of tar- get audiences to improve their personal welfare or that of their society” (p. 7). Social marketing is consumer focused in that it is tailored to the needs and characteristics of a specific target

Population health nurses provide health education to individuals, families, communities, and population groups. (Jules Selmes/Pearson Education. Inc)

M01_MARY9591_06_SE_C01.indd 22 06/09/14 5:52 PM

chaPter 1 Population health and nursing 23

population and is designed to address societal problems at the population level.

Population health nurses involved in social marketing may assist in identifying a needed change in societal behavior, analyzing behavioral motivations and perceived benefits and barriers to action, identifying particular target markets for in- terventions and determining the unique features of those mar- kets, developing and testing strategies to promote the desired

change, implementing those strategies, and evaluating their effectiveness. Concepts and principles of social marketing and related community health nursing functions are discussed in more detail in Chapter 11 .

Promoting evidence-based practice is an overarching inter- vention by population health nurses that involves translating research findings into practice and may inform all of the other interventions described above. Evidence-based practice is a

Evidence-based Practice

understanding the Process Effective population health nursing should be based on scientific evidence combined with clinical expertise and client preferences. Use of a systematic process to critically evaluate available evidence can promote evidence-based practice. A number of models for evidence-based practice are found in the literature (Mitchell, Fisher, Hastings, Silverman, & Wallen, 2010), but they generally incorpo- rate similar steps for integrating evidence as a basis for practice.

The first step in evidence-based practice is to identify a clini- cal question or problem that needs resolution. Clinical questions may be framed in the PICO format in which P stands for the population of interest, I reflects a potential intervention, C is a comparison intervention or group, and O is the desired out- come to be achieved. Some authors add a T to the acronym to make it PICOT, with the T reflecting the time period in which the outcome is expected to be measured (Melnyk, Fineout-Overholt, Stillwell, & Williamson, 2010).

The second step in promoting evidence-based practice in a practice setting is finding the relevant evidence. Evidence fre- quently includes published research, both quantitative and qual- itative (Owens, 2009), but may also include non-research-based evidence from within or outside the setting. Such evidence might include quality improvement data, case studies, or expert opin- ion (Bednarski, 2010). In addition to bringing to light individual research studies, a literature review may produce meta-analyses of several related studies or previously developed clinical prac- tice guidelines related to the topic of interest. Clinical practice guidelines (CPGs) are “general practice recommendations to aid clinical decision making for specific clinical situations” (Ameri- can Professional Wound Care Association, 2010, p. 161) that are usually based on a critical review of research findings, expert opinion, and client preferences.

Once various forms of evidence have been identified, the body of evidence must be critically evaluated in terms of its level, quality, and strength. The level of evidence refers to the hierar- chy of research methodologies used to develop evidence, with randomized controlled strategies having greater credibility than other methods, such as observational studies, cross-sectional

studies, qualitative studies, case reports, and expert opinion or consensus (Stillwell, Fineout-Overholt, Melnyk, & Williamson, 2010). The quality of the evidence refers to the way in which the study was conducted, the validity of the research design and methods for addressing the research question, the clinical relevance of the findings, and the potential applicability of the findings to one’s own practice population (the generalizability of the findings). Finally, the strength of the evidence reflects the extent to which different credible studies support the effec- tiveness of the intervention being considered (Shapiro, 2010). This process of appraisal frequently involves grading each study or other piece of evidence using a critical appraisal guide, or criteria appropriate to the type of study being reviewed (Fineout- Overholt, Melnyk, Stillwell, & Williamson, 2010). Existing clini- cal practice guidelines should also be critically evaluated using a systematic approach such as that provided by the AGREE in- strument (AGREE Next Steps Consortium, 2013; Zadvinskis & Grudell, 2010).

The fourth step in implementing evidence-based practice is to integrate the research evidence with clinical expertise and patient preferences and values (Melnyk et al., 2010). Client situations differ, so the applicability of research findings to a particular client or population must also be evaluated. When there is sufficient evidence for the effectiveness of the proposed intervention, it is implemented on a trial basis and the outcomes of the trial evaluated. Finally, the outcomes of implementation should be disseminated to add to the evidence base for practice in other similar settings. Throughout the remainder of this book, we will examine the evidence for specific interventions as well as address some additional considerations related to evidence- based population health nursing practice.

Evidence-based practice is not a new concept. We opened this chapter with a discussion of the advocacy activities of Florence Nightingale, who was one of the forerunners of evidence-based nursing practice. Nightingale used her notes and observations on mortality in the Crimean War to improve hygiene and sanitation in treating the ill and injured (Pasley, 2010).

M01_MARY9591_06_SE_C01.indd 23 06/09/14 5:52 PM

24 unit 1 Population health nursing: an Overview

strategy for improving patient outcomes by integrating “the best evidence from studies and patient care data with clinician expertise and patient preferences and values” (Melnyk, Fine- out-Overholt, Stillwell, & Williamson, 2009, p. 49). In promot- ing evidence-based practice, population health nurses will be actively involved in searching and critically analyzing related research literature and identifying practice interventions that have significant research support and are appropriate to the population to be served.

The population health nursing interventions presented here are similar to those included in the interventions wheel model developed by Public Health Nursing Section of the Minnesota Department of Health in 2001 (Wisconsin Depart- ment of Health Services, 2014). The 17 interventions included in the model were derived from research on actual practice by public health nurses.

Levels of Health Care The population health nursing interventions described above and those included in the interventions wheel may be em- ployed to address health concerns at one of four levels of care: health promotion, illness and injury prevention, resolution, and restoration. The American Journal of Health Promotion (O’Donnell, 2009) has adopted the definition of health pro- motion as “the art and science of helping people discover the synergies between their core passions and optimal health, en- hancing their motivation to strive for optimal health, and sup- porting them in changing their lifestyle to move toward a state of optimal health” (p. 1). Health promotion, then entails activi- ties designed to foster a healthy lifestyle and develop a state of good health in the population. For example, the population health nurse might engage in a number of interventions, such as education and advocacy for access to healthy foods, designed to foster good nutrition as a health promoting strategy.

Prevention, also referred to as health protection, involves strategies aimed at preventing the occurrence of specific health problems. For example, immunization is a preventive measure for certain communicable diseases. Illness and injury preven- tion may also involve reducing or eliminating risk factors as a means of preventing the occurrence of health problems. Legis- lation to require helmet use for bicycle riders is an example of risk factor modification to prevent injury.

The aim of the resolution level of health care is elimination of an existing health problem. At this level, a health problem has already occurred and population health nursing inter- ventions are directed toward its solution and preventing fur- ther serious consequences. Resolution activities may include screening and early diagnosis as well as treatment for existing health problems. Treatment for a sexually transmitted disease is an example of resolution. Removing a child from an abu- sive home situation and providing respite for caregivers who are overwhelmed are other resolution strategies. Restoration, or rehabilitation, involves activities designed to assist the cli- ent’s or population’s return to a prior state of good health and functional ability. For many health problems restoration is not needed (e.g., after a minor cold) or is not possible (e.g., with a terminal diagnosis). At the population level, resolving immediate problems related to an earthquake, such as rescu- ing victims and restoring power, are examples of resolution. Rebuilding damaged buildings and highways would constitute restoration.

As depicted in Table 1-6•, the levels of care are similar to the public health concept of levels of prevention, which in- cludes primary prevention, secondary prevention, and tertiary prevention. Health promotion and illness and injury preven- tion are elements of primary prevention, which is the inter- vention aimed at preventing health problems from occurring. Secondary prevention focuses on the early identification and treatment of existing health problems and occurs after the health problem has arisen. Tertiary prevention is an activity aimed at returning the client (individual or population) to the highest level of function and preventing further deterioration in health (Gerstman, 2013). Because of the confusion engen- dered by different uses of the term “prevention,” however, we will use the terms of health promotion, illness and injury pre- vention, resolution, and restoration for the levels of health care throughout this book.

Appropriate population health nursing interventions would be used at each level of health care to prevent population health problems or deal with identified problems. Table 1-7• presents interventions at each level of health care related to the prob- lem of increased prevalence of obesity in the population. The elements of the PHN model are used within the context of the nursing process as depicted in Figure 1-3.

Level of Health Care Level of Prevention

Health promotion Primary prevention: Focus on preventing occurrence of health problems

Prevention Primary prevention: Focus on preventing occurrence of health problems

Resolution Secondary prevention: Focus on identification and treatment of existing health problems

Restoration Tertiary prevention: Focus on restoring health status and preventing further deterioration

TAbLE 1-6 Levels of Health Care and Levels of Prevention

M01_MARY9591_06_SE_C01.indd 24 06/09/14 5:52 PM

chaPter 1 Population health and nursing 25

In the assessment stage of the nursing process, the popula- tion health nurse assesses the impact of the six categories of determinants on the health of the population (or individual client/family) and derives nursing diagnoses related to popu- lation health. Nursing diagnoses may be positive or negative. Positive diagnoses are areas in which the population is func- tioning effectively. Negative diagnoses are areas in which in- tervention is required to address identified health problems. In the planning and implementation stages of the nursing process, the nurse develops and carries out, often in collabora- tion with members of the population and others, interventions designed to support population health or to address identified problems. The population health nursing uses evaluation find- ings to assess the effectiveness of interventions and to inform subsequent interventions.

Other models have been developed or modified for use in population health nursing. Information about some of these models is provided on the student resources site.

global Perspectives

The population health nursing (PHN) model described in this chapter forms the theoretical foundation for the rest of the book. The PHN model is one approach to population health nursing. Other models that can be used to direct population health nursing activity are discussed in the Further Information section of the stu- dent resources. The point has been raised, however, that models developed for practice in the United States may not always be ap- propriate and applicable to population health nursing practice in other countries. Another concern in adopting U.S. practice models in other countries is the abstract language that is sometimes used in describing such models and the educational level and facility with English exhibited by nurses in other countries. Of the theoret- ical models presented in the text and on the website, which ones do you think would be most applicable in other countries? Why?

Population Health Models

As we have seen in this chapter, population health is the health status of an entire population and is more than the cumulative health of its individual members. Population health practice is guided by three core public health functions of assessment, policy development, and assurance, and by 10 essential public health services. Healthy People 2020 provides national objec- tives for the improvement of population health.

Population health nursing is nursing care directed toward the improvement of the health of the overall population. It is guided by a set of standards and competencies expected of

population health nurses. Population health nurses use the PHN model, in the context of the nursing process, to direct their practice. Elements of the model include the determinants of health, factors that influence the health of the population, and population health nursing interventions that are employed at four levels of health care, health promotion, illness and injury prevention, resolution, and restoration. Throughout this book, we will use the PHN model to address a variety of population health problems and conditions.

CHAPTER RECAP

Levels of Health Care Selected Population Health Nursing Interventions

Health promotion • Promoting regular exercise in the population • Developing environments that foster physical activity

Prevention • Educating the public on good nutrition • Referring needy families to nutrition support programs • Promoting access to healthy foods • Limiting access to unhealthy food choices

Resolution • Assuring access to weight-reduction programs in the community

Restoration • Providing services to deal with long-term consequences of obesity

TAbLE 1-7 Levels of Health Care and Population Health Nursing Interventions for Obesity

M01_MARY9591_06_SE_C01.indd 25 06/09/14 5:52 PM

26 unit 1 Population health nursing: an Overview

Vista Hills is a small, low-income community within a major metropolitan area. In home visits to several older clients, the population health nurse assigned to the area discovers that they have not been able to keep medical appointments or get prescrip- tions filled due to lack of available transportation. There is a bus that traverses the area, but it only has stops on major thorough- fares, and most older residents have difficulty walking from their homes to the bus stops. In the past, the community had access to a Dial-a-Ride service that provided door-to-door transportation for elderly residents for 50 cents a ride (one-way). This service was discontinued several years ago because of escalating costs.

The city in which the community is located has some funds for transportation services for elderly clients, but they have not

been allocated to this community because older residents com- prise only 11% of the overall population. Some residents use taxi services to meet their transportation needs, but find this very expensive given their limited incomes. 1. What are some of the determinants of health operating in

this situation? 2. What population health nursing interventions might be

needed to address this community health problem? Why are these interventions appropriate to this situation?

3. Give examples of some specific activities the population health nurse might carry out in relation to each intervention.

Transportation Services for Older ClientsCASE STuDy

Abel, W. M., & Elfird, J. T. (2013, December 5). The association between trust in health care providers and medication adherence among Black women with hypertension. Frontiers in Public Health, 1, 66. doi: 10.3389/ fpubh.2013.00066

Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. (2008). Phase I report: Recommendations for the frame- work and format of Healthy People 2020. Washington, DC: U.S. Department of Health and Human Services.

Advocacy. (n.d.a). Dictionary.com unabridged. Retrieved from Dictionary.com website: http://dictionary.reference.com/browse/advocacy

Advocacy. (n.d.b). Retrieved from http://en.wikipedia.org/wiki/Advocacy The AGREE Next Steps Consortium. (2013). Appraisal of guidelines for re-

search and evaluation II. Retrieved from http://www.agreetrust.org/ wp-content/uploads/2013/10/AGREE-II-Users-Manual-and-23-item- Instrument_2009_UPDATE_2013.pdf

American Association of Colleges of Nursing. (2006). Essentials for doctoral education for advanced nursing practice. Washington, DC: Author.

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

American Nurses Association. (1976). Code for nurses with interpretive state- ments. Kansas City, MO: Author.

American Nurses Association. (1986). Standards of community health nursing practice. Kansas City, MO: Author.

American Nurses Association. (2013). Public health nursing: Scope and stan- dards of practice (2nd ed.). Silver Spring, MD: Author.

American Professional Wound Care Association. (2010). SELECT: Evaluation and implementation of clinical practice guidelines: A guidance document from the American Professional Wound Care Association. Advances in Skin & Wound Care, 23, 161–168.

American Public Health Association. (2014). 10 essential public health services. Retrieved from http://www.apha.org/programs/standards/performance- standardsprogram/resexxentialservices.htm

American Public Health Association, Public Health Nursing Section. (2013). The definition of public health nursing. Retrieved from http://www.apha.org/

NR/rdonlyres/284CE437-6AF3-4B23-88BA-52F2A0E329E6/0/PHNdefini- tionNov2013_final125142.pdf

Andreasen, A. R. (1995). Marketing social change: Changing behavior to pro- mote health, social development, and the environment. San Francisco, CA: Jossey-Bass.

Barnum, N. C. (2011). Public health nursing: An autonomous career for World War II nurse veterans. Public Health Nursing, 28, 379–386. doi: 10.1111/j.1525-1446.2011.00949.x

Baum, F. E., Bégin, M., Houweling, T. A. J., & Taylor, S. (2009). Changes not for the fainthearted: Reorienting health care systems toward health equity through action on the social determinants of health. American Journal of Public Health, 99, 1967–1974.

Bednarski, D. (2010). Integrating evidence-based practice. Nephrology Nursing Journal, 37, 113–114.

Bloy, M. (2010). Florence Nightingale (1820–1910). Retrieved from http://www. victorianweb.org/history/crimea/florrie.html

Carel, H. (2009). A reply to “Towards and understanding of nursing as a re- sponse to human vulnerability” by Derek Sellman: vulnerability and illness. Nursing Philosophy, 10, 214–219. doi: 10.1111/j.1466-769X.2009.00401.x

Clark, M. J. (2001). Voicing their voice: The structure of advocacy. Unpublished raw data.

Clark, M. J. (2008). Advocacy in community health nursing. Unpublished raw data. Conceptual model. (n.d.). Dictionary.com’s 21st century Lexicon. Retrieved

from Dictionary.com website: http://dictionary.reference.com/browse/ conceptual model

Council on Linkages Between Academia and Public Health Practice. (2010). Core Competencies for Public Health Professionals: Revisions adopted: May 2010. Retrieved from http://www.phf.org/resourcestools/Documents/ Core_Competencies_for_Public_Health_Professionals_2010May.pdf

Drevdahl, D., Kneipp, S. M., Canales, M. K., & Dorcy, K. S. (2001). Reinvesting in social justice: A capital idea for public health nursing? Advances in Nursing Science, 24(2), 19–31.

Environmental Health Services. (2011). Core functions of public health and how they relate to the 10 essential services. Retrieved from http://www.cdc.gov/ nceh/ehs/ephli/core_ess.htm

REFERENCES

M01_MARY9591_06_SE_C01.indd 26 06/09/14 5:52 PM

chaPter 1 Population health and nursing 27

Fee, E., & Bu, L. (2010). The origins of public health nursing: The Henry Street visiting nurse service. American Journal of Public Health, 100, 1206–1207.

Fineout-Overholt, E., Melnyk, B. M., Stillwell, S. B., & Williamson, K. M. (2010). Critical appraisal of the evidence: Part I. American Journal of Nursing, 110(7), 47–52.

Gerstman, B. B. (2013). Epidemiology kept simple: An introduction to traditional and modern epidemiology (3rd ed.). Hoboken, NJ: Wiley Blackwell.

Hallett, C. E. (2010). Celebrating nurses: A visual history. Hauppauge, NY: Barron’s. Health Advocacy. (2014). Wikipedia, the free encyclopedia. Retrieved from

http://en.wikipedia.org/wiki/Health_advocacy Howse, C. (2009). “The reflection of England’s light”: The Instructive District

Nursing Association of Boston, 1884–1914. Nursing History Review, 17, 47–79. doi: 10.1891/1062-8061.17.47

Institute of Medicine. (1988). The future of public health. Washington, DC: National Academies Press.

Institute of Medicine, Committee on Assuring the Health of the Public in the 21st Century. (2002). The future of the public’s health in the 21st century. Washington, DC: National Academies Press.

Institute of Medicine. (2013). Working definition of population health. Retrieved from http://iom.edu/~/media/Files/Activity%20Files/PublicHealth/ PopulationHealthImprovementRT/Pop%20Health%20RT%20Population% 20Health%20Working%20Definition.pdf

Issel, L. M., & Bekemeier, B. (2010). Safe practice of population-focused nurs- ing care: Development of a public health nursing concept. Nursing Outlook, 58, 226–232. doi:10.1016/j.outlook.2010.06.001

Jacobsen, D. M., & Teutsch, S. (2012). An environmental scan of integrated ap- proaches for defining and measuring total population health by the clinical care system, the government public health system, and stakeholder organiza- tions. Washington, DC: The National Academies Press.

Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93, 380–383.

Levin, P. F., Swider, S. M., Breakwell, S., Cowell, J. M., & Reising, V. (2013). Embracing a competency-based curriculum for community-based nursing roles. Public Health Nursing, 30, 557–565. doi: 10.1111/phn.12042

Lewis, J. J. (2010). Florence Nightingale. Retrieved from http://womenshistory. about.com/od/nightingale/p/nightingale.htm?p=1

Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2009). Igniting a spirit of inquiry: An essential foundation for evidence- based practice. American Journal of Nursing, 109(11), 49–52.

Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). The seven steps of evidence-based practice. American Journal of Nursing, 110(1), 51–53.

Mitchell, S.A., Fisher, C. A., Hastings, C. E., Silverman, L. B., & Wallen, G. R. (2010). A thematic analysis of theoretical models for translational science in nursing: Mapping the field. Nursing Outlook, 58, 287–300. doi:10.1016/j. outlook.2010.07.001

National Public Health Performance Standards Program. (n.d.). Acronyms, glossary, and reference terms. Retrieved from http://www.cdc.gov/od/ ocphp/nphpsp/PDF/glossary.pdf

O’Donnell, M. P. (2009). Definition of health promotion 2.0: Embracing pas- sion, enhancing motivation, recognizing dynamic balance, and creating op- portunities. American Journal of Health Promotion, 24, iv. Retrieved from http://www.healthpromotionjournal.com

Office of Disease Prevention and Health Promotion. (n.d.a). Framework: The vision, mission and goals of Healthy People 2020. Retrieved from http:// www.healthypeople.gov/2020/consortium/HP2020Framework.pdf

Office of Disease Prevention and Health Promotion. (n.d.b). Healthy people 2020: A resource for promoting health and preventing disease throughout the

nation. Retrieved from http://www.healthypeople.gov/2020/consortium/ HealthyPeoplePresentation_2_24_11.ppt

Pasley, J. (2010, Fall). What would Florence think? Vanderbilt Nurse, pp. 8–13.

Population health management. (2010). Thefreedictionary.com. Retrieved from http://medical-dictionary.thefreedictionary.com/population+ health+management

Poulton, B. (2009). Barriers and facilitators to the achievement of community- focused public health nursing practice: A UK perspective. Journal of Nursing Management, 17, 74–83. 10.1111/j.1365-2834.2008.00949.x

Public Health Agency of Canada. (2012). What is the population health ap- proach? Retrieved from http://www/phac-aspc.gc.ca/ph-sp/approach- approche/index-eng.php

Public Health Agency of Canada. (2013). What is the population health ap- proach? Key elements of a population health approach. Retrieved from http://www.phac-aspc.gc.ca/ph-sp/approach-approche/appr-eng. php#key_elements

Public Health Foundation. (n.d.). Core Competencies for Public Health Profession- als: Tiers. Retrieved from http://www.phf.org/programs/corecompetencies/ Pages/COL_CorePublicHealthCompetencies_Guidance_Definitions.aspx

Public Health Foundation. (2014a). About the Core Competencies for Public Health Professionals . Retrieved from http://www.phf.org/ programs/ corecompetencies/Pages/About_the_Core_Competencies_for_ Public_Health_Professionals.aspx

Public Health Foundation. (2014b). Behind the scenes of the Core Competen- cies for Public Health Professionals revisions. Retrieved from http://www. phf.org/phfpulse/Pages/Amos_Behind_the_Scenes_of_the_Core_Com- petencies_Revisions.aspx?utm_source=Council+on+Linkages+Up date+-+March+2014&utm_campaign=Council+on+Linkages+Upd ate+-+March+2014&utm_medium=email

Quad Council of Public Health Nursing Organizations. (2011). Quad Council Competencies for Public Health Nurses. Retrieved from http://www.achne.org/ files/Quad%20Council/QuadCouncilCompetenciesforPublicHealthNurses. pdf

Selanders, L. C., & Crane, P. C. (2012) The Voice of Florence Nightingale on Advocacy. OJIN: The Online Journal of Issues in Nursing, 17(1), Manuscript 1. doi: 10.3912/OJIN.Vol17No01Man01

Senate Subcommittee on Population and Health. (2009). A healthy, productive Canada: A determinant of health approach. Ottawa, ON: Author.

Shapiro, S. E. (2010). Grading evidence for practice. Advanced Emergency Nurs- ing Journal, 32, 59–67.

Shelley, D., Cantrell, M. J., Moon-Howard, J., Ramjohn, D. Q., & VanDevanter, N. (2007). The $5 man: The underground economic response to a large cigarette tax increase in New York City. American Journal of Public Health, 97, 1483–1488.

Simkin, J. (n.d.). Florence Nightingale. Retrieved from http://www.spartacus. schoolnet.co.uk/REnightingale.htm

Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010). Searching for the evidence. American Journal of Nursing, 110(5), 41–47.

Stoto, M. A. (2013). Population health in the Affordable Care Act era. Retrieved from http://www.academyhealth.org/files/AH2013pophealth.pdf

Swider, S. M., Krothe, J., Reyes, D., & Cravetz, M. (2013). The Quad Council practice competencies for public health nursing.Public Health Nursing, 30, 519–536. doi: 10.1111/phn.12090

Swider, S. M., Levin, P., Cowell, J., Breakwell, S., Holland, P., & Wallinder, J. (2009). Community/public health nursing practice leaders’ views of the Doctorate of Nursing Practice. Public Health Nursing, 26, 405–411.

M01_MARY9591_06_SE_C01.indd 27 06/09/14 5:52 PM

28 unit 1 Population health nursing: an Overview

University of Oxford. (n.d.). PICO: Formulate an answerable question. Retrieved from http://learntech.physiol.ox.ac.uk/cochrane_tutorial/ cochlibd0e84.php

U.S. Department of Health and Human Services. (1980). Promoting health/ preventing disease: Objectives for the nation. Washington, DC: Government Printing Office.

U.S. Department of Health and Human Services. (2012a). Healthy people 2020 leading health indicator topics. Retrieved from http://healthypeople. gov/2020/LHI/2020indicators.aspx

U.S. Department of Health and Human Services. (2012b). Leading health indicators. Retrieved from http://healthypeople.gov/2020/LHI/default. aspx

U.S. Department of Health and Human Services. (2012c). Leading health indicators. Retrieved from http://healthypeople.gov/2020/LHI/default. aspx

U.S. Department of Health and Human Services. (2013). 2020 LHI topics. Retrieved from http://www.healthypeople.gov/2020/LHI/2020indicators. aspx

U.S. Department of Health and Human Services. (2014). About healthy people. Retrieved from http://www.healthypeople.gov/2020/about/default. aspx

Wisconsin Department of Health Services. (2014). Public health nursing: The public health intervention wheel. Retrieved from http://www.dhs.wisconsin. gov/phnc/InterventionWheel/

Workhouse. (n.d.). The Metropolitan Asylums Board. Retrieved from http:// www.workhouses.org.uk/MAB/

World Health Organization. (1984). Health promotion: A discussion document on the concept and principles. Copenhagen, Denmark: WHO Regional Office for Europe.

World Health Organization. (2014). The determinants of health. Retrieved from http://www.who.int/hia/evidence/doh/en/print.html

Young, S. (2009). Professional relationships and power dynamics between ur- ban community-based nurses and social work case managers. Professional Case Management, 14, 312–320.

Zadvinskis, I. M., & Grudell, B. A. (2010). Clinical practice guideline appraisal using the AGREE instrument. Clinical Nurse Specialist, 24, 204–214.

M01_MARY9591_06_SE_C01.indd 28 06/09/14 5:52 PM

Key Terms

diagnosis-related groups (DRGs)

missionary nurses

Nursing Interventions Classification (NIC)

Nursing Outcomes Classification (NOC)

variolation

visiting nurse associations

Learning Outcomes

After reading this chapter, you should be able to:

1. Describe the contributions of historical figures who influenced the development of population health nursing.

2. Discuss the contributions of population health nurses to social and health care reform.

3. List significant historical events in the development of population health nursing in the United States.

4. Describe evidence for a shift in public health policy toward a greater emphasis on health promotion.

5. Describe events that are shaping current and future population health nursing practice.

Population Health Nursing: Yesterday, Today, and Tomorrow2

chaPter

M02_MARY9591_06_SE_C02.indd 29 06/09/14 6:01 PM

30

A d

vo ca

cy T

h en The Henry Street Settlement

Known as the founder of American public health nursing and the originator of the term, Lillian Wald was a staunch advocate of population health nursing. A daughter of a well-to-do Jewish family, she chose nursing as a career and worked for a short time in New York City’s Juvenile Asylum. Appalled by the lack of quality care, Wald entered medical school, but left after an exposure to the disease and squalor experienced by immigrant populations in New York City (van Betten & Moriarty, 2004). One day, when called to visit a woman who had been attending a home nursing class she was teaching, Wald encountered the poverty and deprivation in which the family and others around them lived. Wald wrote of her experience, “to me personally it was a call to live near such conditions; to use what power an individual may possess as a citizen to help them.” (quoted in Keeling, 2007, p. 6). As a result, she began her lifelong crusade to improve the health of this population by founding the Henry Street Settlement with colleague Mary Brewster in 1893. She believed that by living among their clients, she and other nurses could teach them routine health measures as well as care for their illnesses and refer them to other sources of care. In addition to her work at Henry Street, Wald was active in a number of other reform initiatives related to the health of children, workers, and women and world peace (Hallett, 2010; Judd, 2010). Her peace-related activities included marching in a parade to protest World War I and led to the loss of donor funds for Henry Street (Jewish Women’s Archive, 2010).

A d

vo ca

cy N

ow Susie Walking Bear Yellowtail Born in 1903 on the Montana Crow Indian reservation, Susie Walking Bear Yellowtail was an orphan at the age of 12. In 1923, she became the first Native American registered nurse after graduating from the Boston City Hospital School of Nursing. Returning to the Montana Crow Agency, Ms. Yellowtail worked at the Bureau of Indian Affairs Hospital and later worked for the U.S. Public Health Service.

Experiences of Native American women sterilized without their consent and children dying on their mothers’ backs while being carried 20 to 30 miles to a hospital led Ms. Yellowtail to a career of ad- vocacy for Native American health care (Susie Walking Bear Yellowtail, RN, 2004). Her advocacy activities encompassed 30 years of midwifery services in the Little Horn Valley and travel to many North American Indian reservations to evaluate health and health care. Through her membership on tribal councils and state health advisory boards, she became well known to health policy makers. She was appointed to the former U.S. Department of Health, Education, and Welfare’s Council on Indian Health, the President’s Special Council on Aging, and the President’s Council on Indian Education and Nutrition, on which she served as an ambassador between her people and the federal government. She and her husband, Tom Yellowtail, also promoted understanding of American Indian culture in Europe and the Middle East as part of a U.S. cultural delegation in 1950 (American Society of Registered Nurses, 2007a; Scozzari, 2009). Throughout her life, she maintained her own cultural heritage, wear- ing Native American dress and engaging in the artistry of traditional Native American beadwork.

Ms. Yellowtail was also active in promoting the profession of nursing and was the founder of the Native American Nurses Association, which honored her as the “Grandmother of American Indian Nurses” (Susie Walking Bear Yellowtail, 2010). Through her advocacy activities at tribal and fed- eral levels, she was able to win funding for nursing education of Native American women.

In 1962, Ms. Yellowtail received the president’s Award for Outstanding Nursing Health Care, and six years after her death her picture was included in the Outstanding Montanans Gallery at the Montana State Capitol. Ms. Yellowtail has been included among the 100 most influential Montanans of the 20th century and on July 1, 2002, became the first American Indian nurse admitted to the American Nurses Association Hall of Fame (ANA, n.d.; First American Indian Nurse, n.d.).

M02_MARY9591_06_SE_C02.indd 30 06/09/14 6:01 PM

chaPter 2 Population health Nursing: Yesterday, today, and tomorrow 31

The history of population health nursing provides important insights into the events and factors that have shaped our practice. Knowledge of where we have been and how we got where we are today gives us a sense of the present and future directions that population health nursing should take to achieve its goal—improved health for all people. Historical events that gave rise to a concern for the health of population groups influenced the development of both public health science and population health nursing.

Historical Roots The roots of modern public health and population health nurs- ing practice go far back in history. For 5,000 years different cul- tural groups have developed a variety of approaches to dealing with common community health problems. Historical records provide evidence of concern for health and prevention of dis- ease in several ancient civilizations. Ancient Mesopotamia, the possible birthplace of humanity, and the Harappan civilization along the Indus River in what is now India employed sewage systems to prevent the spread of disease (Carr, n.d.). Similarly, primitive tribes engaged in public health measures by not bury- ing human wastes where they would contaminate water sup- plies (Association of State and Territorial Directors of Nursing,

2000). The Egyptians, Romans, and Aztecs were all known to emphasize the importance of clean water supplies. Healing in these ancient civilizations was thought to be the province of supernatural beings, and healers often functioned as priests of healing gods (Hallett, 2010).

The ancient Greeks spent a good deal of time theorizing about health and disease causation. Empedocles of Acragas, who lived from 493 to 433 ce, originated the theory of im- balance among four “humors” as the cause of disease. These four humors (blood, yellow bile, phlegm, and black bile) cor- responded to the four elements believed to compose the world (fire, air, water, and earth) as well as to specific temperaments exhibited by individuals (sanguine, choleric, phlegmatic, or melancholic) (Kalisch & Kalisch, 2004). The humoral theory, however, was borrowed and expanded upon a theory of bal- ance between three components of the human body, spirit, phlegm, and bile, derived from 6th century Indian medicine (Reeves, n.d.).

Hippocrates, an eminent Greek physician, rejected the prior concept of disease, as caused by supernatural intervention, in favor of natural causation (Kalisch & Kalisch, 2004). He ac- cepted the theory of the four humors, but believed they were influenced by environmental factors that shaped the physi- ologic response of people living in specific areas (Watts, 2003).

Evidence-Based Practice

A Nursing Historiography Connolly (2004) presented a history of nursing historiography (the study of nursing history) and noted that research in nursing history, as in other fields of historical inquiry, has evolved in the last several decades. She pointed out that early nursing histories were “only weakly linked to the broader social, economic, and cultural contexts in which events unfolded” (p. 10) and tended to focus on the development of institutions in which nurses worked and the “great women” of nursing. These histories lauded nurs- ing’s accomplishments and recounted the profession’s “purity, discipline, and faith [but] contained little about the less glorious aspects of the past” (p. 10).

Historians of this genre engaged in “political history,” exam- ining how public officials, legislation, and formal mechanisms of local, state, and federal government affected nursing. According to Connolly, history from this perspective assumed a coherence and unanimity in nursing that may not have truly existed. She maintained that early nursing political history, like much of his- tory in general, was written from an elitist point of view and ne- glected the perspectives of other, less visible groups within and outside nursing.

During the 1960s and 1970s, historical research in general and nursing history in particular began to focus on those unheard voices,

and a “social history” perspective was born. Connolly defined social history as “that which focuses on the experience, behavior, and agency of those at society’s margins, rather than on its elite” (p. 5). Social historians examined nursing in the context of social factors influencing it (e.g., gender socialization, race relations, etc.).

Connolly recommended melding the two perspectives and ex- amining political influences on nursing and nursing’s influence on policy making in the context of social factors that influence both. For example, the Nurse Reinvestment Act could be exam- ined in the light of the social factors that led to the shortage as well as the political history of legislative efforts to resolve past nursing shortages. Both perspectives can provide information that can direct policy development in ways that capitalize on past successes and avoid past mistakes.

1. How might you combine political and social history to examine some of the issues that affect population health nursing today? (As an example, you might examine the nursing shortage in terms of the lack of ethnic diversity in the profession and how current legislation does or does not address this issue.)

2. What other issues can you think of that could be addressed from a combined political/social historical perspective?

M02_MARY9591_06_SE_C02.indd 31 06/09/14 6:01 PM

32 UNit 1 Population health Nursing: an Overview

There is some controversy regarding which of the writings on health and medicine ascribed to Hippocrates were actu- ally composed by him. There is evidence, however, that he did write the famous treatise entitled On Airs, Waters, and Places as well as two books about epidemics in which he expounded on his theory of environmental contributions to disease (Udwadia, 2001).

The humoral theory, along with other selected elements of Hippocratic thinking, was adopted by the famous physician teacher, Galen. Galen’s teachings were perpetuated in medi- cal education until well into the Middle Ages, to the point that medical students would discard as anatomic abnormalities dis- section evidence that did not support Galen’s teachings. De- spite his many other contributions, Galen has been credited by some authors with retarding the development of medical sci- ence for several hundred years through his erroneous descrip- tion of blood flow in the body (Reeves, n.d.).

Nursing of the sick at this period in history was primarily the function of the women of the family (Kalisch & Kalisch, 2004). In the case of large and wealthy households, the matron of the family cared for the health needs of both family mem- bers and servants or slaves. The care provided, however, was primarily palliative and was only slightly related to today’s con- cept of nursing.

The Influence of Christianity Christianity, with its ethic of service to others, did a great deal to foster health care for particularly vulnerable populations such as lepers and the poor. Gradually that focus expanded to provision of care to other members of the population (e.g., in the many hospitals and other health-related institutions spon- sored by Christian religious groups).

The Early Christian Church The advent of Christianity brought an emphasis on personal responsibility for the corporal and spiritual welfare of others. Care of the sick was seen as one means of fulfilling this respon- sibility, and early Christians employed their time and mone- tary wealth ministering to the sick. Such efforts were intended to provide comfort and material goods to the sick and suffering and bore little resemblance to modern nursing. Such services, although lacking an emphasis on prevention and health pro- motion or cure, did serve to bring about an awareness of illness within the population.

With the growth of Christianity and charitable giving by Christians, the wealth of the early Christian Church began to accumulate. A large portion of this wealth was used for orga- nized care of the sick and needy through almshouses, asylums, and hospitals rather than through personal visitation to the sick. Hospitals or hospices of this time were not designed ex- clusively for care of the sick but ministered to all in need, in- cluding the sick, the poor, and travelers or pilgrims. The first hospital exclusively for the care of the sick was the Nosocomia,

or “house for the sick,” established by the Roman matron Fabia in the 4th century (Udwadia, 2001).

The Middle Ages The mystical tradition of Christianity during the Middle Ages (500–1500 a.d.) led to a decline in population and personal health status. Castigation and neglect of the body to purify the soul resulted in a number of health problems. Many of the health-promotive activities of antiquity were abandoned in fa- vor of fasting and the wearing of sackcloth and ashes. Care of the sick was often undertaken by wise women, women healers who used herbal remedies and extended the usual caring duties of family members (Hallett, 2010).

The need for healthy warriors to fight in the Crusades sparked a slight renewal of interest in health. The Crusades also led to the development of the first hospitals, built in the Holy Land to care for Christian pilgrims and later for wounded Crusaders. The first of these was the Hospital of St. John in Jerusalem. Following the capture of Jerusalem in 1099 by the Christian forces, many Crusader knights were impressed with the care provided at the hospitals and sought to participate in the care of the sick. Their interest eventually led to the estab- lishment of the Knights Hospitalers of St. John of Jerusalem, the first of the religious military orders that were to dominate the provision of nursing care for some time. The establishment of the Hospitalers was followed by the creation of the Knights Templar in 1118 and the Knights of the Teutonic Order in 1190. Interestingly, there were some women involved in the care of the sick under the auspices of female chapters of mili- tary orders, such as the Hospitaler Dames of the Order of St. John of Jerusalem (Hallett, 2010).

Following the Crusades, other religious orders were formed to look after the sick. Groups of monks and nuns established hospitals to care for the ill. Initially, these hospitals provided care primarily for members of religious orders and their lay employees. For example, the Benedictine rule required each monastery to have a hospital for the care of ill brothers. Later, religious orders expanded the focus of their services to the sick poor. Care was often provided by secular orders, called “tertiaries,” groups of people who did not want to join a reli- gious order, but wished to provide service to others. Village wise women and healers unaffiliated with the church, how- ever, were often subject to witch hunts and hideous deaths (Hallett, 2010).

In many instances, particular orders would focus on the care of specific groups or illnesses. For instance, the Antonites cared for persons with skin conditions, whereas Lazarites em- phasized care of those with leprosy (Kalisch & Kalisch, 2004). Thus, the concept of specialization among health care provid- ers is not as recent as one might believe.

Changes in social structure in the Middle Ages led to the de- velopment of cities, which increased the potential for the spread of disease. War and the attendant starvation and poor sanita- tion in cities have been described as the two most significant

M02_MARY9591_06_SE_C02.indd 32 06/09/14 6:01 PM

chaPter 2 Population health Nursing: Yesterday, today, and tomorrow 33

contributions to disease at this time. During the 14th century, recurring epidemics of plague killed nearly one fourth of the population of Europe. Periodic epidemics led to the establish- ment of some public health regulations, such as those related to burials and quarantine. Quarantine was first initiated in the city of Ragusa in 1347, then in Venice and Marseilles (Udwa- dia, 2001). It is interesting to note that the concept of quaran- tine was developed in Europe by town magistrates, not health care professionals. Similarly, an Egyptian Pasha instituted quarantine regulations in defiance of the recommendations of his French medical advisor (Watts, 2003).

Other Religious Influences Other religious groups contributed to the health of populations as well. In ancient times, the Jews developed a significant body of health regulations, incorporated into the Book of Leviticus (Association of State and Territorial Directors of Nursing, 2000). Similarly, Jewish physicians are credited with preserving scientific medicine through the Dark Ages by translating Greek and Arabic texts into Latin and promulgating Greco-Arabic medical knowledge in Europe. Similarly, Islamic medicine was a basis for the revival of the medical profession, embodied in the formation of the medical school at Salerno, Italy (Kalisch & Kalisch, 2004). Similarly, Ayurveda, based on traditional Indian philosophies, originated many of the alternative thera- pies gaining popularity today (Udwadia, 2001).

During the 6th century, nursing was established in Islam by Rufaidah bint Sa’ad. Rufaidah was taught her skills by her physician father and functioned as both nurse and community advocate, seeing to the needs of soldiers wounded in battle as well as the poor and the handicapped. In addition, she taught her nursing skills to other women (Kasule, 2004).

The European Renaissance From 1500 to 1700, the European Renaissance gave rise to the beginnings of scientific thought. Also evident were the devel- opment of a social conscience and early recognition of social responsibility for the health and welfare of the population (Udwadia, 2001). England enacted the first Poor Law in 1601, making families financially responsible for the care of their aged and disabled members and creating publicly funded alms- houses for those with no families. This development reflected the concept of “pauper stigma,” under which the poor were be- lieved to be responsible for their own condition due to lack of effort. The Belle Vue “pest-house,” established in 1794 in Manhattan, was the first public institution developed for the sick in the United States, but charity hospitals were estab- lished as early as 1851 (Jonas, Goldsteen, & Goldsteen, 2007). Another development in this period was the collection of vital statistics as a basis for public health policy decisions. Collection of vital statistics was pioneered by Johann Peter Sussmilch in the 1700s and systematized nationally in Sweden in 1748 and in Britain in 1801 (Udwadia, 2001).

For most of the population, nursing was performed by family members. In 1610, however, Saint Francis DeSales and Madame de Chantal established a Parisian voluntary or- ganization of well-to-do women to care for the sick in their homes. Care of the sick was institutionalized by some orders in the vows of consecration. For example, the Sisters of Char- ity, established in Paris in 1633 by Saint Vincent de Paul and Mademoiselle Louise De Marillac, and the Sisters of Bon Secours, established in 1822, took a fourth vow to care for the sick in addition to the traditional vows of poverty, chastity, and obedience (Hallett, 2010; Kalisch & Kalisch, 2004).

During the Protestant reformation, the monastic orders and the hospitals they provided were dismantled in Protestant countries. Health care in nations that retained their Roman Catholic heritage continued to be provided by religious orders and independent healers, particularly women in rural areas, continued to be persecuted (Hallett, 2010).

A New World The discovery and colonization of the American continents led to different health issues and solutions to them. Communicable disease and poor health habits, for instance, traveled across the oceans in both directions. Native Americans were devastated by such diseases as measles and smallpox brought by European settlers (Hogan, Harchelroad, & McGovern, 2005). Europeans, on the other hand, took tobacco back with them.

The Colonial Period While new avenues of scientific thought were being opened in Europe, some of the ideas generated were being translated into a new way of life on a new continent. Some groups of colonists included members of religious orders who provided care for the sick and injured. For example, Jeanne Mance and the Grey nuns nursed those wounded in battles between French soldiers and the Iroquois, and Dutch deaconesses were among the early settlers in New Amsterdam. Early hos- pitals, however, were frequently linked to poor houses and care was often provided by the untrained paupers residing in them (Hallett, 2010).

In the early colonial period in America, the health status of the colonists was good compared with that of their Euro- pean counterparts, and longevity approached today’s figures. The relative good health of the population was primarily due to low population density and, interestingly, poor transpor- tation. Communities remained relatively isolated, and the spread of communicable diseases, the major health problem of the era, was curtailed by lack of movement between popula- tion groups.

Because doctors were few, health care was primarily a func- tion of the family. Nursing care in the United States was most often provided by the women of the family, with assistance from neighbors where this was possible. The Sisters of Charity also provided services to the sick in the United States, starting

M02_MARY9591_06_SE_C02.indd 33 06/09/14 6:01 PM

34 UNit 1 Population health Nursing: an Overview

in 1809 under the direction of Mother Elizabeth Seton (Kalisch & Kalisch, 2004). In Canada, public health practice was carried out by Christian religious orders as early as the 17th century.

Early Public Health Efforts The growth of population centers led to concern for sanita- tion and vital statistics, the foci of early public health efforts in the colonies. In 1639, both Massachusetts and Plymouth colonies mandated the reporting of all births and deaths, in- stituting the official reporting of vital statistics in what would later become the United States. Environmental health and sanitation were also of concern in the early colonies. Concern for the spread of communicable diseases was manifested in the establishment of “pesthouses” for people with contagious conditions (Kalisch & Kalisch, 2004) as well as isolation and quarantine measures.

For the most part, health was seen as a personal responsi- bility with little governmental involvement. Temporary boards of health were established in response to specific health prob- lems, usually epidemics of communicable disease, and were disbanded after the crisis had passed.

Recognition of the need for a consistent and organized approach to health problems was growing, however, and in 1797, the state of Massachusetts granted local jurisdictions le- gal authority to establish health services and regulations. The following year, Congress passed the Act for Relief of Sick and Disabled Seamen to create hospitals for the care of members of the merchant marine. The group of hospitals created under this Act was renamed the Marine Hospital Service in 1871. Re- sponsibility for quarantine was shifted to the Marine Hospital Service in 1878 as one of the first efforts to deal with health problems at a national, rather than state or local, level (Jonas et al., 2007).

Nursing during this period remained a function of the fam- ily. Although the care given was primarily palliative, the women of the house might also engage in some health- promotive prac- tices, such as regular purging with castor oil. Treatment tended to consist of home remedies, and the literature of the era is replete with housewives’ recipes for the treatment of a variety of ailments.

In 1813, the Ladies’ Benevolent Society of Charleston, South Carolina, was established. This was the first organized approach to home nursing of the sick in the United States. This organization was initiated in response to a yellow fe- ver epidemic and was completely nondenominational and nondiscriminatory in an era characterized by widespread racial discrimination. Care was provided to the sick in their homes by upper-class women. Because these women had no background in nursing, care focused on relieving suffering and providing material aid (Buhler-Wilkerson, 2001). With the exception of a 20-year period during and after the Civil War, the Ladies’ Benevolent Society provided services until the 1950s.

A similar service was instituted in 1819 in Philadelphia’s Jewish community by the Hebrew Female Benevolent Society of Philadelphia. This service was organized by Rebecca Gratz, a Jewish society woman who engaged in nursing activities within her own family and later initiated a number of community service activities directed toward poor Jewish women and chil- dren (Ashton, 2009).

Another early attempt at home care nursing also saw upper-class women visiting the homes of indigent women dur- ing childbirth. The Lying-in Charity for Attending Indigent Women in Their Home was established in 1828 by Dr. Joseph Warrington to assist poor women during and after delivery. Dr. Warrington also established the Philadelphia Nurse Society to train women in obstetric nursing, who then provided ser- vices to this population (Obstetrics, n.d.).

The Industrial Revolution The Industrial Revolution profoundly influenced health in both Europe and the United States. Movement, on both continents, from agricultural to industrial economies led to the development of large industrial centers and the need for a large workforce to labor under unhealthy conditions in mines, mills, and factories. By 1850, half of England’s popu- lation lived in urban areas (Watts, 2003). The demand for manufactured goods and the necessity to get goods to market prompted advancements in transportation, which increased mobility and the potential for spreading communicable dis- eases. In the United States, rural–urban migration and the presence of large contingents of poor immigrants led initially to the conversion of single-family dwellings in less affluent ar- eas of town and then to the development of crowded tenement

Population health nurses often demonstrated appropriate hygiene practices as well as teaching about them. (Popperfoto/Getty Images)

M02_MARY9591_06_SE_C02.indd 34 06/09/14 6:02 PM

chaPter 2 Population health Nursing: Yesterday, today, and tomorrow 35

houses (Fee, Brown, Lazarus, & Theerman, 2002). From 1820 to 1910, 30 million immigrants came to the United States, rep- resenting almost half of the populations of urban slums in ma- jor U.S. cities. By the mid-1890s, for example, two thirds of the population of New York City lived in 90,000 tenement houses (Kalisch & Kalisch, 2004).

The poor were overworked and underpaid. Poor nutrition contributed to increased incidence of a variety of diseases, par- ticularly tuberculosis. Recognition of tuberculosis as a grow- ing problem among the poor led to the creation of the first tuberculosis hospital in England in 1840 (Zilm & Warbinek, 1995). The use of children in the workforce, coupled with low wages, inadequate food, and hazardous living and work- ing conditions, led to many preventable illnesses and deaths among the children of the poor. In the 1870 census, more than 750,000 working children were recorded. This number does not include children of farm families who often worked along- side their parents. In 1930, the Fair Labor Standards Act abol- ished child labor (excluding farm labor) in the United States, but this practice remains rampant in other parts of the world (Helfand, Lazarus, & Theerman, 2001).

The 19th century saw a beginning recognition of the effects of these social and economic conditions on health, and the con- cept of social responsibility for public health began to take root. The growth of this concept was fostered by the publi cation in the mid-1800s of several landmark reports. The first of these

publications was C. Turner Thackrah’s treatise on occupational health, The Effects of Arts, Trades, and Professions . . . on Health and Longevity. In this document, Thackrah described the ef- fects of working conditions on health.

In 1842, Edwin Chadwick’s Inquiry into the Sanitary Conditions of the Labouring Population of Great Britain pro- vided additional fuel for efforts to change the working and social conditions that contributed to disease. Chadwick’s com- mittee recommended extensive changes to sanitation practices, particularly removal of sewage and other noxious toxins (Del Col, 2002). Chadwick’s report led to sanitary engineering so- lutions, and annual local government spending for sanitary improvements increased from £5 million in 1856–1871 to £30 million by 1910 (Watts, 2003). Chadwick’s report heralded a shift in the view of public health from one of social reform to one of sanitary engineering.

While Thackrah and Chadwick addressed the effects of working conditions on health and instigated reforms to prevent disease, Henry W. Rumsey focused on health promo- tion. Rumsey’s Essays on State Medicine emphasized health promotion and illness prevention as social obligations of gov- ernment. Some nations acted on this concept by establishing national health care systems. For example, Germany instituted a state-funded medical insurance program for working men and civil servants as early as 1869. Similar attempts were initi- ated in Britain in the 1860s, but the National Health Insurance

Many families who received population health nursing services lived in a single room. (Popperfoto/Getty Images)

M02_MARY9591_06_SE_C02.indd 35 06/09/14 6:02 PM

36 UNit 1 Population health Nursing: an Overview

Act was not passed until 1911 (Sigerist, 2003; Watts, 2003). In the United States, national health insurance was an element of Theodore Roosevelt’s election platform in 1912 (Jonas et al., 2007).

Documents similar to those of Rumsey, Chadwick, and Thackrah were also published in the United States. The Massachusetts Sanitary Commission was established in re- sponse to concern over the effects of crowded living condi- tions, poverty, and poor sanitation on health. In 1850, Lemuel Shattuck drafted the commission’s findings (Koslow, 2002). The Report of the Massachusetts Sanitary Commission included recommendations for establishing state and local health de- partments, systematic collection of vital statistics, and sani- tation inspections, and for instituting programs for school health and control of mental illness, alcohol abuse, and tuber- culosis. Other recommendations included public education regarding sanitation, control of nuisances, periodic physical examinations, supervision of the health of immigrants, and construction of model tenements. In addition, the report rec- ommended improved education for nurses and the inclusion of content on preventive medicine and sanitation in medical school curricula.

The publication of the Report of the Massachusetts Sanitary Commission marks the beginning of public health practice as we know it today (Koslow, 2002). Recommendations of the report form the basis for much of the present work of official state and local public health agencies. The eventual effect of the commission’s report was the establishment of state boards of health. The first state board was established in Louisiana in the early 1800s (Louisiana Department of Environmental Quality, n.d.), but was not developed along the lines recommended in the report. In 1869, nearly 90 years after the advent of the first temporary boards of health and 19 years after the publication of Shattuck’s report, Massachusetts established the first work- ing board of health (Commonwealth of Massachusetts, 1870), followed by California in 1870 (Timeline, California Board of Health, n.d.).

Collection of vital statistics at the national level was another activity undertaken in the latter half of the 19th century. The first national mortality statistics, for example, were published by the U.S. federal government in 1850 (Epidemiology Pro- gram Office, 1999).

During this period, great strides were made in the fledgling science of epidemiology. In 1854, without knowledge of the nature of the causative organism, John Snow determined the source of a London epidemic of cholera to be something in the water of the Broad Street pump (Centers for Disease Control and Prevention [CDC], 2004; Robinson, 2009). Jacob Henle was the first to postulate microorganisms as a cause of disease rather than miasmas (harmful vapors) or humors (Paneth, n.d.). It was not, however, until 1876 that Louis Pasteur and Robert Koch, working independently, identified specific bac- teria (Watts, 2003). These and other epidemiologic findings allowed more scientific measures to be applied to the con- trol of communicable disease and contributed greatly to the

armamentarium used by later population health nurses in pre- venting disease.

Another significant advance in public health practice was the development of vaccines for communicable diseases. Early practitioners had developed variolation, a process in which material from smallpox lesions was inoculated into the skin, nose, or veins of a healthy person to induce immunity. The first recorded instance of variolation involved the activities of a Buddhist nun at the beginning of the second millennium. In 1713, the Greek physician Timoni submitted a report on vari- olation to the Royal Society, but his conclusions were ignored until Lady Mary Montagu, wife of the British Ambassador to Turkey, wrote about her use of the practice for her children and recommended it to the British royal family (Riedel, 2005). Variolation was widely practiced in the Orient and was used by some European physicians but was not widely accepted. Edward Jenner later used material from cowpox lesions to vaccinate people against smallpox, and this process was more widely adopted (Brannon, 2004).

In 1888, Emil Von Behring used immune serum to provide protection against diphtheria. Tetanus toxoid was introduced in 1914, and vaccines for other communicable diseases fol- lowed (Immunization Action Coalition, n.d.). Some of the sig- nificant events in the development of public health prior to the 20th century are summarized in Table 2-1•.

Organized advocacy for the health of the population by pub- lic health professionals began in 1872 with the establishment of the American Public Health Association (APHA). APHA consists of members of more than 50 public health disciplines and is the oldest and largest association of public health pro- fessionals in the world (APHA, 2010a). Throughout its his- tory, APHA has focused on the development of standards and policies that promote population health. APHA is organized

Date Event

1347 Quarantine first instituted in Ragusa, Italy.

1797 Jurisdiction to establish local boards of health first granted in Massachusetts.

1798 Marine Hospital Service, forerunner of the U.S. Public Health Service, created.

1854 Contaminated water demonstrated to be the cause of cholera by John Snow.

1869

State-funded medical insurance instituted for German workers. First modern state board of health established in Massachusetts.

1872 American Public Health Association established. 1876 Specific bacteria first isolated by Koch and Pasteur. 1888 Immune serum first used to prevent diphtheria.

TABLE 2-1 Significant Public Health Events Prior to the 20th Century

M02_MARY9591_06_SE_C02.indd 36 06/09/14 6:02 PM

chaPter 2 Population health Nursing: Yesterday, today, and tomorrow 37

in 27 discipline-based sections and 8 special interest groups that cut across disciplines (APHA, 2010c). The APHA section of greatest interest to population health nurses is the Public Health Nursing Section, developed to provide leadership in population health nursing practice, policy development, and research (APHA, 2010b).

Nursing in War Throughout history, war has necessitated the care of sick and injured combatants. Nursing, as a profession has been actively involved in these efforts from the time of the crusader orders dedicated to the care of the sick. Florence Nightingale first gained prominence for her work with the British Army in the Crimean war, but other nurses were actively involved in that conflict as well. For example, several groups of Roman Catholic nuns and Protestant nursing sisters were part of Nightingale’s contingent.

Jamaican-born self-proclaimed “nurse-doctress” Mary Seacole also volunteered to join Nightingale in her efforts. Her offer was repeatedly rejected, however, perhaps because of her Creole background. Seacole learned her nursing skills in ap- prenticeship with her mother, a boarding house mistress, and many of her treatments involved herbal remedies (Hallett, 2010). Using her own funds, she traveled to the Crimea and established the British Hotel in Balaclava, where she cared for injured officers. Seacole also ventured onto the battlefields to provide care to injured soldiers on both sides of the conflict. She also provided care during cholera and yellow fever epidem- ics in Jamaica and Panama and later cared for employees of a mining camp run by a relative (Lewis, 2010a). In recognition of her contributions, Seacole has been designated the greatest Black Briton (Anionwu, 2006).

In the United States, nurses were actively involved from the beginning of American Independence. In fact, George Washington called for the employment of women to care for the colonial army at a salary of $2 per month. Most of their work entailed washing and cooking for the troops, but these women and camp followers were also involved in the care of the ill and injured (Sitzman, 2010). Nurses were involved in official and unofficial capacities during both the Span- ish American and American Civil wars. For example, Anna Maxwell, known as the “American Florence Nightingale,” organized the nurses who cared for soldiers wounded in the Spanish American war at Camp Thomas, Georgia. Maxwell and 160 nurses cared for more than 1,000 men affected by ty- phoid, malaria, and measles, with only 67 deaths. Maxwell also organized nurses for Red Cross units during World War I and supported military rank for nurses in the Army Nurse Corps (Hanink, 2010a).

During the American Civil War, more than 2,000 nurses were engaged in the care of the sick and wounded on both sides. Care was initially provided for the northern army by Roman Catholic nursing orders, but their numbers proved

insufficient to meet the need. Perhaps the two most famous of the Civil War nurses were Dorothea Dix and Clara Barton, both of whom gained nursing experience within their families. Dorothea Dix was a social reformer who did much to improve the conditions of people with mental illness in institutions throughout the nation (Bumb, n.d.). During the war, she was engaged by the federal government to establish a volunteer nursing service and served as superintendent of female nurses for the army (Hallett, 2010). Many of the volunteer nurses, such as Walt Whitman and Louisa May Alcott, had no for- mal nursing education, but had cared for sick family mem- bers. Whitman entered the war to care for his purportedly injured brother and stayed to care for other sick and injured soldiers, supporting himself as a paymaster’s clerk in the in- terim (Hallett, 2010).

Clara Barton entered the war as a private citizen to gather needed food and medical supplies (American Red Cross, 2014). Known as the “Angel of the Battlefield,” Barton and one other nurse cared for 3,000 injured after the Battle of Bull Run. Barton later served as the first woman to run a U.S. government office, the Office of Correspondence with the Friends of the Missing Men of the United States Army, in her role locating missing Civil War soldiers (Behling, n.d.). Barton was also instrumental in the establishment of the Red Cross of the United States of America (Hallett, 2010). Harriet Tubman was a former slave who also functioned as a nurse during the Civil War (Lewis, n.d.b). She is probably best known for her activities with the underground railroad in bringing approximately 300 for- mer slaves to freedom in the north (Lewis, n.d.a). In addition, Tubman organized a spy network for the north and person- ally led troops during the Combahee River expedition to dis- rupt southern supply lines (Lewis, n.d.b). Following the war, Tubman was active in women’s suffrage activities and in advo- cacy and service to aged and poor African Americans (Lewis, n.d.c; Ripley & Hembree, 1992). Sojourner Truth was another African American who served during the Civil War and then for the Freedman’s Relief Association during reconstruction (Aetna, 2003).

District Nursing in England The “three great revolutions” of the late 18th and early 19th centuries—the intellectual revolution, the French and American political revolutions, and the Industrial Revolution—set the stage for the development of population health nursing. In England, the same spirit that motivated industrial and prison reform led to concern for the health of large urban popula- tions and the development of nursing practices to address these concerns.

In addition to being the acknowledged founder of mod- ern hospital nursing, Florence Nightingale was instrumental in the development of population health or district nursing. Nightingale received her training in nursing at the school for deaconesses established by Theodor Fliedner. Fliedner’s

M02_MARY9591_06_SE_C02.indd 37 06/09/14 6:02 PM

38 UNit 1 Population health Nursing: an Overview

second wife, Caroline Bertheau, conceived the idea of extend- ing the nursing services offered in the hospital to the sick in their homes. This concept influenced Nightingale, who en- dorsed the idea of health promotion as well as home care for illness (Hallett, 2010).

In 1840, Elizabeth Frye, a Quaker woman, founded the Institution of Nursing Sisters in London to train lower-class women to provide care to the sick poor. Their training con- sisted of 3 months of work in London hospitals. Frye was also actively involved in attempts by reformers to improve condi- tions in British prisons (Hallett, 2010).

William Rathbone, another Quaker philanthropist, instituted professional home care for the sick poor in Liverpool in 1859 after seeing the effectiveness of a trained nurse in caring for his dying wife. Although in the early days of the experiment, the nurse hired was often tempted to leave, the initiative was con- sidered a success and spread to other cities in England (Kalisch & Kalisch, 2004). Unable to recruit sufficient trained nurses on his own, Rathbone turned to Florence Nightingale for assis- tance. Nightingale was instrumental in developing the concept of visiting nursing and viewed public health nursing as includ- ing specific nursing care for the sick poor as well as attention to environmental and sanitation issues. The nursing services pro- vided were organized in terms of local districts—hence the term district nursing (Buhler-Wilkerson, 2001). Similar services were also provided by the Ladies Sanitary Association in Manchester and Salford. In 1928, certification by the Royal Sanitary Institute was made mandatory for health visitors (Hallett, 2010).

The need to standardize population health nursing services was recognized early in the development of district nursing. A committee chaired by Rathbone undertook to conduct a study of district nursing services coordinated by Florence Lee, a nurse trained in one of the Nightingale schools. Lee’s report, published in 1875, noted that many visiting nurses were not adequately trained, that their practice included responsibili- ties beyond hospital nursing, and that they required additional training. In addition, Lee recommended the employment of educated women for district nursing services. The report led to the formation in 1876 of the Metropolitan and National Nursing Association for Providing Trained Nurses for the Sick Poor (Hallett, 2010). Prior to the employment of professional nurses to visit the sick poor, home visiting often provided the oppor- tunity for proselytizing and attempts to convert the client to a specific religious persuasion or to redeem them from moral decrepitude.

Visiting Nurses in America and the World In the United States, proselytizing was also part of the role of women who visited the sick poor in their homes, providing for their material needs. These women were often ill prepared to meet illness care needs, however; so wealthy women in several large cities hired trained nurses to visit the sick. For example,

the Women’s Branch of the New York City Mission first em- ployed trained nurses to provide home visiting services in 1877 (Kalisch & Kalisch, 2004). The role of these and many other missionary nurses was to provide nursing care and religious instruction for the sick poor. Often, visiting of the sick was mo- tivated by beliefs that poverty was a result of moral deficiency and that the poor needed exposure to the “elevating experience of their moral betters” (Buhler-Wilkerson, 2001, p. 18).

In 1839, the Nurse Society of Philadelphia received referrals from physicians to care for women after delivery. Their services were later expanded to care for medical and surgical patients (Hallett, 2010). In the next few years, visiting nurse associa- tions, agencies that provided nursing care to people in their homes, were established in Buffalo (1885) (Visiting Nursing Association of Western New York, 2010), and in Boston and Philadelphia (1886) (Visiting Nurse Association of Boston, 2010; Visiting Nurse Association of Greater Philadelphia, 2010). The Philadelphia agency was the first to institute a nurse’s uniform, a fee for services, and a community nurs- ing supervisor. The Boston Instructive District Nursing Association emphasized the population health nurse’s educa- tive function as well as the role in the care of the sick (Kalisch & Kalisch, 2004), signaling the beginning of the health promotion emphasis that now characterizes population health nursing. By 1890, there were 21 visiting nursing organizations in the United States (Kalisch & Kalisch, 2004), and 22 years later, when the National Organization for Public Health Nursing (NOPHN) was founded, there were 3,000 visiting nurses in the United States (Winslow, 1993).

Similar events were taking place in Canada, with the estab- lishment of the Victorian Order of Nurses (VON) in 1897. VON nurses were required to have basic nursing preparation and ad- ditional education in community work. In 1898, the VON sent four district nurses to the Klondyke region, who were faced with a typhoid epidemic on their arrival. In addition, Canadian Red Cross outposts provided public health and midwifery services in remote parts of the frontier (Hallett, 2010).

In Australia, the Bush Nursing Associations were initiated in 1910 by philanthropic women to provide trained nurses for local communities who would pay their salaries (Hallett, 2010). Plunket Society nurses offered visiting nurse services for moth- ers and their children in New Zealand, starting in 1907. The so- ciety was established by volunteer groups of women with some government support and minimal medical supervision (Bryder, 2002). On a global level, the International Council of Nurses was founded in 1899, with the help of Mrs. Bedford Fenwick, to address international nursing issues (Hallett, 2010).

Nursing and the Settlement Houses The settlement movement was based on the belief espoused by Arnold Toynbee that educated persons could promote learning, morality, and civic responsibility in the poor by

M02_MARY9591_06_SE_C02.indd 38 06/09/14 6:02 PM

chaPter 2 Population health Nursing: Yesterday, today, and tomorrow 39

living among them and sharing certain aspects of their pov- erty. Reformers, acting on this belief, “settled” in homes in the London slums with the idea that their poor neighbors would learn through watching their behavior (Lewis, 2010b).

In the United States, the settlement idea was adapted by nurses such as Lillian Wald, who believed that the most effec- tive way to bring health care to the poor immigrant popula- tion was for nurses to live and work among them. Accordingly, Wald and her associate Mary Brewster established the forerun- ner of the Henry Street Settlement from their Jefferson Street tenement apartment in New York City in 1893 (Kalisch & Kalisch, 2004). The actual Henry Street establishment was purchased in 1895. The house on Henry Street differed from many other settlement houses of the era in its incorporation of visiting nurse services. In addition, visiting nurse services in the United States differed from those in England in their accep- tance of the germ theory and its use as a foundation for many of their interventions.

The Henry Street Settlement is usually considered the first American public health agency because of its incorporation of modern concepts of population health nursing. At Henry Street, Wald redefined the basic principles of home care. She believed that access to the services of a nurse should be determined by the client and not based on a decision by a physician (Keeling, 2007). In spite of the focus on health promotion at the Henry Street Settlement, Wald contended that the primary function of the visiting nurse was care of the sick in their homes, with health education as a secondary focus. She also felt that care of the poor should be equiva- lent to that available to the rich and that services provided should respect the client’s individual dignity and indepen- dence (Buhler-Wilkerson, 2001). The latter principle led her to establish a 3-month probationary period for nurses em- ployed at Henry Street to orient the nurses to the culture of the immigrant populations they served (Kalisch & Kalisch, 2004). Although the nurses were expected to view other cul- tures with tolerance, they often experienced culture shock that subsided as they were exposed to a variety of different cultures (Keeling, 2007).

The nurses of the Henry Street Settlement did more than visit the sick in their homes. Lillian Wald coined the term public health nurse to reflect the focus on service to the whole community to improve both individual and societal conditions affecting health (Fee & Bu, 2010). Health promotion and disease prevention were heavily emphasized, as was political activism. In Wald’s words, “The call of the nurse is not only for bedside care of the sick, but to help in seeking out the deep- lying basic causes of illness and misery. That in the future, there may be less sickness to nurse and cure” (quoted in Buhler- Wilkerson, 2001, p. 98). Wald herself was a prime example of the politi- cal activist, supporting many changes in social conditions that would benefit the health of the public (Jewish Women’s Archive, 2010). In fact, the Henry Street Settlement served as the site for the opening reception of the 1909 National Negro Conference, one of the few places that would host an interracial

gathering. This conference led to the establishment of the Na- tional Association for the Advancement of Colored People (NAACP) (Buhler-Wilkerson, 2001).

Other early population health nurses like Margaret Sanger, Clara Barton, and Dorothea Dix were also actively involved in promoting social change. Margaret Sanger’s contributions to contraceptive services for women are addressed in more detail in Chapter 18 . Care at Henry Street was often provided un- der standing orders that allowed the nurses to avoid charges of practicing medicine without a license. Charges were further defused by pointing out that services were usually provided to those who could not afford a doctor and were not in compe- tition with local physicians. The nurses “used both physician- prescribed medications and middle-class household remedies as they attended lower-class patients and their families. In es- sence, they practiced somewhere between pharmacists and physicians, between domestic care and professional care” (Keeling, 2007, p. 11).

The nurses of Henry Street, like other population health nurs- ing pioneers, were able to accomplish more in the way of social activism than their hospital counterparts because their prac- tice was essentially free of external control (Buhler-Wilkerson, 2001). In fact, the Henry Street nurses have been described as “virtually independent practitioners in sick and preventive care, health, education, and school nursing” in an era when other nurses were experiencing medical domination (Roberts & Group, 1995, p. 82).

Other nursing settlement houses patterned on the Henry Street model were established. One particularly inspiring example was the Nurse’s Settlement established in 1900 in Richmond, Virginia, by nurses working at the Old Dominion Hospital. These nurses had been exposed to the needs of Richmond’s poor during student experiences and were con- cerned about clients discharged too soon from the hospital. Services were provided by the eight founding nurses during their after-work hours (Instructive Visiting Nurse Association, 2008). The settlement they founded differed from the Henry Street Settlement in that it did not have any wealthy patrons to provide support and was initiated with the limited resources of the graduates themselves and on money raised from renting out rooms in the house as well as donations from local churches and women’s groups. Like Henry Street, the Richmond settle- ment focused on health promotion and education as well as care of the sick (Green, 2005).

Expanding the Focus on Prevention The effectiveness of population health nurses in prevent- ing sickness and death among the poor was recognized and became the basis for visiting nurse services offered by the Metropolitan Life Insurance Company. This program was begun at the instigation of Lillian Wald. Wald convinced the Metropolitan board that providing nursing services to its

M02_MARY9591_06_SE_C02.indd 39 06/09/14 6:02 PM

40 UNit 1 Population health Nursing: an Overview

policyholders would improve the public image of an indus- try tarnished by economic scandal. The compelling argu- ment, though, was evidence that community health nursing reduced mortality and would limit the death benefits paid by the company. Services were begun on an experimental basis in 1909 at a cost to the company of 50 cents per visit. The 3-month experiment was such a success that the pro- gram was extended nationwide in 1911 (Buhler-Wilkerson, 2001) and continued to provide services until 1953. In 1923 alone, the nurses made more than 37,000 visits, and by 1926, more than 300,000 visits were made each year (Keeling, 2007). This association with the business world was an edu- cation for population health nurses, who had no conception of marketing or the economic bases for programs. The pro- gram was finally discontinued because of nursing’s failure to grasp economic realities and the realization of diminishing returns by the insurance company.

The emphasis of population health nursing on health pro- motion began with health education in the home during vis- its to the poor in large cities. Gradually, however, the concepts of health promotion and illness prevention were expanded to other population groups to include services to mothers and young children, school-age youngsters, employees, and the ru- ral population.

Concern for the health of mothers and children was grow- ing, and the nurses of the Henry Street Settlement and other

similar programs spent a large portion of their time in health promotion for this group of clients. Because they recognized that services to individual families would not overcome the ef- fects of poverty, they worked actively to improve social con- ditions affecting health. Through the efforts of Lillian Wald and other social activists, the first White House Conference on Children was held in 1909. As a result of the conference, the U.S. Children’s Bureau was established in 1912 to address the issue of child labor. Its efforts were later expanded to encom- pass a variety of initiatives related to child health (Judd, 2010).

School nursing, another arena for health promotion, actu- ally began in London in 1893 (Wolfe & Selekman, 2002) and was introduced in the United States by Lillian Wald in 1902. The initial impetus for school health nursing was the high level of school absenteeism due to illness. In New York City in 1902, 15 to 20 children per school were being sent home daily. In response, Wald assigned Lina Rogers Struthers from the Henry Street Settlement to a pilot project in school nurs- ing. Because of the overwhelming success of the project (a 90% decline in school exclusions in the first year), the New York Board of Health absorbed the program and hired addi- tional nurses to continue the work (Hanink, 2010b; Kalisch & Kalisch, 2004). The program resulted in school exclusion only for those children who were not able to be treated in “dress- ing rooms” at the schools, where the nurses provided treat- ments under protocols or “cards of instruction” developed by

In addition to school inspections, population health nurses made home visits to children excluded from school for communicable diseases. (National Library of Medicine.)

M02_MARY9591_06_SE_C02.indd 40 06/09/14 6:02 PM

chaPter 2 Population health Nursing: Yesterday, today, and tomorrow 41

the New York City Department of Health. After school hours, the nurses made home visits to the families of the children (Keeling, 2007).

The concept of school nursing spread to other parts of the country and to Canada. In 1904, Los Angeles became the first of many municipalities to employ nurses in schools (Spotsylvania County Public Schools, 2009). In 1907, Canada initiated medi- cal inspections of schoolchildren in Ontario. Later Lina Rogers moved from New York City to Toronto to supervise the school inspection efforts (Rutty & Sullivan, 2010).

Early school nursing focused on preventing the spread of communicable diseases and treating ailments related to com- pulsory school life. More recently, however, the focus has shifted to preventive and promotive activities, including case finding, integrating health concepts into school curricula, and maintaining a healthful school environment, as well as caring for sick children.

The first rural nursing service was established in 1896 in Westchester County, New York, by Ellen Morris Wood and was followed in 1906 by the initiation of a nursing service for both the poor and the well-to-do of Salisbury, Connecticut. Despite her usual sphere of activity in the city, Lillian Wald was also involved in the growth of rural population health nurs- ing. She convinced the American Red Cross, founded in 1881, to direct its peacetime attention to expanding community health services in rural America. In 1912, the Red Cross estab- lished the Rural Nursing Service (later the Town and Country Nursing Service) to extend population health nursing services to rural areas (Kalisch & Kalisch, 2004). In Canada, rural nurs- ing services were provided to large immigrant populations by such organizations as the Victorian Order of Nurses for Canada and the Canadian Red Cross Society (Hallett, 2010).

Another pioneer in the provision of health services in rural settings was Mary Breckenridge. In 1928, Breckenridge initi- ated the Frontier Nursing Service (FNS) in the remote areas of rural Appalachia (American Society of Registered Nurses, 2007b). The FNS provided midwifery services by nurses who traveled on horseback and served families in isolated rural Appalachia. An assessment of its outcomes in the first 1,000 cases indicated no maternal mortality and fewer stillbirths and infant deaths than in the general population (Kalisch & Kalisch, 2004). Although midwifery was the primary focus of the FNS, the nurses provided a variety of other services from health education to pulling teeth (Hallett, 2010).

Other largely rural populations experiencing significant health problems were the Native American population on federal reservations and the African Americans in the South. Population health nursing services on the reservations arose out of a 1922 study of health conditions by the American Red Cross commissioned by the Bureau of Indian Affairs (Ruffing- Rahal, 1995). Nurses in this setting often found themselves breaking official rules in order to provide effectively for the needs of their clients (Abel, 1996). To meet the needs of Black women in the South, some states co-opted local Black mid- wives to work closely with public health nurses. As on the reservations, the rules imposed frequently violated accepted cultural health practices. For example, the nurses “forbade midwives to use any folk medicine or herbal remedies in their childbirth work” (Smith, 1994, p. 31). In spite of the cultural insensitivity displayed, the partnership between public health nurses and midwives helped to create a modern public health system in the rural South. In Arkansas, for example, Mamie Odessa Hale Garland was made a midwife consultant and developed a training and supervision program for untrained lay midwives, resulting in dramatic declines in maternal and infant mortality. Later, her work led to the establishment of maternal–child clinics in several counties throughout the state (Bell, 2010).

Occupational health nursing provided another avenue for health promotion by population health nurses. This spe- cialty area began in 1895 when Vermont’s Governor Proctor employed nurses to see to the health needs of villages where employees of his Vermont Marble Company lived. These first employment-based services focused on care of the sick rather than prevention and care of occupation-related conditions (Kalisch & Kalisch, 2004). In 1897, the Employees’ Benefit Association of John Wanamaker’s department store in New York City hired nurses to visit employees’ homes. These nurses soon expanded their role to include first aid and prevention of illness and injury in the work setting.

Dying clients constitute another more recent population for which population health nursing services are required. The hospice movement, initiated in London in 1967 by Cecily Saunders, was established in the United States by Florence Wald in 1974 (Hallett, 2010). Wald founded the Connecticut Hospice to provide interdisciplinary services to dying clients,

Global Perspectives

Cho and Kashka (2004) described the contributions of Korean nurse leader Mo Im Kim in the development of a population health nurse practitioner role to meet the needs of rural commu- nities in Korea. Kim’s vision of the skills needed for population health nursing included political acumen, program management, and community leadership. The authors’ description of Kim’s ac- tivities in the development and support of the rural population health nurse practitioner role provides an excellent example of advocacy for the specialty itself.

Explore how population health nursing practice has developed in another country. What events led to the development of the role? What factors have influenced how the population health nursing role is conceptualized in that country?

Developing the Role of the Population Health Nurse

M02_MARY9591_06_SE_C02.indd 41 06/09/14 6:02 PM

42 UNit 1 Population health Nursing: an Overview

both in their homes and in hospital settings. From this be- ginning, there are now more than 2,500 independent hospice centers in the United States (American Society of Registered Nurses, 2007c). More recently, care has been expanded to pal- liation of long-term symptoms such as chronic pain, for both terminal and nonterminal clients, and in 2007 the Worldwide Palliative Care Alliance was formed to address end-of-life is- sues at the global level (National Hospice and Palliative Care Organization, 2010).

Standardizing Practice The need to standardize population health nursing practice was recognized in both the United States and England. Early American attempts to standardize visiting nursing services in- cluded publications related to public health nursing and the de- velopment of a national logo by the Cleveland Visiting Nurse Association (VNA). This logo, or seal, was made available to any visiting nurse organization that met established stan- dards. Both the Chicago (1906) and Cleveland (1909) VNAs published newsletters titled Visiting Nurse Quarterly to aid at- tempts to standardize care (Brainerd, 1985). Another attempt to standardize practice was the development of a list of standing orders for public health nurses by the Chicago Visiting Nurse Association in 1912 (Kalisch & Kalisch, 2004).

In 1911, a joint committee of the American Nurses Asso- ciation (ANA) and the Society for Superintendents of Training Schools for Nurses met to consider the need for standardization. The result was a second meeting, held in 1912. Letters inviting representation were sent to 1,092 organizations employing vis- iting nurses at that time. These organizations included VNAs, city and state boards of health and education, private clubs and societies, tuberculosis leagues, hospitals and dispensaries, busi- nesses, settlements and day nurseries, churches, and charitable organizations. A total of 69 agencies responded with their in- tent to send a representative to the meeting. The result of this second meeting was the formation of the National Organiza- tion for Public Health Nursing (NOPHN) (Brainerd, 1985). The objective of this organization was to provide for stimula- tion and standardization of public health nursing. This was the first professional body in the United States to include lay membership. Similar activity was undertaken in Canada, lead- ing to the creation in 1920 of the public health section of the Canadian Association of Trained Nurses (Duncan, Liepart, & Mill, 1999).

The NOPHN was influential in maintaining population health nursing services at home during World War I and in the organization of the Division of Public Health Nursing within the U.S. Public Health Service in 1944. The NOPHN also pro- vided advisory services regarding postgraduate education for public health nursing in colleges and universities. The NOPHN was incorporated into the National League for Nursing (NLN) in the restructuring of professional nursing organizations in the 1950s (Kalisch & Kalisch, 2004).

In 1986, the American Nurses Association developed the Standards of Community Health Nursing Practice. As we saw in Chapter 1 , the standards are based on the use of the nurs- ing process in population health nursing practice. In 1999, the standards were revised by the Quad Council of Public Health Nursing Organizations as the Scope and Standards of Public Health Nursing Practice and have subsequently undergone additional revisions (ANA, 2013).

Attempts were also made over the years to standardize the functions and competencies of population health nurses. These culminated in the Quad Council’s 2003 adoption of the public health nursing competencies discussed in Chapter 1 (Quad Council, 2003, 2004, 2011), but began as early as 1931, when the Field Studies Committee of NOPHN developed functions and related objectives for generalized and specialized prac- tice (King & Erickson, 2006). These objectives were revised in 1936 and 1944 and again in 1949 in a document entitled Public Health Nursing Responsibilities in a Community Health Program (Abrams, 2004). Although the Quad Council ac- cepted the Council on Linkages competencies for public health practice as the basis for the public health nursing competen- cies, they were modified to reflect the dual focus of population health nursing on the care of individuals and families as well as populations (King & Erickson, 2006).

Educating Population Health Nurses As Steven Jonas, noted public health author, has observed, whenever a new area of nursing practice is established, it is inevitably followed by the development of practice standards and related curricula (Jonas et al., 2007). Public health nursing was no exception, and during the 1920s, nursing education was under study. The Goldmark Report, Nursing and Nursing Education in the United States, published in 1923, dealt with nursing education in general and pointed out the need for advanced preparation for population health nursing. The re- port recommended that nursing education take place in in- stitutions of higher learning (Kalisch & Kalisch, 2004). As a result, the Yale University School of Nursing and the Frances Payne Bolton School of Nursing at Western Reserve University opened in 1923. Canada’s first baccalaureate program in nurs- ing (also the first in the British Empire) was established in 1918 at the University of British Columbia (Canadian Museum of Civilization, 2004). The curricula of both U.S. and Canadian programs included population health nursing content.

Prior to the education of nurses in university settings, spe- cial postgraduate courses in public health nursing had been es- tablished by various agencies. The first of these in the United States was undertaken by the Instructive District Nursing Association of Boston in 1906 (Buhler-Wilkerson, 2001). In 1910, Teachers’ College of Columbia University offered the first course in public health nursing in an institution of higher learning (Brainerd, 1985), and in 1927 the NLN curriculum

M02_MARY9591_06_SE_C02.indd 42 06/09/14 6:02 PM

chaPter 2 Population health Nursing: Yesterday, today, and tomorrow 43

Date Event

1813 Ladies’ Benevolent Society of Charleston, South Carolina, organized as first home nursing service in the United States. 1819 Visiting nursing services organized through the Hebrew Female Benevolent Society of Philadelphia. 1832 Lying-in Charity for Attending Indigent Women in Their Homes established. 1840 Institute of Nursing in London founded by Elizabeth Frye to provide care in homes and prisons. 1859 District nursing initiated in Liverpool, England, by William Rathbone. 1876 Metropolitan and National Nursing Association for Providing Trained Nurses for the Sick Poor founded in England. 1877 Women’s Branch of the New York City Mission is first to employ trained nurses for home visiting. 1880 Health promotion and education focus initiated by the Boston Instructive District Nursing Association. 1881 American Red Cross founded by Clara Barton. 1885–86 Visiting nurse associations established in Buffalo, Boston, and Philadelphia.

1893 First school nurse employed in London. Henry Street Settlement founded by Lillian Wald.

1896 First rural nursing service established (Westchester County, New York). 1897 Victorian Order of Nurses (VON) founded to pioneer community health nursing in Canada. 1899 International Council of Nurses established. 1900 Nurse’s Settlement house founded in Richmond, Virginia. 1902 First school nursing program in the United States established by Henry Street Settlement. 1903 Henry Street Settlement school nursing program absorbed by New York City Department of Health. 1904 First school nurse is employed by a municipality (Los Angeles, California). 1906 The Visiting Nurse Quarterly first published (Chicago).

First postgraduate course in public health nursing established by Instructive District Nursing Association of Boston. 1907 Public health nurse employment by government agencies first approved by Alabama.

1909 Metropolitan Life Insurance Company offers visiting nurse services to policyholders.Red Cross Nursing Service established. 1910 First postgraduate course in community health nursing in an institution of higher learning is established at Columbia University.

(Continued )

document, A Curriculum for Schools of Nursing, emphasized the need for specific training for public health nursing (Kalisch & Kalisch, 2004).

In addition to witnessing the movement of population health nursing education to institutions of higher learning, the 1920s saw a shift in the employment of population health nurses. Before this time, most population health nursing ser- vices were provided by voluntary agencies such as the Red Cross and similar organizations. Although some local jurisdic- tions, such as Los Angeles, employed public health nurses in communicable disease control, no state recognized the role of this nursing specialty in an official health or education agency until 1907, when Alabama became the first state to approve public health nurse employment by government agencies. By 1924, a survey by NOPHN found that half of all nurses em- ployed in public health nursing worked for official govern- ment agencies and approximately 41% of all U.S. counties had access to public health nursing services (Kalisch & Kalisch, 2004). This same movement of public health nurses from char- itable organizations to governmental agencies also occurred in Canada (McKay, 2009).

The Brown Report of 1948, Nursing for the Future, reempha- sized the need for nurses to be educated in institutions of higher learning to prepare them to meet population health needs (Ka- lisch & Kalisch, 2004). A similar, but earlier, report in Canada, Survey of Nursing Education in Canada (Weir, 1932), also known as the Weir Report, had recommended advanced educational preparation for population health nurses, particularly those practicing in rural areas. In 1964, the American Nurses As- sociation (ANA) formally defined the public health nurse as a graduate of a baccalaureate program in nursing. In 1995, the Pew Health Professions Commission report, Critical Challenges: Revitalizing the Health Professions, reinforced baccalaureate edu- cation as the entry level for population-based practice. Today, in some states, such as California, only graduates from baccalaure- ate programs in nursing can be certified as public health nurses. Moreover, there are now master’s and doctoral programs with a population health nursing focus, including recently developed Doctor of Nursing Practice Programs with an aggregate focus (American Association of Colleges of Nursing [AACN], 2006). Table 2-2• presents a summary of significant events in the de- velopment of population health nursing practice.

TABLE 2-2 Historical Events in the Development of Population Health Nursing

M02_MARY9591_06_SE_C02.indd 43 06/09/14 6:02 PM

44 UNit 1 Population health Nursing: an Overview

TABLE 2-2 (Continued)

Date Event

1911 Metropolitan Life Insurance visiting nurse services expanded nationwide.

1912 National Organization for Public Health Nursing (NOPHN) established. Red Cross Town and Country Nursing Service established. Standing orders for public health nursing activities adopted by Chicago Visiting Nurse Association.

1918 University of Alberta offered first Canadian course in public health nursing. 1919 Alberta District Nursing Service established to meet the needs of frontier families. 1920 Public health section of the Canadian National Association of Trained Nurses established. 1921 Maternity and Infancy (Sheppard–Towner) Act passed.

1923 Goldmark Report recommended education for nurses in institutions of higher learning and additional preparation for popula-tion health nursing. 1928 Frontier Nursing Service initiated by Mary Breckenridge.

1929 NOPHN established criteria and procedures for grading courses in public health nursing, initiating the accreditation process. 1931 Functions of public health nurses and related objectives first developed by the Field Studies Committee of NOPHN.

1932 Weir Report on nursing education in Canada recognized need for advanced education for public health nurses and recom-mended an increase in the public health nurse workforce.

1933–1935 Nurses employed during the Depression in the Federal Emergency Relief Administration (FERA), Civil Works Administration (CWA), and Works Progress Administration (WPA). 1934 First public health nurse employed by USPHS. 1936 Public health nursing functions and objectives revised.

1944 Division of Public Health Nursing established in USPHS.Public health nursing functions and objectives revised.

1948 Brown Report reemphasized the need to educate nurses in institutions of higher learning and to include population health nursing content in curricula.

1949 Public health nursing functions and objectives revised in Public Health Nursing Responsibilities in a Community Health Program. 1952 NOPHN absorbed into National League for Nursing (NLN). 1964 Public health nurse defined by American Nurses Association as a graduate of a baccalaureate program in nursing. 1973 Provision of home health services mandated for health maintenance organizations. 1974 First U.S. hospice established by Florence Wald 1986 Standards of Community Health Nursing Practice published by the American Nurses Association. 1988 Institute of Medicine report published, recommending restructuring of public health. 1993 National Center for Nursing Research established. 1995 Pew Health Professions Commission reinforced baccalaureate as entry level for population health nursing practice.

1999 Population health nursing standards revised by Quad Council of Public Health Nursing Organizations as Scope and Standards of Public Health Nursing. 2003 Public health nursing competencies established by the Quad Council of Public Health Nursing Organizations.

2006 Essentials for doctoral education for advanced nursing practice published by the American Association of Colleges of Nursing including an aggregate/populations focus.

2007 Public Health Nursing: Scope and Standards of Practice revised.Worldwide Palliative Care Alliance established. 2013 Public Health Nursing: Scope and Standards of Practice (2nd ed.) published.

Federal Involvement in Health Care For most of its history, the federal government has left health matters to the states. It was not until 1879 that the United States established a National Board of Health in response to a yellow fever epidemic. This board continued to function until 1883, when it was dissolved. In 1912, the need for a per- manent national agency responsible for the country’s health was recognized, and the U.S. Public Health Service (USPHS)

was created out of the reorganization of the Marine Hospital Service (Timeline, U.S. Public Health Service, n.d.). In that same year, federal legislation created the office of the Sur- geon General and mandated federal involvement in health promotion. It was not until 1953, however, that the need for advisement on health matters at the cabinet level was recog- nized with the creation of the Department of Health, Educa- tion, and Welfare. This department was reorganized in 1980 to create the present Department of Health and Human Ser- vices (DHHS).

M02_MARY9591_06_SE_C02.indd 44 06/09/14 6:02 PM

chaPter 2 Population health Nursing: Yesterday, today, and tomorrow 45

Since the beginning of the 20th century, the federal gov- ernment has become progressively more involved in health care delivery. Unfortunately, this involvement has been rather haphazard, dependent on the interests and concerns of differ- ent administrations. In the early years of the 20th century, the health needs of specific segments of the population began to be recognized, resulting in federal programs designed to en- hance the health of mothers and children, the poor, those with sexually transmitted diseases, the mentally ill, and others. For example, in 1921, Congress passed the Sheppard–Towner Act to help state and local agencies meet the health needs of moth- ers and children. In addition to providing funds for maternity centers, prenatal care, and child health clinics, the legislation provided monies to enhance visiting nurse services (Kalisch & Kalisch, 2004). These funds allowed local agencies—for ex- ample, the San Diego County Health Department—to hire ad- ditional public health nurses, known as “Sheppard–Towner nurses” (Interview with Harney M. Cordua, son of Dr. Olive Cordua, San Diego County Medical Officer). In 1930, recog- nition of the need for federal support of health care research to address the health needs of mothers and children and other special groups led to the development of the National Institutes of Health.

As a result of the Great Depression of the 1930s, the fed- eral government became even more active in health and so- cial welfare programs. Jobs were created to employ thousands of the unemployed. Nurses were employed under Regulation 7 of the Federal Emergency Relief Act (1933), the Civil Works Administration (1933–34), and the Works Progress Administration (1935) to meet the health needs of the popu- lation (Kalisch & Kalisch, 2004). The first public health nurse was employed by the USPHS in 1934.

Recognition of the economic plight of the elderly led to pas- sage of the Social Security Act in 1935, 60 years after the efforts of Lavinia Dock and others to provide health care to the elderly poor. This act established the Old-Age and Survivors Insur- ance (OASI, better known as Social Security) to improve the financial status of the elderly. Interestingly, the Act also pro- vided funds for the education of public health professionals, including public health nurses (Kalisch & Kalisch, 2004).

World War II also influenced health care delivery. Wage and price freezes and a dearth of skilled labor led industries to offer health insurance benefits in an attempt to compete for com- petent workers. During the war, some 15 million U.S. service members were exposed to quality health care, some for the first time in their lives. Afterward, these veterans began to demand the same quality of care for themselves and their families in the civilian sector. This increased demand for care led to new ar- rangements for financing health care and the subsequent bur- geoning of the health insurance industry. The growth in health insurance was further influenced by the 1954 inclusion of pre- miums as legitimate tax deductions. This development led to the use of insurance benefits as a tax-deductible substitute for higher wages in business and industry. Because such benefits were tax exempt for employees, they were readily accepted in

lieu of salary increases by unions and other bargaining agents. Blue Cross hospitalization insurance was initiated at this time under the leadership of the American Hospital Association (Kalisch & Kalisch, 2004).

Increased demands for services also led to a lack of ad- equate facilities, especially in nonurban areas. In 1946, pres- sured by USPHS officials, Congress responded with passage of the Hill–Burton Act to finance hospital construction in underserved areas (Kalisch & Kalsich, 2004). Hospital con- struction and insurance coverage for care provided in the hospital further strengthened the national emphasis on cura- tive rather than preventive care and widened the gap between bedside nursing and health promotion and prevention. In fact, a 1928 Bureau of Indian Affairs (BIA) circular directed BIA public health field nurses to promote the use of hospi- tals over home care (Abel, 1996). Hospitals became a major focus for health and illness care. Ironically, during this same period, the first hospital-based home care program was estab- lished at Montefiore Hospital in New York (Fondiller, n.d.), setting a precedent for the burgeoning home care industry of today. The present emphasis on cost containment has led to a shift away from institutional care and more toward home and community-based care. This development has also resulted in a growing need for population health nurses to provide home health services.

The Latter Half of the 20th Century In 1966, the Social Security Act was amended to create the Medicare program to address the health care needs of older Americans. Medicaid, a program that funds health care for the indigent, was instituted in 1967. These two programs contributed to increased demands for health care services and resulted in rapid increases in the cost of health care. In 1965, when they were introduced as part of Lyndon Johnson’s “Great Society” program, Medicare and Medicaid were seen by some as initial steps toward universal health care coverage in the United States, a vision that has yet to be fulfilled (Jonas et al., 2007).

Acknowledging the growing demand for health care and recognizing the differing abilities of certain areas of the country to meet those needs, the U.S. federal government responded with the Comprehensive Health Planning Act of 1966 and the National Health Planning and Resources De- velopment Act of 1974. Both pieces of legislation were at- tempts to organize the planning of health care delivery to meet differing needs throughout the country. Unfortunately, both efforts failed. One positive effect of the 1974 Act was recognition of the contribution of nurse practitioners to the health status of the public, 9 years after the establishment of the first nurse practitioner program in 1965 (Jenkins & Sullivan-Marx, 1994).

The Child Health Act of 1967 and the Health Maintenance Organization Act of 1973 also recommended the use of nurses

M02_MARY9591_06_SE_C02.indd 45 06/09/14 6:02 PM

46 UNit 1 Population health Nursing: an Overview

in extended roles. The 1971 publication of a report entitled Extending the Scope of Nursing Practice provided additional support for the use of nurses in expanded capacities (Kalisch & Kalisch, 2004). Subsequent legislation has led to the increased use of nurse practitioners in a variety of settings. Over the last few years, there has been increased use of population health nurses with advanced educational preparation as nurse practi- tioners providing primary care to selected populations. Many of these nurses are employed in nurse-managed community health centers that continue the vision of Wald and Brecken- ridge of providing care to people where they are. Established in the 1970s with funding from the Office of Economic Opportu- nity during Lyndon Baine Johnson’s presidency, the number of nurse- managed centers had increased to 150 within a decade (Malka, 2007).

While the United States was attempting to decentralize health care policy making through health planning legislation, efforts were being made elsewhere to focus attention on risk factors for population health problems. The Lalonde Report, New Perspectives for the Health of Canadians, was published in Canada in 1974, identifying the importance of biological, en- vironmental, and lifestyle risks as determinants of health and recommending greater attention to the elimination of risks in each of these areas. The Lalonde Report marked the initial shift away from a treatment paradigm to a health promotion focus at the national level in Canada (Stachenko, Legowski, & Geneau, 2009). As a result of the Lalonde Report, the Health Promo- tion Directorate was formed in Canada in 1978 (Glouberman & Millar, 2003).

In 1978, at an international conference on primary health care, the Declaration of Alma-Ata was developed, calling for access to primary health care for all. The resulting slogan for this campaign was “Health for all by the year 2000,” a goal which has not yet been achieved (Watts, 2003). In 1984, the Beyond Health Care conference in Toronto established two key health promotion concepts: healthy public policy and healthy cities. These developments were followed by the adoption of health-for-all strategies in many nations, in- cluding the Canadian Epp report, Achieving Health for All: A Framework for the Health of Canadians, in 1986 (Glouberman & Millar, 2003).

The comparable movement in the United States is the focus on the achievement of the national health objectives discussed in Chapter 1 . The need for systematic data collection rela- tive to the achievement of the objectives was recognized in the introduction of the Behavioral Risk Factor Surveillance System (BRFSS). The system involves periodic surveys of the U.S. pub- lic to determine trends in specific health behaviors and health indicators (National Center for Chronic Disease Prevention and Health Promotion, 2008).

The health-for-all concept was further developed in the World Health Organization’s Global Strategies for Health for All by the Year 2000, published in 1981, and the Ottawa Charter for Health Promotion, developed at the First International

Conference on Health Promotion in 1986. Both focused on social, economic, and political reform and empowerment as strategies for improving the health of the world’s popula- tions (Glouberman & Millar, 2003). The importance of health promotion at the global level was reinforced in the Jakarta Declaration on Health Promotion into the 21st Century (World Health Organization [WHO], 2010).

Reform efforts in the United States in the late 20th cen- tury focused more on health care financing and the organiza- tion of services than on changes in social conditions affecting health. The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 had a profound effect on health care and community health nursing. This Act, passed in an effort to reduce Medi- care expenditures, led to the development of diagnosis-related groups (DRGs) as a mechanism for prospective payment for services provided under Medicare (Kalisch & Kalisch, 2004). Basically, prospective payment means that health care insti- tutions are paid a flat fee set in advance under Medicare. The fee is based on the client’s diagnosis. The effect of this legis- lation has been earlier discharge of sicker clients and greater demand for home health and population health nursing ser- vices. Diagnosis-related groups and their effects have changed the role of population health nurses, who may need to return to the earlier role of care of the sick in their homes in addi- tion to their roles in promoting health and preventing illness in populations.

Public health practice, including population health nursing, is being restructured in light of the 1988 Institute of Medicine report, The Future of Public Health. This report identified the three core functions of public health as assessment, policy formation, and assurance discussed in Chapter 1 . Similarly, the September 11, 2001, terrorist attacks on New York and the Pentagon and the development of new and reemerging com- municable diseases, such as autoimmune deficiency syndrome (AIDS), later labeled acquired immunodeficiency syndrome, and, more recently, severe acute respiratory syndrome (SARS), Ebola virus, and hantavirus, have highlighted inadequacies in the public health infrastructure here and internationally (CDC, 2002; Watts, 2003). These events are beginning to result in in- creased funding for public health efforts, including those re- lated to terrorism.

Another event that could have a significant impact on population health nursing is the development of the Nurs- ing Interventions Classification (NIC) system to categorize nursing services and facilitate their direct reimbursement (McCloskey, Butcher, & Bulechek, 2007). The NIC system should lend itself to direct reimbursement for nursing ser- vices under managed care, the new focus of the U.S. federal government. The Nursing Outcomes Classification (NOC) system is a parallel development that will allow nurses to doc- ument the effectiveness of intervention (Moorhead, Johnson, Maas, & Swanson, 2007).

Another significant accomplishment was the interna- tional eradication of smallpox. The World Health Organization

M02_MARY9591_06_SE_C02.indd 46 06/09/14 6:02 PM

chaPter 2 Population health Nursing: Yesterday, today, and tomorrow 47

initiated its campaign to eradicate smallpox in 1966, and the last reported naturally occurring case in the world occurred in 1977. In 2002, the world marked the 25th anniversary of its freedom from this previously devastating disease (CDC, 2002). Significant events in American public health in the 20th and 21st centuries are presented in Table 2-3•. Table 2-4• summarizes recent international events related to global public health.

The Present and Beyond The eradication of smallpox highlighted the effectiveness of international cooperation in health matters, which we will discuss in more detail in Chapter 5 . Unfortunately, this ac- complishment has had a negative consequence. The last case of smallpox in the United States occurred in 1949, prompting

Date Event

1906 Pure Food and Drug Act passed.

1912 Children’s Bureau established to foster child health. Marine Hospital Service changed to U.S. Public Health Service.

1915 Tetanus antitoxin introduced.

1929 Blue Cross insurance instituted. Penicillin discovered by Alexander Fleming (discovery not acted on until World War II).

1930 National Institutes of Health established to conduct health-related research. Food and Drug Administration established. National Fair Labor Standards Act passed.

1935 Social Security Act established Old-Age and Survivors Insurance (OASI). 1938 Garfield/Kaiser Prepaid Group Practice established (forerunner of managed care).

1946 Hospital Survey and Construction (Hill–Burton) Act passed. Communicable Disease Center (CDC) established.

1953 U.S. Department of Health, Education, and Welfare (USDHEW) established. 1954 Health insurance premiums first allowed as tax deductions. 1955 Salk polio vaccine widely used. 1957 Nationalized Canadian health care system established. 1964 U.S. Surgeon General’s report on smoking published.

1966 Comprehensive Health Planning and Public Health Services Act passed. Medicare program instituted to fund health care for the elderly.

1967 Medicaid program initiated to fund health care for the medically indigent.

1970 Occupational Safety and Health Administration established. Environmental Protection Agency established.

1974 National Health Planning and Resources Development Act passed. Lalonde Report, New Perspectives for the Health of Canadians, published.

1978 Canadian Health Promotion Directorate formed. 1979 Healthy People: Surgeon General’s Report on Health Promotion and Disease Prevention published.

1980 USDHEW reorganized to form U.S. Department of Health and Human Services (USDHHS). Promoting Health/Preventing Disease: Objectives for the Nation published, creating the first set of national health objectives for the United States.

1981 Autoimmune deficiency syndrome (AIDS) identified (later labeled acquired immunodeficiency syndrome). 1982 Tax Equity and Fiscal Responsibility Act (TEFRA) passed. 1983 Prospective payment system based on diagnosis-related groups (DRGs) initiated. 1984 Behavioral Risk Factor Surveillance System (BRFSS) initiated. 1986 Achieving Health for All: A Framework for the Health of Canadians published. 1988 Institute of Medicine report, The Future of Public Health, published.

1989 U.S. Public Health Services Task Force: Guide to Clinical Preventive Services published, recommending standardized evidence-based screening and prevention strategies for specific populations.

1990 Healthy People 2000: National Objectives for Health Promotion and Illness Prevention published. 1993 Health Plan Employer Data and Information Set (HEDIS) created. 1996 Report on the Health of Canadians identified environmental challenges to health.

2000 Healthy People 2010 published. Public Health Improvement Act passed to assist state and local agencies in enhancing public health services.

2010 Healthy People 2020 published. Affordable Care Act passed.

TABLE 2-3 Significant 20th- and 21st-Century Events in American Public Health

M02_MARY9591_06_SE_C02.indd 47 06/09/14 6:02 PM

48 UNit 1 Population health Nursing: an Overview

discontinuation of smallpox vaccination in 1971 (Immuniza- tion Action Coalition, n.d.). This development has led to a gen- eration of Americans who are vulnerable to the use of smallpox as a mechanism of bioterrorism and has prompted plans for preventive immunization of persons at greatest risk and mass immunization campaigns in the event of an attack.

Other advances of previous eras may also be undone in the current political climate. For example, in 2001, the U.S. Congress repealed the ergonomic standards put forth by the Occupational Safety and Health Administration under pres- sure from businesspeople who feared the cost of implement- ing measures to prevent repetitive motion injuries and other related conditions (Fee & Brown, 2001). Similarly, activities taken to prevent terrorist initiatives may undermine individual freedoms, and the focus on terrorism may serve to detract at- tention from other critical issues in public health, such as dis- parities in health status and societal conditions that affect the health of all. The wars in Iraq and Afghanistan also drew away resources that could have been used to improve the overall health of the population. Population health nurses will need to reemerge as social activists to maintain a balance among these concerns that fosters the health of populations, both nationally and internationally.

Growing evidence indicates a shift to greater emphasis on health promotion and illness prevention in national and in- ternational health policy. The U.S. national health objectives published first in 1980 and again in 1990, 2000, and 2010, and discussed in Chapter 1 , are one sign of this shift. A second bit of evidence is the 1988 creation of the Center for Nursing Research (now the National Institute for Nursing Research) within the National Institutes of Health. One reason given in

Senate testimony favoring the center was the health promo- tion and illness prevention focus in much of nursing research. Another somewhat encouraging sign is the passage of the Public Health Improvement Act of 2000, which provides funds for the development of public health activities at state and local levels (CDC, 2001).

In addition, one of the focus areas for Healthy People 2010 and continued in the current Healthy People 2020 was the development of the public health infrastructure. The public health infrastructure includes the organizational structure of official government health agencies, the public health work- force, and the information systems employed in public health practice (Advisory Committee on National Health Promo- tion and Disease Prevention Objectives for 2020, 2008). The most recent development is the March 23, 2010, signing of the Affordable Care Act by President Barack Obama. The pri- mary provisions of the bill include the provision of affordable health care through new consumer protections against de- nial of coverage due to pre-existing conditions and removal of lifetime limitations on coverage; support for the Medicare program, particularly for drug costs; provision of insurance assistance for small business owners through tax credits; and inclusion of preventive services in coverage (Internal Revenue Service, 2010; U.S. Department of Health and Human Ser- vices, 2010). This legislation will be discussed in more detail in Chapter 7 .

Recently the Global Public Health Achievements Team (2011) within the Centers for Disease Control and Prevention highlighted 10 of the most significant worldwide public health accomplishments of the first decade of the 21st century. These accomplishments are summarized in Table 2-5•.

Date Event

1902 Pan-American Health Organization (PAHO) founded. 1919 Health Organization of the League of Nations established. 1948 World Health Organization (WHO) established. 1977 Smallpox eradicated worldwide. 1979 Call for access to primary care for all established in Declaration of Alma-Ata. 1981 Need for primary health care emphasized by World Health Organization report, Global Strategies for Health for All by the Year 2000. 1986 Prerequisites to and strategies for achieving health for all identified in The Ottawa Charter for Health Promotion. 1988 WHO goal for poliomyelitis eradication set. 1992 WHO goal for integration of hepatitis B vaccination into childhood immunization programs set. 1993 Global emergency declared by WHO in response to worldwide incidence of tuberculosis. 1994 Goal of measles elimination established by WHO Region of the Americas. 1998 Concepts of global health promotion reinforced in Jakarta Declaration on Health Promotion into the 21st Century. 2000 World Health Report 2000, Health Systems: Improving Performance, published. 2001 United Nations General Assembly Special Session on HIV/AIDS held.

2002 European Region of WHO declared polio-free. WHO goal of reducing worldwide measles mortality by 50% established.

TABLE 2-4 International Events Influencing Public Health

M02_MARY9591_06_SE_C02.indd 48 06/09/14 6:02 PM

chaPter 2 Population health Nursing: Yesterday, today, and tomorrow 49

In this chapter, we have seen how population health nursing grew to its present state. The future direction of population health nursing will be determined by the population health nurses of today and tomorrow. The times we live in are not dissimilar to those encountered by Lillian Wald and other population health nursing pioneers. Lack of access to care and

environmental conditions that are not conducive to health im- pede the ability of the world’s citizens to live healthy and pro- ductive lives. It may be time to return to the dual nature of the initial public health nursing role: personal care in conjunction with population-based health promotion and illness preven- tion.

CHAPTER RECAP

Focus Area Achievements

Child mortality • Decrease of 2 million deaths in children under 5 years of age from 77 deaths to 62 deaths per 1,000 live

births

Vaccine-preventable diseases

• 2.5 million deaths prevented each year in children under 5 years of age • 78% decline in measles mortality • Decrease in the number of countries with endemic poliomyelitis from 20 to 4 • Fewer than 1,500 cases of poliomyelitis in 2010 • Global coverage with a third dose of DTP vaccine increased from 74% to 82% • Global coverage with hepatitis B vaccine increased to 70% • Global coverage with Hib vaccine increased to 38% and 130,000 pneumonia and meningitis deaths

prevented

Safe water and sanitation • Increase in the proportion of the world’s population with access to improved drinking water sources from 83%

to 87% • Increase in the proportion of the world’s population with access to improved sanitation from 58% to 61%

Malaria prevention and control • Increased annual funding for prevention in endemic countries from $100 million to $1.8 billion • Reduction in annual number of cases to 225 million • 21% decrease in malaria deaths

HIV/AIDS prevention and control

• Annual number of new infections dropped from 3.1 million to 2.6 million • Annual AIDS-related deaths decreased to 1.8 million • Antiretroviral therapy (ART) provided to 5.25 million persons in low- and middle-income countries

Tuberculosis control • 20% increase in case detection and treatment success rates • Declining incidence and prevalence in every region worldwide

Control of neglected tropical diseases

• Annual number of dracunculiasis cases reduced to 1,797 with probable global eradication by 2012 • Elimination of new cases of onchocercal blindness in all 13 regions of the Americas, with transmission

completely interrupted in 8 regions • 9.5 million cases of filariasis prevented and 32 million disability-adjusted life years averted

Tobacco control

• WHO Framework Convention on Tobacco Control adopted by 168 countries • 50% of the world’s population protected from second-hand smoke in health care and educational facilities

(but only 5% in all public places) • Population covered by comprehensive smoke-free laws increased from 3.1% to 5.4% from 2007 to 2008

Global road safety • 36% reduction in annual traffic-related fatalities in Europe • 2009 adoption of UN General Assembly resolution initiating 2011–2020 Decade of Action for Road Safety

Preparedness and response to global health threats

• Adoption of the 2005 International Health Regulations • Increased global laboratory and epidemiologic capacity • Development of 21 new field epidemiology training programs • Most rapid and effective response to a global pandemic ever in relation to the H1N1 influenza epidemic in

2009, with vaccine development within 20 weeks of virus detection and deployed in 86 countries

Based on: Global Public Health Achievements Team. (2011). Ten great public health achievements—Worldwide, 2001–2010. Morbidity and Mortality Weekly Report, 60, 814–818.

TABLE 2-5 Worldwide Public Health Achievements, 2001–2010

M02_MARY9591_06_SE_C02.indd 49 06/09/14 6:02 PM

50 UNit 1 Population health Nursing: an Overview

Population health nursing in the United States arose in response to identified health needs among European immigrants. 1. What recently arrived immigrant populations live in the

area where you live? 2. In what ways are these new immigrants similar to and dif-

ferent from those arriving in the United States at the end of the 19th century?

3. How do their health needs compare to those encountered by the nurses on Henry Street?

4. What population health nursing interventions might be needed to improve their health status?

Continuing the Focus on the Population’s HealthCASE STuDY

Abel, E. K. (1996). “We are left so much alone to work out our own problems”: Nurses on American Indian reservations during the 1930s. Nursing History Review, 4, 43–64.

Abrams, S. E. (2004). From function to competency in public health nursing, 1931 to 2003. Public Health Nursing, 21, 507–510.

Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. (2008). Phase I report: Recommendations for the frame- work and format of Healthy People 2020. Washington, DC: U.S. Department of Health and Human Services.

Aetna. (2003). African American history calendar: History. Retrieved from http://www.aetna.com/diversity/aahcalendar/2003/history.html

American Association of Colleges of Nursing. (2006). Essentials for doctoral education for advanced nursing practice. Washington, DC: Author.

American Nurses Association. (n.d.). Susie walking bear yellowtail (1903– 2002) . 2002 Inductee. Retrieved from http://www.nursingworld .org/FunctionalMenuCategories/AboutANA/Honoring-Nurses /HallofFame/20002004Inductees/SusieWalkingBearYellowtail.aspx

American Nurses Association. (2013). Public health nursing: Scope and stan- dards of practice (2nd ed.). Silver Spring, MD: Author.

American Public Health Association. (2010a). About APHA. Retrieved December 14, 2005, from http://www.apha.org/about

American Public Health Association. (2010b). APHA sections and special interest groups. Retrieved December 14, 2005, from http://www.apha.org /sections/sectdesc.htm

American Public Health Association. (2010c). Sections, SPIGs and caucuses. Retrieved December 14, 2005, from http://www.apha.org/sections

American Red Cross. (2014). Founder Clara Barton. Retrieved from http:// www.redcross.org/about-us/history/clara-barton

American Society of Registered Nurses. (2007a). Big heart. Retrieved from http://www.asrn.org/newsletter_article.php?journal=&issue_id= 37&article_id=205

American Society of Registered Nurses. (2007b). Mary Breckenridge. Retrieved from http://www.asrn.org/newsletter_article.php?journal=&issue_id= 37&article_id=206

American Society of Registered Nurses. (2007c). Meet Florence Wald. Retrieved from http://www.asrn.org/newsletter_article.php?journal=&issue_id= 37&article_id=224

Anionwu, E. (2006). About Mary Seacole. Retrieved from http://www.maryseacole .com/maryseacole/pages/aboutmary.html

Ashton, D. (2009). Rebecca Gratz. Jewish women: A comprehensive historical encyclopedia. Retrieved from http://jwa.org/encyclopedia/article/gratz- rebecca

Association of State and Territorial Directors of Nursing. (2000). Public health nursing: A partner for healthy populations. Washington, DC: American Nurses Publishing.

Behling, S. (n.d.). Note on Clara Barton. Retrieved September 12, 2004, from http://www.rootsweb.com/~nwa/barton.html

Bell, P. L. (2010). Mamie Odessa Hale Garland (1911–1968?). The Encyclope- dia of Arkansas History & Culture. Retrieved from http://www.encyclope- diaofarkansas.net/encyclopedia/entry-detail.aspx?entryID=1662

Brainerd, A. M. (1985). The evolution of public health nursing. New York: Garland. Reprinted from Brainerd, 1922 Brainerd, A. M. (1922). The evolu- tion of public health nursing. Philadelphia: Saunders.

Brannon, H. (2004). The history of smallpox: The rise and fall of a disease. Re- trieved from http://dermatology.about.com/cs/smallpox/a/smallpoxhx.htm

Bryder, L. (2002). The Plunket nurses as a New Zealand icon. Retrieved from http://www.nursing.manchester.ac.uk/ukchnm/publications/seminarpa- pers/plunketnurse.pdf

Buhler-Wilkerson, K. (2001). No place like home: A history of nursing and home care in the United States. Baltimore: Johns Hopkins University.

Bumb, J. (n.d.). Dorothea Dix . Retrieved from http://www.webster .edu/~woolflm/dorotheadix.html

Canadian Museum of Civilization. (2004). A brief history of nursing in Canada from the establishment of new France to the present. Retrieved from http:// www.civilization.ca/cmc/exhibitions/tresors/nursing/nchis01e.shtml

Carr, T. J. (n.d.). The Harappan civilization. Retrieved from http://www.archae- ologyonline.net/artifacts/harappa-mohenjodaro.html

Centers for Disease Control and Prevention. (2001). The Public Health Im- provement Act: Priority Capacities, Section 319 (A). Retrieved from http:// www.publichealthgrandrounds.unc.edu/performance/pshandout_phim- provement.htm

Centers for Disease Control and Prevention. (2002). 25th anniversary of last case of naturally occurring smallpox. Morbidity and Mortality Weekly Re- port, 51, 952.

Centers for Disease Control and Prevention. (2004). 150th anniversary of John Snow and the Pump Handle. Morbidity and Mortality Weekly Report, 53, 783.

Cho, H. S. M., & Kashka, M. S. (2004). The evolution of the community health nurse practitioner in Korea. Public Health Nursing, 21, 287–294.

REFERENCES

M02_MARY9591_06_SE_C02.indd 50 06/09/14 6:02 PM

chaPter 2 Population health Nursing: Yesterday, today, and tomorrow 51

Commonwealth of Massachusetts. (1870). First annual report of the State Board of Health of Massachusetts. Boston, MA: Wright & Potter. Retrieved from http://www.archive.org/details/annualreportofst1869mass

Connolly, C. A. (2004). Beyond social history: New approaches to understand- ing the state of and the state in nursing history. Nursing History Review, 12, 5–24.

Del Col, L. (2002). Chadwick’s report on sanitary conditions. Retrieved from http://www.victorianweb.org/history/chadwick2.html

Duncan, S. M., Leipart, B. D., & Mill, J. E. (1999). “Nurses as health evange- lists”? The evolution of public health nursing in Canada, 1918–1939. Advances in Nursing Science, 22(1), 40–51.

Epidemiology Program Office, Centers for Disease Control and Prevention. (1999). Changes in the public health system. Morbidity and Mortality Weekly Report, 48, 1141–1147.

Fee, E., & Brown, T. (2001). Editor’s note. American Journal of Public Health, 91, 1381.

Fee, E., Brown, T. M., Lazarus, J., & Theerman, P. (2002). Baxter Street then. American Journal of Public Health, 92, 753.

Fee, E., & Bu, L. (2010). The origins of public health nursing: The Henry Street visiting nurse service. American Journal of Public Health, 100, 1206–1207.

First American Indian nurse named to nursing hall of fame. (n.d.). Retrieved from http://www.minoritynurse.com/vital-sign/first-American-Indian-nurse- named-nursing-hall-fame

Fondiller, S. H. (n.d.). The promise and the reality: Our history from 1944 to 1993. Retrieved from http://www.vnsny.org/mh_about_history_more.html

Global Public Health Achievements Team. (2011). Ten great public health achievements—Worldwide, 2001–2010. Morbidity and Mortality Weekly Report, 60, 814–818.

Glouberman, S., & Millar, J. (2003). Evolution of the determinants of health, health policy, and health information systems in Canada. American Journal of Public Health, 93, 388–392.

Green, E. C. (2005). Gendering the city, gendering the welfare state. Virginia Magazine of History and Biography, 113, 277–308.

Hallett, C. E. (2010). Celebrating nurses: A visual history. Hauppauge, NY: Barron’s.

Hanink, E. (2010a). Anna Maxell, the American Florence Nightingale. Retrieved from http://www.workingnurse.com.articles/anna-maxwell-the-American- florence-nightingale

Hanink, E. (2010b). Lina Rogers, the first school nurse. Retrieved from http:// www.workingnurse.com.articles/Lina-Rogers-the-First-School-Nurse

Helfand, W. H., Lazarus, J., & Theerman, P. (2001). Night shift in a glass factory. American Journal of Public Health, 91, 1370.

Hogan, C. J., Harchelroad, F., & McGovern, T. W. (2005). Smallpox. Retrieved from http://www.emedicinehealth.com/smallpox/article_em.htm

Immunization Action Coalition. (n.d.). Historic dates and events related to vac- cines and immunization. Retrieved from http://immunize.org/timeline

Instructive Visiting Nurse Association. (2008). IVNA home health care. Re- trieved from http://www.ivna.org/history.html

Internal Revenue Service. (2010). Small business health care tax credit for small employers. Retrieved from http://www.irs.gov/newsroom/ article/0,id=223666,00.html

Interview with Harney M. Cordua, son of Dr. Olive Cordua, San Diego County Medical Officer. San Diego: San Diego Historical Society.

Jenkins, M. L., & Sullivan-Marx, E. M. (1994). Nurse practitioners and commu- nity health nurses: Clinical partnerships and future visions. Nursing Clinics of North America, 29, 459–470.

Jewish Women’s Archive. (2010). Lillian Wald, 1867–1940. Retrieved from http://jwa.org/historymakers/wald

Jonas, S., Goldsteen, R., & Goldsteen, K. (2007). An introduction to the U.S. health care system (6th ed.). New York: Springer.

Judd, D. (2010). Nursing in the United States from 1900 to the early 1920s: A new century brings novel ideas and social concerns. In D. Judd, K. Sitzman, & G. M. Davis (Eds.), A history of American nursing: Trends and eras (pp. 60–93). Boston, MA: Jones and Bartlett.

Kalisch, P. A., & Kalisch, B. J. (2004). American nursing: A history. Philadelphia: Lippincott Williams & Wilkins.

Kasule, O. H. (2004). History of medicine (Tarikh al tibb). Retrieved from http:// omarkasule-03.tripod.com/id782.html

Keeling, A. W. (2007). Nursing and the privilege of prescription, 1893–2000. Columbus, OH: Ohio State University Press.

King, M. G., & Erickson, G. P. (2006). Development of public health nursing competencies: An oral history. Public Health Nursing, 23, 196–201.

Koslow, J. (2002). Lemuel Shattuck. In L. Breslow & G. Cengage (Eds.), Encyclopedia of public health. Retrieved from http://www.enotes.com/ public-health-encyclopedia/shattuck-lemuel

Lewis, J. J. (n.d.a). Harriet Tubman—From slavery to freedom: Civil war ser- vice: Nurse, scout, spy. Retrieved from http://womenshistory.about.com/od/ harriettubman/a/tubman_civilwar.htm

Lewis, J. J. (n.d.b). Harriet Tubman—From slavery to freedom: Later years of activism and reform. Retrieved from http://womenshistory.about.com/od/ harriettubman/a/tubman_later.htm

Lewis, J. J. (n.d.c). Harriet Tubman—From slavery to freedom: Underground rail- road conductor, abolitionist, women’s rights. Retrieved from http://women- shistory.about.com/od/harriettubman/a/tubman_moses.htm

Lewis, J. J. (2010a). Mary Seacole: British black nurse. Retrieved from http:// womenshistory.about.com/od/nursesandnursing/a/mary_seacole_2. htm?p=1

Lewis, J. J. (2010b). Settlement houses: Basics about the settlement house movement . Retrieved from http://womenshistory.about.com/od/ settlementhouses/a/settlements.htm?p=1

Louisiana Department of Environmental Quality. (n.d.). History of the depart- ment. Retrieved from http://www.deq.louisiana.gov/portal/ABOUT/Histo- ryoftheDepartment.aspx

Malka, S. G. (2007). Daring to care: American nursing and second-wave feminism. Urbana, IL: University of Illinois Press.

McCloskey, J. C., Butcher, H. K., & Bulechek, G. M. (Eds.). (2007). Nursing in- terventions classification (5th ed.). St. Louis, C: Mosby.

McKay, M. (2009). Public health nursing in early 20th century Canada. Re- trieved from http://www.thefreelibrary.com/Public+health+nursing+in+ea rly+20th+century+Canada%2FLes+services...-a0209404149

Moorhead, S., Johnson, M., Maas, M., & Swanson, E. (2007). Nursing outcomes classification (NOC). St. Louis, MO: Mosby.

National Center for Chronic Disease Prevention and Health Promotion. (2008). BRFSS history. Retrieved from http://www.cdc.gov/brfss/history.htm

National Hospice and Palliative Care Organization. (2010). History of hospice. Retrieved from http://www.nhpco.org/i4a/pages/index.cfm?pageid=3285

Obstetrics: A brief history of obstetrical care at Pennsylvania Hospital. (n.d.). Retrieved from http://www.uphs.upenn.edu/paharc/timeline/

Paneth, N. (n.d.). Jacob Henle. Retrieved from http://www.enotes.com/ public-health-encyclopedia/henle-jacob

Pew Health Professions Commission. (1995). Critical challenges: Revitaliz- ing the health professions for the twenty-first century. San Francisco: UCSF Center for the Health Professions.

Quad Council of Public Health Nursing Organizations. (2003). Quad Council PHN competencies. Retrieved from http://www.uncc.edu/achne/quadcoun- cil/final_phn_competencies.doc

M02_MARY9591_06_SE_C02.indd 51 06/09/14 6:02 PM

52 UNit 1 Population health Nursing: an Overview

Quad Council of Public Health Nursing Organizations. (2004). Public health nursing competencies. Public Health Nursing, 21, 443–452.

Quad Council of Public Health Nursing Organizations. (2011). Quad Council competencies for public health nurses. Retrieved from http://www.achne.org/ files/Quad%20Council/QuadCouncilCompetenciesforPublicHealthNurses. pdf

Reeves, C. (n.d.). History of medicine. Retrieved from http://www.historyworld. net/wrldhis/plaintexthistories.asp?historyid=aa52

Riedel, S. (2005). Edward Jenner and the history of smallpox and vaccination. Baylor University Medical Center Proceedings, 18(1), 21–25.

Ripley, C. P., & Hembree, M. F. (Eds.). (1992). The black abolitionist papers: Vol. V, the United States, 1859–1865. Chapel Hill, NC: University of North Carolina Press.

Roberts, J. I., & Group, T. M. (1995). Feminism and nursing: An historical per- spective on power, status, and political activism in the nursing profession. Westport, CT: Praeger.

Robinson, B. (2009). Victorian medicine—From fluke to theory. Retrieved from http://www.bbc.co.uk/history/British/victorians/victorian_medicine _01.shtml

Ruffing-Rahal, M. A. (1995). The Navajo experience of Elizabeth Foster, public health nurse. Nursing History Review, 3, 173–188.

Rutty, C., & Sullivan, S. C. (2010). This is public health: A Canadian history. Retrieved from http://cpha100.ca/sites/default/files/History-book-print_ ALL_e.pdf

Scozzari, T. E. (2009). The journey of America’s first native nurse. Retrieved from http://yellowstonevalleywoman.com/view_article?id=202

Sigerist, H. E. (2003). Medical care for all the people. American Journal of Public Health, 93, 57–59. (Reprinted from “Medical care for all people,” by H. E. Sigerist, 1944, Canadian Journal of Public Health, 35, 253–267.)

Sitzman, K. (2010). Nursing in the American colonies from the 1600s to the 1700s: The influence of past ideas, traditions, and trends. In D. Judd, K. Sitzman, & G. M. Davis (Eds.), A history of American nursing: Trends and eras (pp. 8–21). Boston, MA: Jones and Bartlett.

Smith, S. L. (1994). White nurses, black midwives, and public health in Mississippi, 1920–1950. Nursing History Review, 2, 29–49.

Spotsylvania County Public Schools. (2009). Celebrating 100 years of school nursing. Retrieved from http://www.spotsylvania.k12.va.us/Page/546

Stachenko, S., Legowski, B., & Geneau, R. (2009). Improving Canada’s response to public health challenges: The creation of a new public health agency. In R. Beaglehole & R. Bonita (Eds.), Global public health: A new era (2nd ed., pp. 123–137). Oxford: Oxford University Press.

Susie Walking Bear Yellowtail. (2010). Retrieved from http://www.nurses.info/ personalities_susie_yellowtail.htm

Susie Walking Bear Yellowtail, RN (1903–1981). (2004). Retrieved from http:// nsweb.nursingspectrum.com/NursesWeek/SusieWalkingBearYellowtail. htm

Timeline, California Board of Health. (n.d.). California Board of Health. Re- trieved from http://www.google.com/search?q=California+board+of+healt h+history&hl=en&rls=com.microsoft:en-US&tbs=tl:1&tbo=u&ei=7-BqTL v2O4v0tgPborwb&sa=X&oi=timeline_result&ct=title&resnum=11&ved= 0CD8Q5wIwCg

Timeline, U.S. Public Health Service. (n.d.). U.S. Public Health Service. Re- trieved from http://www.google.com/search?q=US+public+health+servic e+history&hl=en&rls=com.microsoft:en-US&tbs=tl:1&tbo=u&ei=qONqT OHpOJHCsAPk5OBH&sa=X&oi=timeline_result&ct=title&resnum=11& ved=0CEgQ5wIwCg

Udwadia, F. E. (2001). Man and medicine: A history. Cary, NC: Oxford Univer- sity Press.

U.S. Department of Health and Human Services. (2010). About the law. Re- trieved from http://www.healthcare.gov/law/about

Van Betten, P., & Moriarty, M. (2004). Nursing illuminations: A book of days. St. Louis, MO: Mosby.

Visiting Nurse Association of Boston. (2010). About the VNA of Boston. Re- trieved from http://www.bostonvna.org/site/c.frLJKYPJLuF/b.3890097/ k.64F6/About_the_VNA_of_Boston.htm

Visiting Nurse Association of Greater Philadelphia. (2010). Mission and history of the VNA. Retrieved from http://www.vnaphilly.org/visiting-nurse-mis- sion-history.aspx

Visiting Nursing Association of Western New York. (2010). The first in 1885… the largest today. Retrieved from http://www.vna-wny.org/

Watts, S. (2003). Disease and medicine in world history. New York: Routledge. Weir, G. M. (1932). Survey of nursing education in Canada. Toronto: University

of Toronto Press. Winslow, C. E. A. (1993). Nursing and the community. Public Health Nursing,

10, 58–63. (Reprinted from The Public Health Nurse, April 1938). Wolfe, L. C., & Selekman, J. (2002). School nurses: What it was and what it is.

Pediatric Nursing, 28, 403–407. World Health Organization. (2010). Jakarta declaration on leading health promotion

into the 21st century. Retrieved from http://www.who.int/healthpromotion/ conferences/previous/jakarta/declaration/en/index1.html

Zilm, G., & Warbinek, E. (1995). Early tuberculosis nursing in British Columbia. Canadian Journal of Nursing Research, 27(3), 65–81.

M02_MARY9591_06_SE_C02.indd 52 06/09/14 6:02 PM

chaPter

Epidemiology and Population Health Nursing

Key Terms

Learning Outcomes

After reading this chapter, you should be able to:

1. Describe at least two theories of disease causation.

2. Identify at least three criteria for determining causality in a relationship between two events.

3. Define risk, relative risk, and absolute risk.

4. Distinguish between morbidity and mortality rates.

5. Identify the six steps of the epidemiologic process.

6. Apply three epidemiologic models.

absolute risk

agent

antigenicity

attack rate

case fatality rate

causality

epidemiology

exposure potential

host

incidence

infectivity

mode of transmission

morbidity

mortality

pathogenicity

populations at risk

portal of entry

portal of exit

prevalence

relative risk

relative risk ratio

resistance

risk

survival rate

survival time

susceptibility

target group

toxigenicity

virulence

3

M03_MARY9591_06_SE_C03.indd 53 06/09/14 6:06 PM

54

The Father of Epidemiology

John Snow, a physician and anesthesiologist known as the father of epidemiology, used epidemio- logic statistical mapping methods to determine the source of a cholera epidemic (Centers for Dis- ease Control and Prevention [CDC], 2004; Robinson, 2009). Prior to the outbreak, Snow had sought to convince medical colleagues that several diseases thought to be spread by air were, in fact, spread through contaminated drinking water. In 1854, an epidemic of cholera began in the Soho district. On one day, 56 new cases occurred, with 143 cases and 70 deaths by the next day. Snow plotted each case on a map of the area and found that all of the early cases were in the vicinity of one particular municipal pump (see Figure 3-1•). His early investigations indicated that workers at a nearby brewery and a workhouse were not affected, as one might have expected them to be, and additional cases were found in the outlying villages of Hampstead and Islington (The puzzle, 2002).

Conducting house-to-house interviews, Snow discovered that the workhouse had its own well and the workers drank only beer, being leery of public water. In addition, the woman affected by the dis- ease in Hampstead had her water delivered each day from the Broad Street pump and had shared the water with her visiting niece from Islington (The puzzle, 2002). Based on this knowledge of disease incidence, he deduced that the source of the infection was the water from the Broad Street pump. Snow was able to persuade local government officials to remove the handle of the pump, prevent- ing access to the contaminated water (Ludwig, 2000). This action led to a decrease in the number of new cases of cholera and the end of the epidemic. Later examination of the pump indicated that a nearby sewer pipe was allowing seepage into the well (The puzzle, 2002). Snow published his theories on the transmission of cholera in a book entitled On the Mode of Communication in Cholera before there was evidence of bacteria as a source of infection (Snow, 1855). A 2003 poll of readers of the journal Hospital Doctor selected Snow as the “greatest doctor” in history (John Snow, n.d.).

A d

vo ca

cy T

h en

Figure 3-1 John Snow’s Map of Cholera Cases in London, 1854

M03_MARY9591_06_SE_C03.indd 54 08/09/14 4:01 PM

Population health nurses deal with conditions affect-ing whole populations as well as subgroups within populations; therefore, they need to be conversant with the basic principles of epidemiology. The term epidemiology derives from three Greek words: epi meaning among, demos or people, and logos meaning discourse or study (Epidemiology – Definition, n.d.). Literally, then, epidemiology is a study of what occurs among the people. A more formal def- inition of epidemiology is the science that deals with the study of the causes, distribution, and control of disease in populations (epidemiology, n.d.).

Epidemiology involves examination of the distribution of health and illness within a population, factors that determine the population’s health status, and use of the knowledge gen- erated to control the development of health problems (Friis & Sellers, 2014). Epidemiologic perspectives on the factors that contribute to disease and illness have changed remarkably over time, and some authors describe four eras of epidemiologic thought. The first was the sanitary era, with interventions based on the ancient theory of miasmas discussed in Chapter 2 .

The second era was that of communicable diseases, in which interventions were based on the germ theory. Emphasis in the third or chronic disease era was on multiple layers of personal risk factors contributing to chronic diseases. The focus of the fourth era, at the beginning of the 21st century, remains to be seen, but the era may turn out to be what some have termed an “ecosocial” perspective (Krieger, 2011), emphasizing the mul- tiple interactions among biological, environmental, and social factors that lead to health or illness in population groups. An alternative direction for epidemiology in this fourth era might be molecular epidemiology, which focuses on the contribution of genetic– environmental interactions to the development, distribution, and prevention of disease (Cabaret, Morand, & Beaudeau, 2012).

Basic Epidemiologic Concepts Three basic concepts underlie epidemiologic perspectives on health and illness. These concepts are causality, risk, and rates of occurrence.

A d

vo ca

cy N

ow Uncovering an Escherichia coli Outbreak

A population health nurse employed by a local county health department made several home vis- its to families in her district. Throughout the day, she heard reports of family members in several households experiencing diarrhea. The families involved did not tend to interact much, and had not attended any common functions in the neighborhood. Operating on a hunch that the increase in diarrhea incidence was more than coincidental, the nurse made visits to several families in the area who were not part of her normal case load, explaining to them that she was checking on reports of diarrhea in the neighborhood and asking if any family members in those households had been having gastrointestinal problems. In this way, she uncovered several more cases of diarrhea and initiated an epidemiologic investigation. As part of the investigation, she went house to house for several blocks locating additional people who were affected and collecting stool specimens from those with diarrhea.

The majority of the stool specimens tested positive for E. coli. When the source of the infection was identified, it proved to be the city water system. One of the water mains providing water to that particular neighborhood had developed a leak. Recent heavy rains in the area had caused contaminated water to seep into the water supply. Ordinarily such a leak would have been addressed by the chlorination process, but further investigation indicated that one of the chlorinators in the city water system was malfunction- ing. In addition to identifying people in the neighborhood affected by the problem, the population health nurse referred them for treatment. Fortunately, there were no long-term consequences for those affected.

55

Evidence-Based Practice

Incorporating Epidemiologic Findings Epidemiologic findings are part of the evidence base used by population health nurses to identify health problems in the population and the factors that contribute to them. Knowing the epidemiology of a specific problem in a specific population

permits the population health nurse, in collaboration with others, to design interventions tailored to the needs and circumstances of a particular population, making interventions more likely to achieve the desired outcomes.

M03_MARY9591_06_SE_C03.indd 55 08/09/14 4:01 PM

56 Unit 1 Population health nursing: an Overview

Causality To control health problems, epidemiologists and population health nurses must have some idea of their causes. The concept of causality is based on the idea that one event is the result of another event. The main purpose of epidemiology is to identify causal links between contributing factors and resulting states of health and illness.

THEOrIEs OF CAUsATION. Theories about the cause of disease and ill health have evolved over time. The first recog- nized attempt to attribute a cause to illness occurred during the “religious era,” which extended from roughly 2000 ce through the age of the early Egyptian and Greek physicians to around 600 ce. During this period, disease was thought to be caused directly or indirectly by divine intervention, possibly as punish- ment for sins or as a trial of faith.

Subsequent to the religious era, disease was often attributed to various physical forces, such as miasmas, or mists. A rudimen- tary theory of disease was put forth by Hippocrates in the famous treatise, On Airs, Waters, and Places, written about 400 ce. The primary belief at that time was that disease was caused by harm- ful substances in the environment (Friis & Sellers, 2014).

The bacteriologic era commenced in the late 1870s with the discovery of specific organisms as etiologic (causative) agents for specific diseases. As we saw above, early hypotheses were derived by John Snow during the 1854 London cholera epi- demic. Subsequently, actual bacteria were isolated and found to be the source of this and other infectious diseases. These dis- coveries gave rise to theories of a single cause for any specific

disease. Single-cause theories were further supported by the identification of specific agents as causative elements in the development of other health problems. For example, lack of vitamin C was found to result in scurvy. The discovery of spe- cific agents responsible for particular diseases did not, how- ever, explain why some people exposed to an agent developed the disease, while others did not. The result of this explanatory failure was the movement into the current era of multiple cau- sation or the ecosocial perspective described above.

The era of multiple causation is characterized by the rec- ognition that multiple factors interact in the development of health or illness in a given person or population and that there is seldom one single cause. Recent advances in epidemi- ology and biomolecular technology are moving toward an era of multiple causation that encompasses the gene–environment interactions discussed earlier.

Epidemiology examines the interaction among factors at the population level with an eye toward controlling particular health problems. Prevention or control of any disease within population groups depends on knowledge of these factors and determina- tion of the point at which intervention will be most feasible and most effective. The historical development of theories of disease causation is summarized in the Highlights box on the left.

CrITErIA FOr CAUsALITy. With the advent of single- cause/single-effect theories of disease causation during the bacte- riologic era, the scientific community began to look for specific causes for all health problems. Now, however, the concept of cau- sality has become more complicated in view of the recognized in- terplay among several factors in the development of a particular health problem. A factor may be considered causative if the health condition is more likely to occur in its presence and less likely to occur in its absence. Even when these conditions are met, how- ever, a specific factor may not necessarily cause a particular condi- tion. Several criteria can be used in determining causality (Friis & Sellers, 2014). These criteria include the consistency of the rela- tionship, strength of the association, specificity, the temporal re- lationship between the supposed cause and effect, and coherence.

Consistency. The first criterion for establishing a causal rela- tionship is the consistency of the association between the sup- posed causal factor and its presumed effect. The condition in question must occur when the factor is present, not when it is absent. For example, people cannot develop measles without be- ing exposed to the measles virus. In addition, the association must always occur in the same direction. Exposure cannot re- sult in disease in one case, and disease result in exposure to the virus in another.

Strength of association. The second criterion for establish- ing causality is the strength of the association. The greater the correlation between the occurrence of the factor and the con- dition, the greater the possibility that the relationship is one of cause and effect. For example, not every susceptible person who is exposed to the measles virus develops the disease, but most of them do. The association between exposure and disease, in this

Historical Development of Theories of Causation • Religious era (2000–600 ce)

Disease is thought to be caused by divine intervention, possibly as punishment for sins or as a test of faith.

• Environmental era (circa 400 ce)

Disease is believed to be caused by harmful miasmas, or mists, or other substances in the environment.

• Bacteriologic era (1870–1900)

Disease is thought to be caused by specific bacteriologic or nutritive agents.

• Era of multiple causation/Ecosocial perspective (1900 to present)

Occurrence of disease and other health problems is a result of the interaction of multiple individual risk factors and population exposure patterns.

• Molecular epidemiology perspective (future)

Occurrence of health-related conditions results from a complex interaction of genetic and environmental factors.

Highlights

M03_MARY9591_06_SE_C03.indd 56 06/09/14 6:06 PM

chaPter 3 epidemiology and Population health nursing 57

instance, is quite strong and supports the idea that the measles virus caused measles. The strength of the association may reflect a dose-response gradient in which the greater the exposure to the presumed cause, the greater the likelihood of developing the problem (Gordis, 2014). For example, the fact that people who smoke two packs of cigarettes a day are more likely to develop lung cancer than those who smoke one pack is strong evidence for a causal relationship between smoking and lung cancer.

Specificity. Specificity is the third criterion for causality. Speci- ficity is present when the factor in question results in one spe- cific condition. For example, exposure to measles virus results only in measles, not mumps or varicella (chicken pox). Speci- ficity is the weakest of the criteria with respect to causation in noninfectious conditions. For example, smoking is known to be related to lung cancer, but is also related to stomach and bladder cancer and heart disease.

Temporal relationship. The fourth criterion for establishing causality is the time (or temporal) relationship between the fac- tor and the resulting condition. The factor thought to be caus- ative should occur before the condition occurs. For example, one has to be exposed to the measles virus before, not after, one gets the disease.

Coherence. Coherence with the established body of scientific knowledge is the last criterion for determining causality. The idea that one condition causes another must be logical and should be congruent with other known facts. For example, it is known that alcohol consumption increases the time required for voluntary muscles to react to stimuli. Therefore, it is rea- sonable to consider alcohol consumption as a causative factor in many accidents because this interpretation is consistent with the idea of a slowed response to changing driving conditions.

The only criterion absolutely required for attributing causa- tion is the presence of a correct temporal relationship. For ex- ample, Snow’s hypothesis that the water from the Broad Street pump was the cause of the cholera epidemic was certainly not congruent with the prevalent belief that such diseases were caused by the presence of effluvia or noxious substances in the air. The greater the number of criteria met, however, the more credible the idea that the factor in question causes the condi- tion of interest. The criteria for determining causality are sum- marized in the Highlights box at the right.

Risk In addition to establishing the causes of health-related condi- tions, epidemiologists are interested in estimating the like- lihood that a particular condition will occur. Risk is the probability that a given individual will develop a specific con- dition. Risk may be absolute or relative. Absolute risk is the probability that anyone in a given population will develop a particular condition. Relative risk is the probability that some- one in a group of people with a particular characteristic will develop the condition when compared to people without that

characteristic (Absolute risk and relative risk, 2011). For exam- ple, the absolute risk of breast cancer is about one in every eight U.S. women, but the relative risk of developing breast cancer is much higher for women with a family history of breast cancer than for those without a family history. One’s risk of develop- ing a particular condition is affected by a variety of physical, emotional, environmental, lifestyle, and other factors. When epidemiologists speak of populations at risk, they are referring to groups of people who have the greatest potential to develop a particular health problem because of the presence or absence of certain contributing factors. “Risk factor epidemiology” may underplay the role of social structure and social relationships in people’s response to risk factors. Risk factor epidemiology also tends to assume that people are free to choose their responses, which may or may not be the case.

The basis for risk may lie in one’s personal susceptibility to a condition or the potential for exposure to causative factors. Susceptibility is the ability to be affected by factors contribut- ing to a particular health condition. For example, very young unimmunized children are susceptible to, and constitute the greatest population at risk for, pertussis (whooping cough). In this case, the basis for increased risk lies in the increased susceptibility of this group. Children who have been immu- nized against pertussis are less likely to develop the disease and therefore are not part of the population at risk. Another exam- ple of risk based on susceptibility is found in the population of sexually active women of childbearing age who are at risk for pregnancy. Men, children, and older women are not suscepti- ble to pregnancy and, therefore, are not considered part of the population at risk.

Exposure potential is another factor in one’s risk of devel- oping a particular health problem. Exposure potential is the likelihood of encountering or being exposed to factors that contribute to a condition. For example, those most at risk for sexually transmitted diseases are adolescents and young adults. In this instance, the basis of risk is not increased susceptibil- ity, as is the case in pertussis, but an increased potential for

Criteria for Determining Causality • Consistency: The association between the supposed cause

and its effect is consistent and always occurs in the same direction.

• Strength of Association: The greater the correlation between supposed cause and effect, the greater the possi- bility the relationship is a causal one.

• Specificity: The supposed cause always creates the same effect.

• Temporal relationship: The supposed cause always occurs before the effect.

• Coherence: The supposition that one event causes another is coherent with other existing knowledge.

Highlights

M03_MARY9591_06_SE_C03.indd 57 06/09/14 6:06 PM

58 Unit 1 Population health nursing: an Overview

children under the age of 10 as well as college students whose immunity is waning.

Rates of Occurrence The rate of occurrence of a health-related condition is also of concern to population health nurses. Rates of occurrence are statistical measures that indicate the extent of health problems in a group. A rate is simply the number of a particular event (e.g., cases of illness) divided by the size of the population at risk for the event in a given time period (e.g., annually, per quarter) (CDC, 2011). Rates of occurrence allow comparisons between groups of different sizes with respect to the extent of a particular condition. For example, a community with a popula- tion of 1,000 may report 50 cases of syphilis this year, whereas another community of 100,000 persons may report 5,000 cases. On the surface, it would seem that the second community has a greater problem with syphilis than the first; however, both communities have experienced 50 cases per 1,000 population. In other words, both have a problem with syphilis of compa- rable magnitude.

Computing the statistical rates of interest in population health nursing involves dividing the number of instances of an event during a specified period by the population at risk for that event and multiplying by 1,000 (or 100,000 if the numbers of the event are so small that the result of the calculation using a multiplier of 1,000 would be less than 1). The basic formula for calculating statistical rates of interest to community health nurses is presented at left.

Both mortality and morbidity rates are of concern in popu- lation health nursing. Mortality is the ratio of the number of deaths in various categories to the number of people in a given population, whereas morbidity is the ratio of the number of cases of a disease or condition to the number of people in the population. Mortality rates describe deaths; morbidity rates de- scribe cases of health conditions that may or may not result in death. For example, the number of people in a particular group who die as a result of cardiovascular disease is reflected in the mortality rate; however, the number of people experiencing cardiovascular disease is indicated by the morbidity rate.

MOrTALITy rATEs. Mortality rates of interest in popula- tion health nursing include the overall or “crude” death rate, cause-specific death rates, infant and neonatal mortality, fetal and perinatal mortality, and the maternal death rate. Each rate is calculated from the number of events during a specified time period (e.g., a year) and the average population at risk during that same time. Formulas for calculating some specific rates of inter- est are presented on the next page.

Rates are reported in terms of the multiplier used to calcu- late them. For example, overall cancer deaths usually occur in fairly large numbers, so a cause-specific death rate for all can- cers would be calculated using 1,000 as the multiplier. The re- sulting death rate is reported as the number of deaths per 1,000 population. For example, if City A, with a population of 50,000, had 100 cancer-related deaths in 2010, the cause-specific death

Basic Formula for Calculating Statistical Rates

Rate = Number of events over a time period

Population at risk at that time *

1,000 (or 100,000)

For example, in a community with a population of 10,000 females aged 13 to 18 years, there were 200 teenage pregnancies in 2010. What is the rate of teenage pregnancy?

Rate of teenage

pregnancy =

200 pregnancies in females 13-18

during 2010 10,000 females

aged 13-18 in the population at midyear

* 1,000 = 20 pregnancies

per 1,000 females

Highlights

exposure due to more frequent and less selective sexual activ- ity than may occur among older adults. Another population at risk through increased chance of exposure includes individuals whose occupations bring them in contact with toxic substances.

Members of a population at risk have a greater probability of developing a specific health problem than those who are not affected by factors known to contribute to its occurrence. This difference in the probability of developing a given condi- tion between those exposed to causative factors and those who are not is known as the relative risk ratio (Relative risk, 2014). This ratio is derived by comparing the frequency of occurrence of the condition in a group exposed to known risk factors with its occurrence among individuals who have not been exposed. For example, if 50% of smokers develop heart disease versus only 5% of nonsmokers, smokers have a relative risk ratio of 10:1, or have a 10 times greater risk of heart disease than their nonsmoking counterparts.

The relative risk ratio is useful in identifying areas in which preventive interventions will have the greatest impact on the oc- currence of the condition. When the relative risk is greater than 1:1, there is a positive association between the factors and the condition, suggesting that eliminating the factor may prevent the condition from occurring. A negative association, in which the relative risk ratio is less than 1:1 (e.g., 1:5), suggests that enhancing the factor or causing it to be present may prevent the condition. For example, smoking has a positive relation- ship with heart disease and regular exercise has a negative re- lationship, so both preventing smoking and promoting exercise should decrease the incidence of heart disease in the population.

The population at risk becomes the target group for any in- tervention designed to prevent or control the problem in ques- tion. The target group includes those individuals who would benefit from an intervention program and at whom the pro- gram is aimed. The target group for an immunization campaign against pertussis, for example, would include unimmunized

M03_MARY9591_06_SE_C03.indd 58 06/09/14 6:06 PM

chaPter 3 epidemiology and Population health nursing 59

rate for cancer for that year would be reported as 2 deaths per 1,000 population. Deaths from pancreatic cancer, on the other hand, occur relatively infrequently, so 100,000 would be the multiplier used to calculate the pancreatic cancer death rate for 2010. If there were six deaths from pancreatic cancer in City B in 2010, and City B had a total population of 500,000 people at midyear, the annual pancreatic cancer mortality rate would be reported as 1.2 deaths per 100,000 population.

Age-adjusted mortality rates can be calculated to account for differences in age distribution between groups. This allows the population health nurse to make more accurate compari- sons of mortality between groups with varying age distribu- tions. For example, City A might have a considerably higher crude death rate for influenza than City B. If, however, City A also has a larger proportion of elderly people in the population, more influenza deaths would be expected, because older people are more vulnerable to this condition. Age-adjusted mortality

rates, on the other hand, allow the population health nurse to compare the effects of influenza on Cities A and B as if they had similar proportions of elderly residents. If City A’s death rate remains higher when adjusted for age, the nurse would look for other factors in the community to explain this difference.

A case fatality rate is another form of mortality rate. The case fatality rate is the percentage of persons who develop a health problem and who die as a result of it. For example, at present many people infected with Ebola virus die because of the lack of an effective treatment and the case fatality rate for Ebola virus infection is close to 100%. In the early days of the AIDS epidemic, case fatality rates were also extremely high. Now, with more effective treatment, many people with AIDS can live for significantly longer periods.

A related concept is survival time, or the average length of time from diagnosis to death. For example, given current health care technology, the survival time for children with Down syn- drome is much longer today than at the turn of the century. Caution should be used, however, when interpreting trends in both survival rate and survival time. Diagnostic technology has permitted earlier diagnosis of many conditions, increasing the time from diagnosis to death, but not appreciably lengthening one’s life (Gordis, 2014).

MOrBIdITy rATEs. Morbidity rates reflect the number of persons within the population who experience a particular condition. Like mortality rates, morbidity rates can be calcu- lated for specific subsets of the population; for example, extent of diabetes or heart disease occurring among people in specific age groups or from different ethnic backgrounds. Morbidity is further described in terms of the incidence and prevalence of a condition. Incidence reflects the number of new cases of a par- ticular condition identified during a specified period of time. Prevalence is the total number of people affected by a particular condition at a specified point in time.

To illustrate the concepts of incidence and prevalence, con- sider a town with a population of 30,000 in which 15 new cases of hypertension were diagnosed in June. This is an indication of the incidence of hypertension. People who were diagnosed as hypertensive prior to June and who continue to live in the town still have hypertension. These additional cases of hypertension, however, are not reflected in the hypertension incidence rate for June, but are included in the prevalence, the total number of people in the community affected by hypertension. The for- mulas on the next page are used to calculate annual incidence and prevalence rates. Again, the results of the calculations are reported in terms of the multiplier used (e.g., per 1,000 popula- tion or per 100,000 population).

The converse of the case fatality rate discussed earlier under mortality rates is the survival rate. The survival rate is the pro- portion of people with a life-threatening condition who remain alive for a specific period of time (usually 5 years) (National Cancer Institute, n.d.). For example, the 5-year survival rate for women with breast cancer is relatively high compared to the survival rate for those with pancreatic cancer.

Formulas for Calculating Selected Mortality Rates

Crude death rate =

Total number of deaths during year

Total population at midyear * 1,000

Cause@specific annual death

rate =

Number of deaths from specific cause during year

Total population at midyear

* 1,000

Annual infant mortality rate

=

Number of deaths during year (birth to 1 year of age)

Number of live births during year

* 1,000

Annual neonatal mortality rate

=

Number of deaths during year (birth to 28 days of age)

Number of live births during year

* 1,000

Annual fetal death rate

=

Number of fetal deaths during year (20 to 28 weeks> gestation)

Number of live births plus fetal deaths during year

* 1,000

Annual perinatal death rate

=

Number of perinatal deaths during year (20 weeks> gestation to 1 week of age)

Number of live births plus fetal deaths during year

* 1,000

Annual maternal death rate

=

Number of maternal deaths during year

Number of live births during year

* 100,000

Highlights

M03_MARY9591_06_SE_C03.indd 59 06/09/14 6:06 PM

60 Unit 1 Population health nursing: an Overview

Other rates that may be of interest to population health nurses include marriage and divorce rates, unintended preg- nancy rates, employment rates, utilization rates for health ser- vices and facilities, and rates for alcohol and drug use and abuse. Population health nurses use morbidity and mortality data and information about other rates in assessing the health status of the population. Population morbidity or mortality rates that are generally higher than state or national rates indicate health problems that require intervention at the population level. For example, the nurse may note that local morbidity rates for vac- cine preventable illnesses such as measles and rubella are twice those of the rest of the state. These differences indicate that a significant portion of the population is not immunized. The nurse then uses these data to begin an investigation of factors involved in the problem and to plan a solution. Is it a matter of inaccessibility of immunization services, lack of education on the need for immunization, or poor surveillance of immuniza- tion levels in the schools? The solution to the problem must be geared to the cause. Statistical data merely serve to indicate the presence of a problem; they do not delineate its specific nature.

Low morbidity and mortality rates do not indicate the ab- sence of health problems in the population because biostatistics are only one indicator of population health status. Many health problems are not reported statistically, and their presence in the population is not reflected in morbidity and mortality rates. The nutritional status of the population is one area not addressed by biostatistics such as morbidity and mortality rates. Other indi- cators that the population health nurse employs in assessing the population’s health status are discussed in Chapter 15 . A soft- ware program for creating epidemiologic questionnaires to cap- ture some of these forms of data is available from the Centers for Disease Control and Prevention. Source information for the program is included in the student resources site.

The Epidemiologic Process Epidemiologists use a systematic process, similar to the nurs- ing process, to study states of health and illness in an effort to

control disease and promote health. The steps of the epidemio- logic process are:

• Defining the condition • Determining the natural history of the condition • Identifying strategic points of control • Developing control strategies • Implementing control strategies • Evaluating the effects of control strategies

Determining the natural history of the condition is analo- gous to the assessment and diagnosis phases of the nursing process. Identifying strategic points of control and designing control programs reflect the planning aspects of the nurs- ing process, and the implementation and evaluation steps are equivalent to similar steps in the nursing process.

Defining the Condition The first step in the epidemiologic process is defining the health condition requiring intervention. As we will see in Chapter 11 , the epidemiologic process can be applied to health as well as ill- ness. In either case, it is necessary to define specifically the state or condition for which intervention is required. Taking a health pro- motion focus, one needs to define what is meant by health. With respect to a specific disease or health problem, one must clearly define what is and what is not an instance of the problem. For ex- ample, to study the factors contributing to child abuse one must be able to differentiate abuse from accidental harm to a child. Similarly, one must be able to differentiate cases of measles from other similar diseases in order to study and control the disease.

Determining the Natural History of the Condition The natural history of a disease or condition is a description of the events that precede its development and occur dur- ing its course, as well as its typical outcomes. Determining a condition’s natural history involves identifying factors that contribute to its development, typical signs and symptoms of the condition, its effects on the human system, and its typical outcomes and factors that may affect those outcomes. For ex- ample, crowded living conditions, lack of immunization, and exposure to influenza virus are some of the factors involved in the development of influenza. The typical course of influenza includes a short incubation period and rapid onset of respira- tory and/or gastrointestinal symptoms. Most cases of influenza resolve after several days, but the eventual outcome depends on such factors as the individual’s overall health, age, nutritional status, and personal habits such as smoking. All of these bits of information are part of the natural history of influenza.

The description of the natural history of a particular condi- tion also incorporates information on the frequency of occur- rence, severity of outcomes, and its geographic distribution. Information is obtained on time relationships and trends re- lated to the condition. Time relationships refer to the occur- rence of the condition at specific times or during particular

Formulas for Calculating Annual Incidence and Prevalence Rates

Annual incidence rate

=

Number of new cases of a condition last year

Total population at risk at midyear

* 1,000

Annual prevalence rate

=

Total number of cases of a condition last year

Total population at risk at midyear

* 1,000

Highlights

M03_MARY9591_06_SE_C03.indd 60 06/09/14 6:06 PM

chaPter 3 epidemiology and Population health nursing 61

seasons. For example, influenza occurs primarily in the winter, and the incidence of suicide rises around holidays. Similarly, a first incident of spousal abuse is often associated with the vic- tim being pregnant. Trends refer to patterns of occurrence for the condition. Incidence of vaccine preventable diseases, for ex- ample, declined considerably when vaccines became available, but several of these diseases have shown a trend of increasing incidence, particularly among certain population groups.

The natural history of a condition is often divided into four stages: susceptibility, preclinical, clinical, and resolution (CDC, 2011). In the susceptibility stage, factors contributing to development of the condition are present and the person is at-risk for its development. When exposure to causative fac- tors has occurred, but no symptoms have appeared, the condi- tion is in the preclinical stage. The clinical stage begins with the onset of signs and symptoms characteristic of the disease or condition. In the resolution stage, the condition culminates in a return to health, death, or continuation in a chronic state. These stages are depicted in Figure 3-2•. We can use the ex- ample of arthritis to clarify the stages of the natural history. In the preexposure stage, factors contributing to arthritis (e.g., overweight, history of prior joint injury, etc.) are pres- ent, but the disease has not manifested yet. In the preclini- cal stage, changes have begun to occur in joint tissue, but no symptoms are present. In the clinical stage, the person be- gins to experience pain, joint swelling, and other symptoms typical of arthritis. Because arthritis is a lifelong condition,

the resolution stage does not involve a return to a prearthritic state, but involves continuation as a chronic condition that will require continuing care.

Determining the factors involved in the natural history of a condition is usually undertaken from the perspective of a par- ticular epidemiologic model. Three such models are presented later in this chapter. The PHN model discussed in Chapter 1 is based on one of these epidemiologic models.

Identifying Strategic Points of Control Knowledge of the natural history of a disease or condition al- lows epidemiologists and population health nurses to identify strategic points at which the development or course of the con- dition might be controlled. One might, for example, design in- terventions to eliminate or modify the factors contributing to the condition to prevent it from occurring. Similarly, knowl- edge of factors affecting the course of a condition might lead to interventions designed to minimize its effects.

Strategic points of control might occur at any of the levels of health care. For example, health promotion and illness or injury prevention strategies might be employed in the preex- posure and preclinical stages of the condition. As an example, good nutrition and immunization are health promotion and prevention strategies that might prevent a child from develop- ing varicella (chickenpox). Resolution strategies might be used during the clinical stage when symptoms of the condition have

Figure 3-2 Stages in the Natural History of a Condition and Their relationship to the Levels of Health Care

Susceptibility Stage

Factors leading to develoment

are present

Preclinical Stage Exposure to

causative agent: no symptoms present

Exposure to agent

Symptom development

Clinical Stage Symptoms

present

Resolution Stage Problem resolved Return to health,

chronic state, or death

Speci�c Prevention

Health promotion

Resolution

Restoration

M03_MARY9591_06_SE_C03.indd 61 06/09/14 6:06 PM

62 Unit 1 Population health nursing: an Overview

occurred. If long-term complications arise from the condition, other strategies might be needed to restore normal function or prepare for a peaceful death.

Designing, Implementing, and Evaluating Control Strategies Once strategic points of control have been identified, health care interventions or programs can be designed to prevent or minimize the effects of the condition on the health of the popu- lation. These interventions or programs are then implemented and evaluated in terms of their effects on the occurrence and outcomes of the particular condition.

Epidemiologic Investigation The basic requirement for using the epidemiologic process to control health and illness is information on contributing fac- tors as well as on effective control strategies. Information about any given condition is usually obtained over time from mul- tiple epidemiologic investigations. Epidemiologic studies are of three general types: descriptive, analytic, and experimental.

Descriptive Epidemiology Descriptive epidemiology is the study of the distribution of a given health state in a specified population in terms of per- son, place, and time (CDC, 2011). The person element reflects the characteristics of people who develop the condition, such as age, gender, race and ethnicity, economic status, and so on. Place variables include where the condition tends to occur, and the time element reflects when the condition occurs. For ex- ample, who tends to develop arthritis and who has the most se- vere consequences of the disease (person)? Does arthritis occur more frequently in some parts of the country than others? What features of those areas might explain differences in arthritis in- cidence (place)? Finally, is arthritis diagnosed more frequently in certain seasons than others? Is the incidence of arthritis in- creasing or decreasing over time? What factors account for the seasonal differences or changes in incidence (time)

Types of descriptive studies include prevalence surveys, cross-sectional studies, case reports, and surveillance studies. Prevalence surveys are aimed at determining the frequency of occurrence of a condition in the population. Prevalence surveys may also provide information about the extent of exposure of the population to risk factors involved in a given condition. A cross-sectional study examines the extent of a health condition and exposure to its contributing factors in a given population at a given point in time (Michigan Center for Public Health Preparedness, 2010).

A case report provides in-depth information about a single instance of the condition. A case series is an examination of several case reports to determine common features. As we saw in Chapter 1 , surveillance is a systematic approach to monitoring trends in the occurrence of health conditions of interest.

Descriptive epidemiology is useful for several purposes. These include evaluating trends in the occurrence of a condi- tion within a given population and comparing occurrences between populations. Descriptive epidemiology also provides a basis for planning health services and allocating resources. Finally descriptive epidemiology identifies problems for ana- lytic epidemiologic investigations. Descriptive studies may provide causal hypotheses that can be tested in other types of Some diseases occur primarily in winter. (Patryk Kosmider/Fotolia)

Global Perspectives

Questions related to person, place, and time address three of the key features of an epidemiologic investigation. The person component of epidemiology addresses who is affected by the condition? Are certain age groups more likely to develop the con- dition than others? Does the condition occur more frequently in members of certain ethnic groups or those of a particular socio- economic level?

The time component reflects when the condition occurs. Is incidence higher at certain times of the year? Does the condition tend to occur after certain other events or does it occur before other events. What else is happening about the time the condi- tion is noted?

Place reflects the locales where the condition tends to oc- cur. Does it occur in areas with certain weather patterns? Is it confined to certain geographic areas or particular neigh- borhoods? The place component was a key feature of Snow’s identification of the Broad Street pump as the source of the London cholera epidemic. Place may also affect the way in which a particular condition develops. How might the epide- miology of a particular condition, such as HIV/AIDs, differ in a place like the United States versus a rural African village? What are the features of place that influence the development of HIV infection and AIDS disease in these two parts of the world?

Epidemiologic Investigation

M03_MARY9591_06_SE_C03.indd 62 06/09/14 6:07 PM

chaPter 3 epidemiology and Population health nursing 63

epidemiologic studies, but do not themselves provide evidence of causation (Friis & Sellers, 2014).

Analytic Epidemiology Analytic epidemiology is the study of factors contributing to health states. Its purposes are to (a) suggest mechanisms of cau- sation, (b) generate etiologic (causal) hypotheses, and (c) test those hypotheses. Analytic epidemiology can be divided into three categories of investigations: ecological studies, case–con- trol studies, and cohort studies (Friis & Sellers, 2014). Ecologi- cal studies compare rates of disease occurrence among several population groups, usually 10 or more. For example, one might compare the rates of HIV infection among heterosexuals and sexual minority group members of different races/ethnicities. Ecological studies are useful when the extent of exposure of specific individuals to factors contributing to a problem is un- known, but information about the general level of exposure in the population is available. Ecological studies can be used to as- sess relationships between exposure rates and disease rates in different populations. They also provide information on trends in exposures as compared to trends in disease occurrence. For example, frequency of sexual activity among persons of differ- ent age groups would suggest differential probabilities of being exposed to HIV infection.

Case–control studies involve comparisons between peo- ple with a specific condition and those without it. Differ- ences in characteristics of members of these two groups may suggest causative or preventive factors related to the health condition of interest. For example, we might compare people who develop bladder cancer with those who do not with re- spect to their smoking behavior. Cohort studies, also called prospective or longitudinal studies, follow over time people

exposed to a supposed causative factor, but without the con- dition, to determine the proportion of people who actually develop the condition of interest. For example, we might fol- low a group of smokers over time to determine how many of them develop bladder cancer, or examine the levels of certain chemicals in the body to determine links to mental illness.

Experimental Epidemiology Experimental epidemiology is a subset of analytic epidemiol- ogy in which exposure to certain variables is manipulated by the researcher to determine the results (Friis & Sellers, 2014). Experimental studies are used to test the effectiveness of interventions. Application of an intervention by the researcher is called a trial. Clinical trials apply interventions to individu- als; community trials test interventions with population groups (Friis & Sellers, 2014). Trials can involve removal of a risk factor for a condition or addition of some other factor and can be either prophylactic or therapeutic in nature, depending on the timing of the intervention.

In prophylactic trials, the intervention is designed to pre- vent the occurrence of a condition. Interventions designed to promote health are also tested in prophylactic trials. Thera- peutic trials, on the other hand, investigate the effects of treat- ments at the resolution and restoration levels of health care. In these studies, the researcher exposes a group of people to an in- tervention designed to resolve an existing health problem. The intervention may be either positive or negative. Positive inter- ventions add a factor to the situation being studied (e.g., a new form of education to prevent smoking among teens). Negative interventions reduce or eliminate causative factors (e.g., pre- venting access to tobacco products among teens). In another example, a population health nurse might explore the effects of teaching parenting techniques (a positive intervention) or reducing environmental stressors (a negative intervention) on the incidence of child abuse by already abusive parents. The

Tests of biomarkers may help to identify populations at risk for specific diseases. (Panupong1982/Fotolia)

Door-to-door surveys are one way of obtaining epidemiologic data. (JackF/Fotolia)

M03_MARY9591_06_SE_C03.indd 63 06/09/14 6:07 PM

64 Unit 1 Population health nursing: an Overview

relationships among the types of epidemiologic investigations presented here are depicted in Figure 3-3•. The selection of a particular investigative approach depends on the study to be conducted and the extent of prior research on the topic. For example, descriptive studies are appropriate in studying condi- tions about which little is known. For example, a descriptive study might be conducted among male-to-female transgender individuals regarding their access to and use of mammogra- phy screening services. In other areas where there is already evidence of possible relationships between variables, analytic or experimental studies might be more appropriate. Choice of an analytic or experimental approach depends primarily on whether the situation permits the researcher to manipulate the variables of interest. In some instances, manipulation of vari- ables is not possible; in others, manipulation of the variables involved would be unethical. For example, if a particular vac- cine has been shown to be effective in preventing a specific dis- ease, it would not be ethical to give some people the vaccine and others a placebo to see what the rate of infection in the two groups is.

Population health nurses may be actively involved in epide- miologic investigations. For information about agencies and organizations that support epidemiology and epidemiologic

research, see the External Resources section of the student resources site.

Epidemiologic Models Both nurses and epidemiologists use epidemiologic infor- mation to direct interventions to control health-related con- ditions. Determining appropriate control strategies often involves collecting large amounts of data about multiple factors that may be contributing to the condition. For this reason, it is helpful to have a model or framework to direct the collection and interpretation of these data. We explore three epidemio- logic models here: the epidemiologic triad, the web of causa- tion model, and determinants-of-health models.

The Epidemiologic Triad Model Traditionally, epidemiologic investigation has been guided by the epidemiologic triad. In this model, data are collected with respect to a triad of elements: host, agent, and environment (Friis & Sellers, 2014). The interrelationship of these elements results in a state of relative health or illness. The relationships among host, agent, and environment and specific consider- ations under each are depicted in Figure 3-4•. HOsT. The host is the client system affected by the particu- lar condition under investigation. Population health nursing is concerned with the health of human beings, so, for our pur- poses, the host is a human being. A variety of factors can in- fluence the host’s exposure, susceptibility, and response to an agent. Host-related factors include intrinsic factors (e.g., age, race, and sex), physical and psychological factors, nutritional status, genetics, and the presence or absence of disease states or immunity, among others (Friis & Sellers, 2014).

AGENT. The agent is the primary cause of a health-related condition. After specific microorganisms were found to cause specific diseases, the concept of agents of disease originated in the context of communicable diseases. Although the causes of some health problems may be so complex that no single agent can be identified, the concept of agent remains useful for ex- ploring many health problems.

Agents can be classified into six types: physical agents, chemical agents, nutritive elements, infectious agents, genetic agents, and psychological agents. Physical agents include heat, trauma, and radiation. Chemical agents include various sub- stances to which people may develop untoward reactions. Some plants such as poison ivy and ragweed can be considered chemical agents because they cause a chemical reaction result- ing in an allergic response. An absence or an excess of a vari- ety of nutritive elements is known to result in disease, as do the presence of and exposure to a number of infectious agents that cause communicable diseases. Genetic agents arise from genetic transmission from parent to child. Finally, psychologi- cal agents such as stress can produce a variety of stress-related Figure 3-3 Approaches to epidemiologic investigation

Epidemiologic Investigations

Descriptive Studies

Ecological Studies

Case–Control Studies

Analytic Studies

Clinical Trials

Prophylactic Trials

Cohort Studies

Experimental Studies

Community Trials

Therapeutic Trials

M03_MARY9591_06_SE_C03.indd 64 06/09/14 6:07 PM

chaPter 3 epidemiology and Population health nursing 65

conditions. The types of agents and examples of health condi- tions to which they contribute are listed in Table 3-1•.

An agent’s characteristics influence whether a given individual develops a particular health-related condition. These characteris- tics vary somewhat depending on the type of agent involved.

Characteristics of infectious agents. Characteristics that influ- ence the effects of infectious agents include the extent of expo- sure to the agent and the agent’s infectivity, pathogenicity, and virulence. Additional characteristics of infectious agents include toxigenicity, resistance, and antigenicity (Friis & Seller, 2014). The extent of exposure to a disease-causing microorganism, or the infective dose, affects the outcome of the exposure. For ex- ample, a person exposed to a few Mycobacterium tuberculosis organisms is unlikely to develop tuberculosis (TB). The greater the number of disease organisms inhaled, however, the greater the likelihood of developing TB.

Infectivity is the ability of an infectious agent to enter, sur- vive and reproduce within, and cause disease in an individual host (Infectivity, 2014). Infectivity is determined, in part, by the organism’s portals of entry and exit. The portal of entry is the means by which the agent invades the host; the portal of exit

is the avenue by which the agent leaves the host. The portals of entry and exit also influence the mode of transmission, or the means by which an infectious agent is transmitted from a source (an infected person, animal, or other source) to a suscep- tible host. Modes of transmission are discussed in more detail in Chapter 26 . Measles virus, for example, has a higher infectiv- ity than does tetanus bacillus. The measles virus enters the body quite easily through the respiratory system, whereas tetanus gains entry through a break in the skin, usually a deep puncture wound. Similarly, variola virus, the causative agent for smallpox, is usually inhaled and can be transmitted by means of an aerosol cloud, making it a possible weapon of biological terrorism.

Pathogenicity is the ability of an agent to cause disease when a susceptible person is exposed or the proportion of people who develop clinical disease when infected by the agent (CDC, 2011). In terms of infectious agents, measles virus causes disease in most of the susceptible exposed indi- viduals. M. tuberculosis, on the other hand, produces disease in only a small portion of the individuals exposed.

Another concept closely related to pathogenicity is that of attack rate, which is the proportion of those exposed to an agent who develop the disease. As is the case with pathogenicity,

Figure 3-4 elements of the epidemiologic Triad Model

?

HOST

AGENT

ENVIRONMENT

Physical, biological, socioeconomic

Intrinsic factors, physical factors, psychological factors, immunity

HEALTH OR

ILLNESS

M03_MARY9591_06_SE_C03.indd 65 06/09/14 6:07 PM

66 Unit 1 Population health nursing: an Overview

measles has a high attack rate, whereas tuberculosis has a low attack rate. The attack rate for smallpox among unvaccinated individuals is greater than 37% of those exposed ( Smallpox of poxviruses infection, n.d.).

Virulence is the term used to describe the severity of the health problem caused by an agent or the proportion of people with the disease who develop serious illness or die (CDC, 2011). Rubeola or measles has a relatively low virulence because un- complicated measles is not a serious disease. Tetanus, on the other hand, is extremely virulent because it results in fatality unless treatment is instituted. The virus that causes AIDS is an- other infectious agent with a very high virulence. Virulence is frequently confused with pathogenicity, but the two terms re- fer to different agent characteristics. For example, cold viruses that cause disease in exposed individuals are highly pathogenic, but have a low virulence because the diseases caused are rela- tively minor. Virulence is closely related to case fatality rates discussed earlier in this chapter.

The toxigenicity of an infectious agent refers to its ability to produce toxins that are harmful to the human body. The pri- mary effect of tetanus is due to the effects of the toxin produced by tetanus bacilli on the human nervous system. Resistance re- fers to the ability of an infectious agent to survive in adverse conditions, including exposure to antibiotics, but also includ- ing heating, drying, and so on. Antigenicity is the ability of the agent to trigger the formation of immune antibodies and is the basis for immunization practices.

Characteristics of noninfectious agents. Noninfectious agents share some of the characteristics of infectious agents. For ex- ample, the extent of exposure to an agent affects its ability to cause health problems. Ingesting moderate amounts of alcohol or aspirin does not cause problems, and may, in fact, be benefi- cial. Excessive consumption of either substance, however, can cause difficulties. The amount of stress, a psychological agent, to which one is exposed can also affect the development of stress-related health problems.

The concept of infectivity can also be applied to other types of agents, although the term was developed in relation to in- fectious agents. For example, asbestos, which can be inhaled, has a higher “infectivity” than an overdose of aspirin, which must be ingested. Stress, as an agent of health problems, also has a high infectivity because it is an everyday factor imping- ing on people. All of us are “infected” by stress.

Stress can also be viewed in terms of its ability to cause dis- ease. Although everyone experiences some degree of stress, not all people develop stress-related illnesses. Stress, therefore, has a relatively low pathogenicity. Noninfectious agents may vary in terms of their virulence as well. Stress may produce a mild stomach upset in some individuals and drive others to suicide. In the first instance, stress has a low virulence, and in the second, a high virulence.Many diseases are spread by respiratory transmission. (Xalanx/Fotolia)

Type of Agent Example Problems Physical Heat Burns, heat stroke

Trauma Fractures, concussion, sprains, contusions

Radiation Genetic changes

Chemical Medications Accidental poisoning, suicide

Chlorine Poisoning, asphyxiation (in gas form)

Poison ivy Rash and pruritus

Nutritive Vitamin C Scurvy (in absence of vitamin C)

Iron Anemia (in absence of iron)

Vitamin A Poisoning (in excess)

Infectious Measles virus Measles, measles encephalitis

HIV AIDS

Varicella virus Chickenpox

Influenza virus Influenza

Genetic Genetic predisposition to disease Sickle cell disease

Genetic abnormality Down syndrome, Turner’s syndrome

Psychological Stress Ulcerative colitis, heart disease, suicide, asthma, alcoholism, drug abuse, violence

TABLE 3-1 Agents and selected Health Problems to Which They Contribute

M03_MARY9591_06_SE_C03.indd 66 06/09/14 6:07 PM

chaPter 3 epidemiology and Population health nursing 67

ENvIrONMENT. The third element of the epidemiologic triad includes factors in the physical, biological, and socio- economic environments that contribute to health-related conditions (Friis & Sellers, 2014). The physical environment consists of such factors as weather, terrain, and buildings. A va- riety of physical environment factors can influence health. For example, air pollution contributes to respiratory disease as well as other physiologic and psychological effects in human beings. Similarly, elements of community design such as walking trails have been shown to affect exercise behavior and health status (Parra et al., 2010).

The biological environment, in the triad model, consists of all living organisms other than humans. Components of the biological environment include plants and animals as well as microorganisms, all of which can influence health.

The socioeconomic environment includes factors related to social interaction that may contribute to health or disease. For example, cultural factors, which are part of the social environ- ment, can influence health behaviors. In a similar fashion, social norms may influence health and illness. For example, societal views of alcoholism and drug abuse as character weaknesses have hampered efforts to control these problems. Growing so- cietal acceptance of marijuana use is another example of the effects of culture on health. Conversely, in a health conscious culture, behaviors such as smoking are considered unacceptable.

Factors in each of these three environments were ad- dressed in more detail in the discussion of the PHN model in Chapter 1 . Because of the triad model’s failure to address multiple causative factors completely, it has not been as useful for chronic diseases or other health problems (e.g., societal vio- lence) as it has for communicable diseases.

The Web of Causation Model The “web of causation” is a second model for exploring the influence of multiple factors on the development of a specific health condition. In this model, factors are explored in terms of their interplay, and both direct and indirect causes of the problem are identified. The web of causation approach allows the epidemiologist to map the interrelationships among factors contributing to the development (or prevention) of a particu- lar health condition. This approach also assists in determining areas where efforts at control will be most effective.

Some of the factors in a web of causation for the problem of adolescent tobacco use are depicted in Figure 3-5•. It is ob- vious from the complexity of Figure 3-5 that multiple factors contribute to adolescent tobacco use. The interplay of these fac- tors determines whether or not the problem occurs. The most direct causes are those linked directly to tobacco use—purchase of tobacco products and the decision to use them. Numerous other factors, however, contribute to the adolescent’s decision to engage in the use of tobacco. These include perceptions of tobacco use as grown-up or “cool,” peer pressure, and easy access to tobacco products. Perceptions of tobacco use are

influenced by media messages and adult role models as well as by peer perceptions. Easy access to tobacco products is in- fluenced by poor enforcement of laws regarding the sale of to- bacco products to minors, which is in turn influenced by public acceptance of tobacco use. Other contributing factors and their interrelationships are also depicted in Figure 3-5.

Determinants-of-Health Models Because of the complexity of causal associations in many health problems, the triad and web of causation models have largely been replaced by models that focus on a variety of determinants of health. As we saw in Chapter 1 , determinants of health are categories of factors that influence health and illness. Empha- sis on broad determinants of health and illness marks a change from individually focused explanations of disease to a focus on social and environmental contributions to health and illness. A focus on broad determinants of health acknowledges that in- dividual behaviors are shaped by interaction with the environ- ment and that contextual variables found in the environment probably interact in complex ways with individual variables to determine health and illness.

McKeown has been credited with coining the term deter- minants of health, which was incorporated into The Lalonde Report discussed in Chapter 2 . The Lalonde Report incorpo- rated the concept of four general determinants (human biol- ogy, health system, environment, and lifestyle) into the health field concept (The Social Determinants of Health, 2008).

Over the years, the number and categories of determinants have varied among models. For example, Evans and Stoddart (2003) developed the Producing Health, Consuming Health Care (PHCHC) model in 1990, which included determinant categories such as social environment, physical environment, genetic endowment, individual biological and behavioral re- sponse, health and function, disease, health care, well-being,

insect vectors in the biological environment are responsible for the spread of a variety of diseases. (Panupong/Fotolia)

M03_MARY9591_06_SE_C03.indd 67 06/09/14 6:07 PM

68 Unit 1 Population health nursing: an Overview

and prosperity. The Mandala model developed by Hancock and Perkins and embodied in the Ottawa Charter included only seven categories of determinants. The Population Health Promotion model included nine categories (Evans & Stod- dart, 2003) and other conceptualizations include as few as six categories. Some of the models focus primarily on social

determinants of health and illness, whereas others address biophysical, psychological, and environmental determinants as well.

Determinants-of-health models examine the interplay of factors at each level (individual, family and social network, community, and general societal conditions) and their con- tribution to the development of health-related problems. The broad array of factors contributing to a problem, as suggested by determinants-of-health models, underscores the fact that resolution of population health problems lies outside the realm of individual effort or medical science and involves action in multiple societal sectors. For example, addressing the issue of handicapping conditions involves not only providing the needed medical care for the condition, but may also require making changes in the built environment to promote access, as well as making changes in work environments to permit handi- capped individuals to make productive contributions to soci- ety. Figure 3-6• depicts a composite determinants-of-health model that reflects elements included in many of the models found in the literature.

Population health nurses use epidemiologic models to un- derstand the multiple influences on the health of the popula- tion. These models highlight the factors contributing to, or in some cases preventing, the occurrence of population health problems and suggest strategic points and interventions that may help in controlling them.

Behavioral determinants, such as smoking, are contributing factors in the development of many diseases. (Nickolae/Fotolia)

Poor understanding of health effects

Media images

Public acceptance

View of use as adult behavior

Adult role models

Poor enforcement

Easy access

Peer pressure

Testing of family values

Desire to conform

Tobacco purchase

Decision to use tobacco

Tobacco use

Figure 3-5 The Web of Causation for Adolescent Tobacco use, indicating the interplay Between Multiple Direct and indirect Causes

M03_MARY9591_06_SE_C03.indd 68 06/09/14 6:07 PM

chaPter 3 epidemiology and Population health nursing 69

Epidemiology is concerned with the development of an un- derstanding of factors that influence the health of population groups. Originally developed for use in examining communica- ble diseases, epidemiologic principles and processes can be used to study any health-related issue.

Population health nurses use epidemiologic strategies to as- sess the health of the population and identify factors affecting health status. Epidemiologic findings may also help to identify points at which intervention may help to prevent or minimize the consequences of population health problems.

CHAPTEr rECAP

As the population health nurse responsible for five census tracts in a small city, you are making a Monday home visit to a young mother with a newborn infant who lives in your area. In ask- ing about the health of other family members, you discover that the woman’s husband has been experiencing vomiting and diar- rhea for the last day and a half. She says her husband thinks it is

something “going around at work” because several people in his office called in sick yesterday and today with similar symptoms. She and the baby have been fine.

The company the client’s husband works for is outside of your census tracts, but he happens to mention that he went to the company picnic on Saturday. His wife didn’t go because the

Absences from WorkCAsE sTUdy

Figure 3-6 A Composite Determinants-of-Health Model

Human Behavioral Determinants Health-promoting behaviors

Risk behaviors

Environmental Determinants

Built environment Natural environment

Sustainability

Human Biological Determinants

Intrinsic characteristics Genetics

Physical health status Maturation/development

Functional status Nutritional status

Immunity

Social Determinants Social status

Politics/power Education

Culture Religion

Social support/capital Social stability

Health System Determinants Acceptability Accessibility Affordability

Appropriateness Competence Continuity

Effectiveness Ef�ciency

Safety Utilization

Economic Determinants Income

Employment Poverty/prosperity

Psychological Determinants

Stress Coping abilities Mental health/

illness

Population Health

M03_MARY9591_06_SE_C03.indd 69 06/09/14 6:07 PM

70 Unit 1 Population health nursing: an Overview

Absolute risk and relative risk. (2011). Retrieved from http://www.patient.co.uk /health/Risks-of-Disease-Absolute-and-Relative.htm

Cabaret, J., Morand, S., & Beaudeau, F. (2012). Introduction. In S. Morand, F. Beaudeau, & J. Cabaret (Eds.), New frontiers of molecular epidemiology in infectious diseases (pp. 1–8). New York: Springer.

Centers for Disease Control and Prevention. (2004). 150th anniversary of John Snow and the pump handle. Morbidity and Mortality Weekly Report, 53, 783.

Centers for Disease Control and Prevention. (2011). Principles of epidemiology in public health practice (3rd ed.). Retrieved from http://www.cdc.gov/osels /scientific_edu/SS1978/index.html

Epidemiology. (n.d.). Retrieved from http://www.answers.com/topic /epidemiology

Epidemiology—Definition. (n.d.). Retrieved from http://www.wordiq.com /definition/Epidemiology

Evans, R. G., & Stoddart, G. L. (2003). Consuming research, producing policy? American Journal of Public Health, 93, 371–379.

Friis, R. H., & Sellers, T. A. (2014). Epidemiology for public health practice (5th ed.). Sudbury, MA: Jones & Bartlett.

Gordis, L. (2014). Epidemiology: With student consult online access. Philadelphia, PA: Saunders Elsevier.

Infectivity. (2014). Retrieved from http://medical-dictionary.thefreedictionary. com/infectivity

John Snow. (n.d.). Retrieved from http://www.ph.ucla.edu/epi/snow.html Krieger, N. (2011). Ecosocial theory of disease distribution: Embodying societal

and ecologic context. In N. Krieger (Ed.), Epidemiology and people’s health: Theory and content (pp. 202–235). Oxford, UK: Oxford University Press.

Ludwig, J. (2000, June 13). UCLA epidemiologist creates a web site about a pioneer in the field. Chronicle of Higher Education. Retrieved from http://www .ph.ucla.edu/epi/snow/chronicle_article.html

Michigan Center for Public Health Preparedness. (2010). Cross sectional study /prevalence study. Retrieved from http://practice.sph.umich.edu/micphp /epicentral/cross_sectional.php

National Cancer Institute. (n.d.). NCI dictionary of cancer terms. Retrieved from http://www.cancer.gov/dictionary?cdrid=44301

Parra, D. C., McKenzie, T. L., Ribeiro, I. C., Hino, A. A. F., Dreisinger, M., Coniglio, K., ..., Simoes, E. J. (2010). Assessing physical activity in public parks in Brazil using systematic observation. American Journal of Public Health, 100, 1420–1426. doi:10-2105/AJPH.2009.181230

Relative r i sk . (2014) . Retr ieved f rom http://medical-dict ionar y .thefreedictionary.com/Risk+ratio

Robinson, B. (2009). Victorian medicine—From fluke to theory. Retrieved from http://www.bbc.co.uk/history/british/victorians/victorian_medicine_01 .shtml

Smallpox of poxviruses infection. (n.d.). Retrieved from http://virology-online .com/viruses/Poxviruses2.htm

Snow, J. (1855). On the mode of communication of cholera. London: John Churchill. Retrieved from http://www.ph.ucla.edu/epi/snow/snowbook .html

The puzzle was a maddening one. (2002, Fall). The Handle: The Magazine of the University of Alabama School of Public Health, pp. 4–5.

The social determinants of health. (2008). Health Affairs, 27, 320. doi:10.1377/ hlthaff.27.2.320

rEFErENCEs

baby was too young and she was feeling pretty tired after being up for several night-time feedings. When you talk to the hus- band, you discover that several of the other people who called in sick also attended the picnic, but he is not sure about the oth- ers as this is a large company with about 200 employees and he doesn’t know exactly who attended the picnic and who did not. 1. What is your first step in determining whether or not an epi-

demiologic investigation is warranted?

2. How would you go about initiating such an investigation in the jurisdiction where you are doing your population health nursing clinical rotation?

3. What is the usual role of population health nurses in epide- miologic investigations in that jurisdiction?

M03_MARY9591_06_SE_C03.indd 70 06/09/14 6:07 PM

2 unit

Influences on Population Health

2 unit

C h

a p

te rs 4 — Environmental Influences on Population Health

5 — Cultural Influences on Population Health

6 — Economic Influences on Population Health

7 — Health System Influences on Population Health

8 — Global Influences on Population Health

M04_MARY9591_06_SE_C04.indd 71 06/09/14 6:08 PM

chaPter

Environmental Influences on Population Health4

Key Terms

built environment

ecological footprint

environmental health

hazardous waste

mixed-use development

natural environment

smart growth

sustainable development

urban sprawl

zoonoses

Learning Outcomes

After reading this chapter, you should be able to:

1. Analyze the interrelationships among environmental factors, human behavior, and human health.

2. Discuss elements of the natural, built, and social environments that affect population health.

3. Analyze the role of the population health nurse with respect to environmental health issues at the individual/family and population levels.

4. Analyze the role of the population health nurse in prevention measures for environmental issues that affect population health.

5. Identify measures to resolve environmental health problems in individuals and populations and the role of the population health nurse in their implementation.

6. Discuss health restoration measures related to environmental health problems in individuals and populations and the role of the population health nurse related to each.

M04_MARY9591_06_SE_C04.indd 72 06/09/14 6:08 PM

73

Game Day Challenge

In 2010, 77 colleges and universities participated in the Environmental Protection Agency’s “Game Day Challenge” to reduce the amount of waste generated during football games. Schools competed in recycling, composting, reusing, or donating waste generated during one home football game. As a result of the competition, more than 500,000 pounds of materi- als were diverted from landfills, contributing greatly to environmental sustainability (Schools divert trash, 2011).A

d vo

ca cy

N ow

Walt Whitman

As we saw in Chapter 2 , Walt Whitman, in addition to being a renowned writer, was a nurse dur- ing the American Civil War. What is even less well known is his advocacy of public health issues, such as personal hygiene and clean water. Whitman used his position as editor of the Brooklyn Daily Eagle to advocate for health promotion and conditions to promote health. In one essay, Whitman spoke of the “great sanitative power of the bath, as a general aid to health among the laboring classes” (quoted in Rezick & Fee, 2011, p. 1051) and recommended “immersion in water as often as once every other day” (p. 1050). In another essay, he expounded on the need for clean water and noted that “rum and bad milk [other public health issues of the day] are not as nasty as city pump- water, which is the most stinking and villainous liquid known upon land or sea” (p. 1052). He pointed out the potential for contamination of water through filtration of sewage and decomposing matter into the water system. In his paper, he actively supported the development of the Brooklyn waterworks and later described its completion as “a feather in my wings” (p. 1053).

A d

vo ca

cy T

h en

Concerns for environmental effects on human health were documented nearly 2,500 years ago when Hippocrates wrote his famous treatise, On Airs, Waters, and Places. Although Hippocrates and his contemporaries mistakenly believed illness resulted from miasmas, or unhealthy vapors, in specific locales, their conception of environmental effects on health was correct. Nursing, as a profession, has also had an abiding concern for the effects of environment on health. Florence Nightingale’s campaign for cleanliness in the surroundings of wounded British soldiers in the Crimean War is a legendary example of this concern. What are less well known are her support for re- forestation (McDonald, 2004) and a paper she presented in 1887 to the International Congress of Hygiene and Demography castigating the British government for the unsanitary condi- tions found in India. This last activity is particularly interest- ing since Miss Nightingale did not believe that diseases such as cholera, often seen in India, were contagious and perceived quarantine measures as “evil” (Watts, 2003).

Other early population health nurses were equally con- cerned about the contribution of the environment to human

disease. Lillian Wald and her compatriots were concerned about both physical and social environmental effects on health, and much of their work was directed toward chang- ing social conditions that contributed to disease and illness. Population health nurses remain concerned with the effects of environmental factors on health and regularly engage in interventions related to environmental concerns that affect individuals, families, and population groups. To engage in ef- fective action at all levels, population health nurses must have an understanding of environmental influences on health.

Environment and Health According to the World Health Organization (2011), environ- mental health involves action that

addresses all the physical, chemical, and biological factors external to a person, and all the related factors impacting be- haviors. It encompasses the assessment and control of those environmental factors that can potentially affect health. It is targeted towards preventing disease and creating health- supportive environments. (para. 1)

M04_MARY9591_06_SE_C04.indd 73 06/09/14 6:08 PM

74 unit 2 influences on Population health

According to WHO data, approximately 24% of the global burden of disease and 23% of mortality worldwide are related to environmental conditions (Prüss-Üstün & Corvalán, 2006). In recent years, greater attention has been given to the health risks posed by environmental conditions. This attention is evident in the number of national health objectives that focus on environmental health issues.

The Healthy People 2020 objectives for environmen- tal health encompass 24 objectives, several of which have a number of subobjectives. The objectives address six major environmental themes, including outdoor air quality, surface and groundwater quality, toxic substances and hazardous wastes, homes and communities, infrastructure and surveil- lance for environmental hazards, and global environmental health. The objectives are presented on pages 75–77, and progress on their achievement can be tracked on the Healthy People website.

Many environmental forces influence human health. Micro- organisms such as bacteria, viruses, and fungi cause commu- nicable diseases, and animals contribute to the spread of these diseases. Plants may contribute to accidental poisoning or to

allergic reactions. Industry, vehicles, and buildings add to air and water pollution and excess noise. Climate and terrain con- tribute to natural disasters, which are discussed in Chapter 25 . In addition, climate and terrain may promote air and water pollution, which have long-term effects on health. Community design and the incorporation of walking and biking areas influ- ence opportunities for healthy physical activity, and the quality of interpersonal interactions within the population influence people’s willingness to take advantage of these opportunities. All of these facets of the environment give rise to environmen- tal hazards that affect human health. Some of the environmen- tal components that produce health hazards are presented in Figure 4-1•.

Human health requires a viable environment that incor- porates the local ecosystem, including the air, water, and soil, and the availability of safe and adequate food. In addition, a viable environment requires sustainable development, which has been defined as economic development that complies with “maintaining the function and integrity of the ecosystems that support human societies and the things that they value” (Michael & Beaglehole, 2009, p. 4).

Figure 4-1 Selected environmental Components influencing Health

SOCIAL ENVIRONMENT

NATURAL ENVIRONMENT

BUILT ENVIRONMENT

Social interaction

Traf�c

Plants Climate

Terrain

Animals

Microorganisms

Buildings

Social participation

Human health and behavior

Industry

M04_MARY9591_06_SE_C04.indd 74 06/09/14 6:08 PM

chaPter 4 environmental influences on Population health 75

ObjeCtive

baSeline (year)

target

Current data (year)

data SOurCe

EH-1: Reduce the number of days the Air Quality Index (AQI) exceeds 100

11 (2008)

10 NDA Air Quality System, EPA

EH-2: Increase the use of alternative modes of transportation for work • Bicycling • Walking • Transit • Telecommute

(2008) 0.5% 2.8% 5% 4.1%

0.6% 3.1% 5.5% 5.3%

NDA NDA NDA NDA

American Community Sur- vey, U.S. Bureau of the Census

EH-3: Reduce air toxic emissions to decrease the risk of adverse effects caused by airborne toxics • Mobile sources • Area sources • Major sources

(2005) 1.8 mil tons 1.3 mil tons 0.8 mil tons

1 mil tons 1.7 mil tons 0.7 mil tons

NDA NDA NDA

National Emissions Inven- tory (NEI), EPA, Office of Air and Radiation (OAR), Office of Air Quality Planning and Standards (OAQPS)

EH-4: Increase the proportion of persons served by community water systems who receive a supply of drinking water that meets the regulations of the Safe Drinking Water Act

(2008) 92%

91%

NDA

Potable Water Surveillance System, Safe Drinking Water Information System, EPA, OW, OGWDW

EH-5: Reduce waterborne disease outbreaks arising from water intended for drinking among persons served by community water systems

7 per year (1999–2008)

2 per year NDA Waterborne Disease Out- break Surveillance System (WBDOSS) Morbidity and Mortality Weekly Report, CDC, NCID, State Health Departments

EH-6: Reduce per capita domestic water withdrawals with respect to use and conservation

99 gallons (2005)

89.1 gallons NDA U.S. Department of the Interior, U.S. Geological Survey, USGS National Water-use Information Program

EH-7: Increase the number of days that beaches are open and safe for swimming

95% of beach days (2008)

96% of beach days NDA BEACH program, EPA, Office of Water

EH-8: Reduce blood lead levels in children • Elevated blood lead levels • Mean blood lead levels

(2005–2008) 0.9% 1.5 µg/dL

0% 1.4 µg/dL

NDA NDA

National Health and Nutri- tion Examination Survey (NHANES), CDC, NCHS

EH-9: Minimize the risks to human health and the environment posed by hazardous sites

(2010) 1, 279 sites

1,151 sites

NDA

Comprehensive Environ- mental Response and Cleanup Liability Informa- tion System (CERCLIS), EPA, OSWER, OSRTI

EH-10: Reduce pesticide exposures that result in visits to a health care facility

15,965 (2008)

10,377 NDA Nation Poison Data System, American Association of Poison Control Centers

Healthy People 2020

Objectives for Environmental Health

Continued on next page

M04_MARY9591_06_SE_C04.indd 75 06/09/14 6:08 PM

76 unit 2 influences on Population health

ObjeCtive

baSeline (year)

target

Current data (year)

data SOurCe

EH-11: Reduce the amount of toxic pol- lutants released into the environment

3.9 billion pounds (2008)

3.5 billion pounds NDA U.S. National toxics Re- lease Inventory (TRI), EPA

EH-12: Increase recycling of municipal solid waste

33.2% (2008)

36.5% NDA Characterization of Munici- pal Solid Waste, EPA, OSW

EH-13: Reduce indoor allergen levels • Cockroach • Mouse

0.51 units/g settled dust 0.16 mcg/g (2006)

0.46 units/g 0.14 mcg/g

NDA

American Healthy Homes Survey, HUD

EH-14: Increase the number of homes with operating radon mitigation system for persons in homes at risk for radon exposure

10.2% (2007)

30% NDA EPA report by Radon Vent Fan Manufacturers, EPA, Indoor Environments Division

EH-15: Increase the percentage of new single-family homes constructed with radon-reducing features, especially in high-radon-potential areas

28.6% (2007)

100% NDA Annual Builder and Con- sumer Practices Surveys, National Association of Home Builders Research Center, reported to EPA, In- door Environments Division

EH-16: Increase the proportion of the nation’s elementary, middle, and high school students that have official school policies and engage in practices that promote a healthy and safe physical school environment • Indoor air quality management program • Plan for addressing mold problems • Plan for hazardous materials • Reduction of pesticide exposures • Drinking water inspection for

• Lead • Bacteria • Coliforms

(2006) 51.4% 67% 85.9% 57.9%

55.7% 58.8% 55.2%

56.5% 74% 94.5% 63.7%

61.3% 64.7% 60.7%

NDA NDA NDA NDA

NDA NDA NDA

School Health Policies and Programs Study, CDC

EH-17: Increase the proportion of per- sons living in pre-1978 housing that has been tested for the presence of lead- based paint or related hazards

Developmental Developmental NDA Potential data source: National Health Interview Survey

EH-18: Reduce the number of U.S. homes that are found to have lead-based paint or related hazards • Lead-based paint • Paint-lead hazards • Dust-lead hazards • Soil-lead hazards

(2005–2006) 37 mil homes 15.3 mil homes 13.7 mil homes 3.8 mil homes

3.7 mil fewer homes 1.5 mil fewer homes 1.4 mil fewer homes 380,000 fewer homes

NDA NDA NDA NDA

American Healthy Homes Survey, HUD, Office of Health Homes and Lead Hazard Control

EH-19: Reduce the proportion of oc- cupied housing units with moderate or severe physical problems

5.2% of units (2007)

4.2% of units NDA American Housing Survey, U.S. Department of Com- merce, Bureau of the Census

Healthy People 2020 (continued)

M04_MARY9591_06_SE_C04.indd 76 06/09/14 6:08 PM

chaPter 4 environmental influences on Population health 77

ObjeCtive

baSeline (year)

target

Current data (year)

data SOurCe

EH-20: Reduce exposure to selected environmental chemicals in the popula- tion as measured by blood and urine concentrations • Arsenic • Cadmium • Lead • Mercury (children 1–5 years) • Mercury (women 16–49 years)

• Chlordane • DDT • Beta-hexachlorocyclohexane • Paranitrophenol • 3,4,6-Trichloro-2-pyridinol

• 3-Phenobenzoic acid

• PCB 153

• PCB 126 • 1,2,3,6,7,8-Hexachlorodibenzo-

p-dioxin • Bisphenol A • Perchlorate • Mono-n-butyl phthalate • BDE 47

(2003–2004 unless otherwise indicated) 50.4 µg/g of creatinine 1.6 µg/L 4.2 µg/dL 1.8 µg/L 4.6 µg/L (2001–2002) 37.7 ng/g of lipid 1,860 ng/g of lipid 56.5 ng/g of lipid 2.89 µg/g of creatinine 9.22 µg/g of creatinine (2001–2002) 3.1 µg/g of creatinine (2001–2002) 97.1 ng/g of lipid (2001–2002) 68.7 ng/g of lipid 68.5 ng/g of lipid

11.2 µg/g of creatinine 12.0 µg/g of creatinine 91.6 µg/g of creatinine 163 ng/g of lipid

35.28 µg/g of creatinine 1.12 µg/L 2.94 µg/L 1.26 µg/L 3.22 µg/L 26.39 ng/g of lipid 1,302 ng/g of lipid 39.55 ng/g of lipid 2.02 µg/g of creatinine 6.45 µg/g of creatinine 2.32 µg/g of creatinine 67.97 ng/g of lipid 48.09 µg/g of creatinine 47.95 ng/g of lipid

7.84 µg/g of creatinine 8.4 µg/g of creatinine 64.12 µg/g of creatinine 114.1 ng/g of lipid

NDA NDA NDA NDA NDA NDA NDA NDA NDA NDA NDA NDA NDA NDA

NDA NDA NDA NDA

National Report on Human Exposure to Environmental Chemicals, CDC, NCEH, NHANES, CDC, NCHS

EH-21: Improve quality, awareness, and use of existing information systems for environmental health

16 states 51 states and the Dis- trict of Columbia

NDA National Environmental Health Tracking Network, CDC, NCEH

EH-22: Increase the number of states, ter- ritories, tribes, and the District of Columbia that monitor diseases or conditions caused by exposure to environmental hazards • Lead poisoning • Pesticide poisoning • Mercury poisoning • Arsenic poisoning • Cadmium poisoning • Acute chemical poisoning • Carbon monoxide poisoning

29 states, DC 28 states 24 states 22 states 21 states 17 states 20 states

Total coverage in 56 states, territories, and District of Columbia for all subobjectives

NDA Council of State and Ter- ritorial Epidemiologists, State Reportable Condi- tions Data Inventory

EH-23: Reduce the number of new schools sited within 500 feet of an in- terstate or Federal or State highway

18.9% 18.9% or less NDA GRASP/ATSDR geocoded data from Homeland Secu- rity Information Program

EH-24: Reduce the global burden of disease due to poor water quality, sani- tation, and insufficient hygiene

2.2 mil deaths 2 mil deaths NDA Global Burden of Disease Project, WHO

NDA: No data available on objective status from Healthy People 2020 site.

Based on: U.S. Department of Health and Human Services. (2014). Environmental health. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/over- view.aspx?topicId=12

Healthy People 2020 (continued)

M04_MARY9591_06_SE_C04.indd 77 06/09/14 6:08 PM

78 unit 2 influences on Population health

Components of the Human Environment The environmental context that influences human health incor- porates a number of components. These include the natural and constructed, or built, environments, as well as the social and psychological environments. In this chapter, we will deal with aspects of the natural, built, and social environments. Other ele- ments of the social environment and the psychological environ- ment are addressed in other chapters throughout this book.

The Natural Environment The natural environment consists of those features of the environment that exist in a natural state, unmodified in any significant way by human beings. Elements of the natural environment include plants, animals, and biological agents; weather and climate, terrain (e.g., mountains, rivers, oceans), and natural resources (air, wood, water, fuel). Some of the con- cerns related to the natural environment include air and water pollution, global climate change and its consequences, radia- tion and temperature extremes, biological hazards, and the depletion of natural resources. As we will see, many of these concerns are interrelated and are connected to the features of the social and built environments.

PLANTs, ANImALs, AND BIOLOGICAL AGENTs. A variety of living organisms found in the environment affect human health. These include plants, animals, and a myriad of biological agents such as bacteria, viruses, and so on. Some of these living organisms are beneficial to human beings and others contribute to a variety of health problems. For example, plants serve as food sources for humans as well as for animals that, in turn, provide food for people. On the other hand, many plants are poisonous if ingested or cause different types of allergies through pollens (e.g., hay fever-type allergies) or toxins (e.g., poison oak or poison ivy).

Animals also have both beneficial and negative effects on hu- man health. We have already noted animals as a food source for omnivorous human beings. Animals, particularly as pets, serve as a source of companionship and promote psychological health for many people. Similarly, many animals help control other nuisance organisms. For example, birds and fish eat a variety of insects that may cause human disease or destroy food crops.

Animals are also a source of exposure to a variety of patho- gens. Both wild and domestic animals may contribute to hu- man illness. Zoonoses, or diseases transmitted from animals to people, are occurring with greater frequency than in the past because of greater potential for human–animal interaction. The U.S. Agency for International Development (USAID) has de- veloped a tracking system for animal-to-human disease trans- mission throughout the world. This PREDICT system permits identification of animal-to-human disease outbreaks that pro- mote early intervention and prevent further spread of disease (USAID, 2011). For further information about the system, see the External Resources section of the student resources site.

As a result of growth of human populations and encroach- ment on the habitats of wild animals, there is greater potential

for interaction between humans and wild animals (UC Davis Veterinary Medicine, n.d.). This interaction can lead to disease transmission and injury. For example, a variety of diseases, such as Lyme disease, human granulocytic anaplasmosis, and babesiosis, are transmitted by ticks found on wild animals (Joseph et al., 2011). Ticks may also be transferred to domestic animals and then infect people.

Humans encounter animals in several other settings in ad- dition to their wild habitats. The National Association of State Public Health Veterinarians (2011) has noted that many venues promote human–animal interactions including, zoos, petting zoos, pet stores, circuses, farms, state fairs, and in educational settings. Each of these settings promotes interaction and may result in health problems such as enteric diseases, injuries, ra- bies exposure, and other bacterial, viral, fungal, and parasitic infections. For example, tuberculosis has been transmitted from elephants to human handlers in a Tennessee elephant refuge. In addition, the disease was transmitted to several nonhandlers in nearby offices due to aerosolized bacteria that entered the fa- cility’s ventilation system when barns were pressure washed or swept (Murphree, Warkentin, Dunn, Schaffner, & Jones, 2011).

The National Association of State Public Health Veterinari- ans (2011) has developed a set of guidelines for settings in which human–animal interactions occur to limit the transmission of diseases from animals to humans. Use of these guidelines is particularly important in the protection of young children, pregnant women, and persons who are immunocompromised.

Pets also serve as a source of disease for humans. An esti- mated 60% of U.S. households have pets, including approxi- mately 60 million dogs and 75 million cats. As much as 33%

increased interaction between wild animals and human beings increases the potential for transmission of diseases such as plague. (© 46boris48/Fotolia)

M04_MARY9591_06_SE_C04.indd 78 06/09/14 6:08 PM

chaPter 4 environmental influences on Population health 79

of dogs and 60% of cats sleep in or on their owners’ bed in- creasing the potential for disease transmission. In addition, kissing or being licked by a pet may transmit disease. Examples of diseases transmitted by pets include plague (from fleas), cha- gas disease, cat-scratch disease, pasteurella infection, staphylo- coccus (including methicillin-resistant infection), rabies, and parasitic infections. Bites are also a source of potential injury particularly when overly possessive dogs are kept in their own- ers’ bedrooms (Chomel & Sun, 2011).

More and more people are also keeping more exotic pets, which increases the potential for more unusual disease occur- rences. For example, pet African dwarf frogs have been associated with cases of salmonella infection (National Center for Emerging and Zoonotic Infections, 2011). Similarly, pet kinkajous pose a risk of human infestation with raccoon roundworms, which may result in serious neurological disease (Division of Parasitic Dis- eases and Malaria, 2011). Foreign travel may also increase the risk of exposure to zoonotic diseases. For example, nearly a fourth of U.S.-reported cases of rabies were acquired outside of the coun- try, and travelers visiting areas where zoonoses are common should use precautions in interacting with animals (National Center for Emerging and Zoonotic Infections, 2010).

In addition to being spread by animals, biological agents of disease are transmitted from human to human through social interaction as a part of the social environment, which will be discussed later in this chapter. Biological agents are also trans- mitted by food and water. Waterborne illnesses will be discussed in more detail in the section on water pollution. Although foodborne disease incidence reached the Healthy People 2010 target for reduction to less than 1 case per 100,000 population (Division of Foodborne, Waterborne, and Environmental Dis- eases, 2011b), the Centers for Disease Control and Prevention (CDC, 2011a) estimates that 48 million people are affected by foodborne illness in the United States each year. Of these people, 128,000 are hospitalized and 3,000 die. Many of these illnesses result from 31 pathogens known to cause foodborne illnesses, many of which are tracked by public health surveillance systems. Eight pathogens account for an estimated 91% of foodborne ill- nesses. Noroviruses, for example, cause approximately 58% of the foodborne disease cases in the United States, and nontyphoi- dal Salmonella infections cause an estimated 28% of the related deaths. Other offending agents include Clostridium perfringens, Campylobacter, Staphylococcus aureus, Toxoplasma gondii, E. coli, and Listeria monocytogenes (CDC, 2011a).

Foodborne disease outbreaks occur as a result of contamina- tion of food with pathogens and other disease-causing agents (e.g., mercury in fish). Contamination may occur when food is being produced, during processing, or prior to consumption. For example, contamination of oysters and other shellfish oc- curs when shellfish grow in contaminated waters. Similarly, use of human waste as fertilizer or irrigation with untreated waste water for foods crops imported from Mexico and other coun- tries contaminates fresh foods such as strawberries, tomatoes, sprouts, and other fruits and vegetables. Contamination may also occur during food processing or as a result of failure to properly refrigerate foods. For example, cases of botulism have

been associated with commercially produced potato soups that were improperly refrigerated (Division of Foodborne, Water- borne, and Environmental Diseases, 2011a). Finally, contami- nation may occur during preparation in the home, as when fresh foods are prepared on a cutting board that has been used in the preparation of contaminated meats, such as chicken.

WEATHEr AND CLImATE. As we will see in Chapter 25 , the natural environment contributes to a variety of human health hazards in the form of disasters related to high winds, precipitation, earthquakes, and so on. Weather and climate also have positive effects on human health. For example, a moderate level of precipitation (both rain and snow) is required for crop growth and adequate water supplies for human consumption.

Weather has multiple effects on human health. For example, in 2010, weather-related events resulted in 490 deaths, 2,369 in- juries, and nearly $9.9 million in damages (National Weather Service [NWS], 2011c). More than a quarter (28%) of weather- related deaths were due to exposure to excessive heat, and the number of deaths was three times higher than in 2009 (NWS, 2011b, 2011d). From 2000 to 2010, an average of 115 heat- related deaths occurred each year in the United States (NWS, 2011d). Conversely, hypothermia, primarily due to cold weather, accounted for an average of 25 deaths per year during the same period (NWS, 2011a). About half of both cold- and heat-related deaths occurred among elderly persons (NWS, 2011a, 2011b). In addition, poor weather conditions contribute to a significant portion of motor vehicle accidents. Other health-related effects of weather events are summarized in Table 4-1•.

Although there have always been deaths due to hypo- and hyperthermia and motor vehicle accidents caused by weather conditions, the potential for illness and injury due to temperature extremes and adverse weather conditions has increased recently as a result of global climate changes. Population health nurses can educate individuals, families, and communities to prevent weather-related mortality. For example, education tips for pre- venting heat-related deaths are provided on page 80. Guidelines for governmental response to heat waves have also been devel- oped by the WHO European Region (Mathies, Bickler, Marin, & Hales, 2008). For further information about the guidelines, see the External Resources section of the student resources site.

Global climate change has been described as the “biggest global health threat of the 21st century” (Bell, 2011, p. 804). Climate change is a natural phenomenon, but is occurring much more rapidly than it normally would due to human ac- tivities. Mean global temperatures increased by 0.6° to 0.9° Cel- sius from 1906 to 2005, and the rate of temperature increase has more than doubled in the last half century (National Aero- nautics and Space Administration, Earth Observatory, n.d.). A team of U.S. and WHO scientists has estimated that more than 150,000 excess deaths and 5 million illnesses occur yearly due to climate change (West, 2014).

Climate change has both direct and indirect health effects. Direct effects relate primarily to severe weather events dis- cussed above and their impact on human health. Indirect ef- fects arise out of changes in plant allergens and their effect on

M04_MARY9591_06_SE_C04.indd 79 06/09/14 6:08 PM

80 unit 2 influences on Population health

asthma prevalence and severity, increases in insect populations and consequent insect-borne diseases, mental health issues, and increasing health disparities between segments of popula- tions. A number of disease vectors, such as mosquitos, sandflies, ticks, tsetse flies, and black flies, have become more numerous or moved to other areas as a result of climate change (West, 2014). Many diseases have also been found to be climate sensitive (Bell, 2011), and climate change is contributing to the emergence of new diseases and reemergence of several tropical diseases (Yu- mul, Cruz, Servando, & Dimalanta, 2011). Indirect effects may also include social disruption related to population dislocation and civil conflict over scarce food and water resources created by climate changes.

Global efforts have been initiated to address the reduction in CO2 emissions, one of the most significant of greenhouse gases contributing to global warming, within the context of the Kyoto Protocol, which went into effect in February 2005. The Kyoto Protocol amends the United Nations Framework Convention on Climate Change to control emissions of CO2 and five other greenhouse gases. Unfortunately, the protocol remains unsupported by the United States, which contrib- utes a significant proportion of the world’s CO2 emissions. In December 2009, the U.S. Environmental Protection Agency (EPA) promulgated an administrative report that included both “endangerment” and “cause” findings. The endanger- ment findings noted that current and projected concentrations of six greenhouse gases, including CO2, threaten the public health and the welfare of current and future generations. The cause findings specifically implicated motor vehicle engines as contributing to greenhouse gas pollution leading to public endangerment (EPA, 2011e). In spite of these findings, how- ever, the greenhouse gas emission regulations implemented by the EPA in January 2011 are being challenged by entities such as the American Petroleum Institute and other producers (Isakower, 2011). Several challenges to the endangerment finding have been made in Congress and in the court system. Unfortunately, the 1996 Congressional Review Act allows

TABLE 4-1 Health Effects and Populations Affected by selected Weather Events

Weather Event Health Effects Populations most Affected Heat waves Heat stress Extremes of age, athletes, people with

respiratory disease Extreme weather events (rain, hurricane, tornado, flooding)

Injuries, drowning Coastal, low-lying land dwellers, low SES

Drought, floods, increased mean temperature Vector-, food-, and waterborne diseases Multiple populations at risk Sea level rise Injuries, drowning, water and soil salinization,

ecosystem and economic disruption Coastal areas, low SES

Drought, ecosystem migration Food and water shortages, malnutrition Low ES, elderly, children Extreme weather events, drought Mass population movement, international

conflict General population

Increases in ground-level ozone, airborne allergens, and other pollutants

Respiratory disease exacerbations (COPD, asthma, allergic rhinitis, bronchitis)

Elderly, children, those with respiratory disease

Climate change generally, extreme events Mental health Young, displaced, agricultural sector, low SES

Data from: Centers for Disease Control and Prevention. (2009). CDC policy on climate change and public health. Retrieved from http://www.cdc.gov/climatechange/ pubs/Climate_Change_Policy.pdf

congress to veto agency regulations (OMB Watch, 2010). For this reason, it is important for population health nurses to stay abreast of environmental legislation and motivate the public to speak out against actions that imperil the environment.

CLIENT EDuCATION

During heat waves:

• Check on infants, young children, elderly, disabled, mentally ill, or homebound persons frequently.

• Evaluate persons at risk for heat-related death frequently for heat-related hazards and illnesses, and take appropriate preventive action.

• Never leave anyone unattended in a closed vehicle. • Drink plenty of fluids. Refrain from alcohol consumption. • Stay indoors or seek air-conditioned environments. • Take cool showers or baths. • Wear lightweight, light-colored, loose-fitting clothing.

If exposure to heat cannot be avoided:

• Reduce, eliminate, or reschedule strenuous activities. • Limit activity to morning and evening hours. • Reduce exercise or replace fluids and electrolytes during

exercise. • Drink water or nonalcoholic fluids frequently. • Wear a wide-brimmed hat and sunglasses and use broad

spectrum (UVA/UVB protection) sunscreen of SPF 15 or higher.

• Avoid direct sunlight and rest in shady areas.

Data from: Centers for Disease Control and Prevention. (n.d.). Tips for preventing heat-related illness. Retrieved from http://www.bt.cdc.gov/disasters/ extremeheat/heattips.asp

Preventing Heat-related Deaths

M04_MARY9591_06_SE_C04.indd 80 06/09/14 6:08 PM

chaPter 4 environmental influences on Population health 81

POLLuTION. Pollution is another area of environmental concern that has significant health effects for populations. Con- siderations to be addressed in this chapter include water and air pollution, and radiation.

Water pollution. The safety and adequacy of the world’s water supply is of serious concern. Approximately 97.5% of the world’s water is either salt water or is contaminated. Seventy percent of what remains is frozen in the polar ice caps, which leaves only approximately 0.01% of the earth’s water for human consumption. The World Bank estimates that 100 to 200 gallons of water are needed per person per day to meet basic personal needs, excluding water needs for agricultural and industry, yet about 1 billion people lack access to safe water throughout the world. It is anticipated that this number will increase as populations grow (Levy & Sidel, 2011).

As water shortages become more acute, it is likely that waste water will be used increasingly to irrigate food crops. Although waste water has been used for irrigation for more than 3,000 years in China and for centuries in Vietnam, its use poses the risk of disease transmission through contamination of food crops with bacteria-laden water. Because of increasing interde- pendence among nations for food products and greater move- ment of produce worldwide, the potential for global spread of disease is vastly enhanced compared to preglobalization eras, and there is a need for both local and international regulation of water safety and food production.

In the United States, threats to the safety of water supplies arise from an aging water infrastructure, chemical and pathogenic con- tamination, the impact of climate change on water availability, and the development of new ways to obtain and use water (CDC, 2011b). Some of the health effects of water pollution include diar- rheal diseases, malaria, trachomatis infection, intestinal helminths, Japanese encephalitis, heavy metal poisoning, and hepatitis A. The most current U.S. Geological Survey (USGS) data on water sources in the United States indicate that about 80% of water is de- rived from surface water and only 20% from ground water sources (USGS, 2014). Both water sources can become contaminated, with some contamination resulting naturally, and significant pollution arising from pollutants derived from land use, such as use of fertil- izers, agricultural runoff, and industrial pollutants.

Groundwater resources are covered by drinking water regu- lations promulgated by the EPA. Well water, on the other hand, is not covered. The EPA has developed both primary and sec- ondary drinking water regulations. Primary drinking water regulations are legally enforceable standards for public water systems that specify acceptable limits of seven categories of con- taminants. These categories include seven microorganisms (in- cluding turbidity or the amount of suspended solids in water), four disinfection by-products, three disinfectants, 16 inorganic chemicals, 53 organic chemicals, and four radionuclides. Sec- ondary drinking water regulations are unenforceable guidelines for water contaminants that cause cosmetic effects (e.g., discol- oration of teeth and skin), aesthetic effects (e.g., odor, color, or taste), corrosivity, and so on (EPA, 2011d).

There is some fear that diminishing water availability will result in increasing conflict throughout the world. For example,

there have been predictions of conflict between India and Paki- stan over use of the waters of the Indus River (Pappas, 2011). Similarly, conflicts, although not armed, occur among states drawing water from the Colorado River for irrigation as well as for human consumption. In addition, there is a need to assist jurisdictions with water management strategies that conserve water and prevent flooding as climate change occurs.

Several public health roles have been identified for protection of water supplies throughout the world, and population health

Global Perspectives

According to the World Health Organization (WHO) and UNICEF (2014) , 11% or 748 million of the world’s people continued to lack access to improved drinking water sources and 2.5 billion people were without improved sanitation facilities in 2012. An estimated 173 million people rely on untreated surface water sources open to myriad contaminants. Improved drinking water sources are those that protect water supplies against outside contamination, particular fecal contamination. Improved sanita- tion facilities are those that prevent contact with human excreta.

Globally, the Millenium Development Goal (MDG) of halve the proportion of the world’s population without access to improved drinking water sources was met in 2010; however, specific areas have failed to do so and are not on track to meet the goal by the 2015 target. Lack of safe drinking water and sanitation, for ex- ample, are more common in rural areas where residents encom- pass 90% of those without improved water sources or improved sanitary facilities. Similarly, in sub-Saharan Africa, 40% of people are without access to improved drinking water sources and sanitary facilities and this number is increase due to population growth. Open defecation, defined as defecation in open space areas, such as fields, forests, bushes or open bodies of water, continues to be practiced by 1 billion people or 17% of the world’s population who have no access to sanitary facilities of any kind. Open defecation is most common in India where more than 597 million people en- gage in this practice. Open defecation, is actually increasing in sub-Saharan Africa, again, due to a sanitation infrastructure that has not kept up with population growth (WHO & UNICEF, 2014).

Lack of access to safe water supplies and sanitation has a vari- ety of health-related effects. Contaminated water transmits enteric pathogens and other harmful substances resulting in diarrheal dis- ease and other health problems. In addition, the need to collect water from infested sources contributes to diseases caused by contact rather than ingestion (e.g., guinea worm infestation). Lim- ited water resources also limit peoples’ abilities to engage in ap- propriate hygiene, particularly handwashing, which would limit the transmission of communicable diseases. In some places, women and girls face the added threat of violence as well as lost time and productivity through the need to travel significant distances to acquire water. The need to defecate or urinate in open fields also places them at risk for assault (WHO & UNICEF, 2014).

Water Quality and Health

M04_MARY9591_06_SE_C04.indd 81 06/09/14 6:08 PM

82 unit 2 influences on Population health

Evidence-Based Practice

Access to safe Drinking Water Worldwide, 768 million people lacked access to improved drink- ing water sources in 2011 (WHO & UNICEF, 2013). Even if the Millennium Development Goal of halving the number of people without access to safe water by 2015 is achieved, an estimated 600 million people will still lack access to safe water systems. Unsafe water contributes to more than 5 billion waterborne dis- ease fatalities and more than 2 million deaths from diarrhea in

young children each year (Natural Resources Defense Council, n.d.). Research suggests that in developing countries, significant water contamination occurs between water sources and home use and that use of household water treatment and safe storage (HWTS) strategies in individual homes can minimize the health effects of waterborne diseases.

The U.S. Centers for Disease Control has developed an evidence- based strategy for HWTS that includes three aspects: (a) use of an easily accessible, inexpensive chlorine solution in water for home use, (b) storage in safe containers, and (c) education on hygiene and water use practices. The CDC Safe Water System (SWS) has been implemented in more than 30 countries since 1998 and has

provided thousands of people with safe drinking water (Division of Foodborne, Waterborne, and Environmental Diseases, n.d.).

Based on the results of multiple projects to promote SWS use in households in numerous countries, a number of lessons have been learned that can inform other similar projects. These les- sons are summarized in Table 4-2•.

Much of the world’s population does not have access to potable water sources. (africa/Fotolia)

nurses can be actively involved in these roles. They include rais- ing awareness of the need for clean water access among the public and policy makers, documenting water conflicts and their effects on human health, and promoting water conservation and efforts to prevent water contamination. Additional roles include promot- ing nonviolent conflict resolution strategies, promoting proactive cooperation on water issues, and working toward achievement of Millennium Development Goal 7 to reduce the proportion of people without access to safe water and basic sanitation (Levy & Sidel, 2011). This goal reflects the last of the Healthy People 2020 environmental health objectives presented earlier in this chapter.

Air pollution. Hazardous air quality is another issue of concern at both national and global levels. Air pollution arises from the discharge of gaseous and particulate emissions into

the air. Four general categories of air pollution sources are recognized: biogenic sources, mobile sources, point sources, and area sources (EPA, 2011a). Biogenic sources are natural sources of pollutants, such as volcanic eruptions or wild fires that create numerous gaseous pollutants and particulate matter. Plant pollens and dust are other biogenic sources of pollutants. Mobile sources include most forms of transportation as well as lawn mowers and other devices that move and pollute the air (EPA, 2010b, 2011a). Point sources are stationary sources that arise from a single point, such as a factory smoke stack or a storage tank. Area sources are a collection of stationary sources in a specific locale, for example, a residential area in which many homes use coal- or oil-based heating systems (EPA, 2010b).

Six major pollutants, also called criteria pollutants, af- fect air quality in the United States and their emissions are

M04_MARY9591_06_SE_C04.indd 82 06/09/14 6:08 PM

chaPter 4 environmental influences on Population health 83

monitored by the EPA. These include carbon monoxide, lead, nitrogen dioxide, volatile organic compounds, particulate matter, and sulfur dioxide. In 2009, for example, 70  million tons of carbon monoxide were discharged into U.S. air. Simi- lar discharges for other pollutants were as follows: lead— 2000 tons, nitrogen oxides—14 million tons, volatile organic compounds—13  million tons, particulate matter—2 million tons, and sulfur dioxide—9 million tons (EPA, 2011b). Ozone is another major pollutant. Ozone is not typically discharged di- rectly into the air from a pollution source, but results from chem- ical interactions of nitrous oxide and hydrocarbons produced by burning or evaporation of volatile substances (American Lung Association, 2011). Ozone production is exacerbated by heat.

From 1980 to 2009, emissions of six of the criteria pollutants de- creased by 57%, but carbon dioxide emissions increased by 28%. Despite decreases, more than 80 million people in the United States lived in areas where air quality concentrations were above the National Ambient Air Quality Standards for at least part of the year in 2009 (EPA, 2011b). In addition, half of the population lived in areas with dangerous levels of ozone or particulate mat- ter in 2010 (American Lung Association, 2011).

Each of these pollutants has a variety of health consequences. The most obvious are, of course, respiratory effects including lung cancer and exacerbation of asthma and other respira- tory diseases. Air pollution has also been associated with car- diovascular disease, and there is some evidence that exposure

TABLE 4-2 Lessons Learned about safe Water system Campaigns

Category Lessons Learned Project design Target populations in need who have sufficient resources to purchase the products needed and existing

distribution systems Develop long-term funding strategies by creating a locally viable market for the products that is self-sustaining Incorporate a range of technical expertise in planning including consultants and locally knowledgeable staff

Production of safe water product Enable local production of product (bottle, cap, chlorine solution, label) in standardized packaging, consid- ering technical and production capabilities and internal and external quality control mechanisms Provide ongoing product quality monitoring to maintain safety and effectiveness Produce products with an extended shelf life (at least 12 months) Standardize correct chlorine dosage Standardize plastic water containers to assure correct chlorine dose Use packaging appropriate for rural transport and distribution

Regulatory environment Involve all relevant government agencies from the beginning Respond immediately to government concerns Educate program staff to answer technical questions about the product

Marketing and communication Focus on rural communities with unsafe water for program launch rather than high-profile political figures in prominent areas Address specific safe water program behavioral constructs by providing an understanding of diarrheal disease severity, transmission, and effectiveness of SWS strategies and handwashing Use a positive and aspirational branded marketing campaign with focus on positive aspect of use (versus disease severity) Use campaign messages complementary to related campaigns Consider timing of launch efforts (e.g., just before seasonal disease peaks) Choose communication channels appropriate to the context (e.g., media in urban areas and personal com- munication in rural areas) Use targeted technical information to address concerns about chlorine use Provide for sustained funding Develop marketing templates that can be adapted to local needs (verbal, pictorial, or combination designs)

Sales and distribution Combine commercial sector and project push for distribution of the product Capitalize on NGO networks to promote the project, particularly in rural areas Encourage commercial sector participation by use of a socially marketed product

Creating partnerships Develop partnerships at all levels (e.g., government, nongovernment, local, international, etc.) Promote donor advocacy and support for the project through integration into other project contracts Coordinate with NGOs to reach rural and high-risk populations Use trusted spokespersons and product champions

Product costs, pricing, and cost recovery

Recover product costs through sales (usually no need for subsidies, but other costs usually covered by ex- ternal donors)

Integrating safe water into HIV/AIDS programming to meet the needs of the most at risk populations for wa- terborne diseases

Partner with local NGOs that serve the HIV/AIDs population Use interest in reaching the HIV/AIDs population to stimulate a national safe water campaign

Data from: U.S. Agency for International Development. (2007). Best practices in social marketing safe water treatment solution for household water treatment: Lessons learned from Population Services International Field Programs. Washington, DC: Author. Retrieved from http://pdf.usaid.gov/pdf_docs/PNADI479.pdf

M04_MARY9591_06_SE_C04.indd 83 06/09/14 6:08 PM

84 unit 2 influences on Population health

to particulate matter may contribute to insulin resistance in persons with diabetes (American Lung Association, 2011). Population health nurses can educate the public to prevent air pollution as well as assist them in avoiding the worst effects of pollution. Specific strategies are addressed later in this chapter, but population health nurses can also alert people regarding warning mechanisms for unsafe air conditions. Client educa- tion information regarding air quality and health implications is included below.

In addition to exposure to pollutants in the outside or ambient air, many people are also exposed to indoor air pollution, the primary source of which is environmental to- bacco smoke. Exposure to environmental tobacco smoke

contributes to an estimated 50,000 deaths each year in adult nonsmokers due to lung cancer and heart disease. Environ- mental tobacco smoke exposure has also been implicated in sudden infant death syndrome (SIDS) and contributes to na- sal and eye irritation. Approximately 35% of U.S. children (21 million children) are exposed to tobacco smoke in the home, and 49% of nonsmoking children with in-home exposure to tobacco smoke have detectable cotinine blood levels indi- cating increased risk for long-term consequences (Cramer, Roberts, & Stevens, 2011).

Radiation. Radiation also affects the natural environment, often in conjunction with features of the built and social environments. Human health is affected by two types of radiation, ionizing and nonionizing radiation. Ionizing radiation is created through decay of unstable isotopes of certain elements. The term ionizing indicates that the energy created is sufficient to break molecular bonds resulting in charged or “ionized” atoms. Ionizing radiation is of two types; radioactive particles and high-frequency electromagnetic radiation (e.g., X-rays). Human exposure to ionizing radiation occurs both naturally (e.g., radon in the ground in some areas) and by artificial means, such as medical use, radioactive discharges from nuclear plants, and so on. Human effects of ionizing radiation include somatic effects, such as cancer, genetic effects, and teratogenic effects on infants exposed in utero (Environmental Protection Agency, 2012).

An estimated 21,000 lung cancer deaths each year are re- lated to radon exposure. Lung cancer incidence is increased by the interaction of radon exposure in the natural environment and smoking behavior. Although the Healthy People 2020 ob- jectives address radon testing and remediation for homes in areas with high radon levels, it is estimated that declines in

uncontrolled industrial processes may contribute to a variety of environmental health concerns. (Akiyoko/Shutterstock)

Air Quality and Health Implications

Code Air Quality Health Implications Green Good Continue routine activity Yellow Moderate Limited outdoor exertion for highly sensitive

people Orange (advisory) Unhealthy for sensitive groups Limited outdoor exertion for active children,

adults, and people with respiratory conditions Red (alert) Unhealthy Avoid outdoor exertion by active children,

adults, and people with respiratory conditions; limited outdoor exertion by all others

Purple (health alert) Very unhealthy Avoid outdoor exertion by active children, adults, and people with respiratory conditions; limited outdoor exertion by all others

Data from: AIRNow. (2010). Air Quality Index (AQI) – A guide to air quality and your health. Retrieved from http://www.airnow.gov/index.cfm?action=aqibasics.aqi

CLIENT EDuCATION

M04_MARY9591_06_SE_C04.indd 84 06/09/14 6:08 PM

chaPter 4 environmental influences on Population health 85

smoking behaviors will have a greater effect on radon-related lung cancer than home remediation (Mendez, Alshanqeety, Warner, Lantz, & Courant, 2011).

Nonionizing radiation is produced by sources such as power lines, mobile telephones, and so on. There are known ef- fects of exposure to high levels of nonionizing radiation result- ing from the sudden heating of body tissue. The Occupational Safety and Health Administration (OSHA) has developed stan- dards for exposures to sources of nonionizing radiation such as electromagnetic radio waves, due to the potential for adverse health effects of chronic exposure (OSHA, 2013).

ENvIrONmENTAL susTAINABILITy. The last conside- ration with respect to the natural environment to be discussed here is the concept of environmental sustainability. Sustainabil- ity is often viewed as continued growth of the economy and may be conceptualized from both public and business perspec- tives. From a public perspective, environmental sustainability can be defined as “the satisfaction of basic economic, social, and security needs now and in the future without undermining the natural resource base and environmental quality on which life depends” (EPA, 2011h). A business perspective views the goal of sustainability as increasing value while decreasing use of ma- terials and minimizing negative environmental impacts. A syn- ergistic perspective entails “recognition of the need to support a growing economy while reducing the social and economic costs of economic growth” (EPA, 2011h).

Population health nurses can assist members of the popu- lation to recognize environmental sustainability issues and to promote a sustainable environment. This may be done through conservation initiatives and through development of more ef- fective and less environmentally damaging industrial, personal, and transportation-related activities. Strategies that may be used by population health nurses to achieve these ends are pre- sented later in this chapter.

The Built Environment The U.S. Department of Health and Human Services, (USDHHS, 2012) defined the built environment as “human-made ( versus natural) resources and infrastructure designed to support human activity” (p. 64). Elements of the built environment in- clude homes, schools, workplaces, roads, and features such as transportation systems, highways, electrical transmission and waste management systems, and parks and recreation areas. Public health experts have broadened the concept of the built environment to incorporate land use planning and environmen- tal policy, which will be considered in the discussion of the social environment.

The built environment has both direct and indirect effects on health. Direct effects derive from exposure to hazardous conditions arising from the built environment. Examples of direct health effects include lead poisoning arising from inges- tion or inhalation of lead from older structures painted with lead-based paints or respiratory disease due to air pollution. The focused assessment on page 86 provides tips for assessing the potential for lead exposure.

Indirect effects are the result of the effects of the built en- vironment on the natural environment (e.g., contamination of air and water) or on human health-related behaviors. As we saw earlier, much of the contamination of the natural environ- ment arises from features of the built environment. For exam- ple, air pollution is a result of motor vehicle use in the built environment, and pollution tends to be worse in areas near major highways and other heavily traveled areas.

Home safety is another area of concern related to the built en- vironment. In 2009, for example, more than 5% of U.S. housing units were considered inadequate, with deficiencies in plumb- ing, heating, electricity, hallways, or upkeep. An additional 21% of housing units were considered unhealthy due to potential for exposure to toxins, rodents, water leaks, peeling paint, and lack of functional smoke detectors (Raymond, Wheeler, & Brown, 2011). Home conditions can also influence a variety of chronic illnesses for better or worse. For example, homes specifically constructed to minimize the presence of asthma triggers have been associated with an increase in asthma-free days and a de- crease in urgent care visits for people affected by asthma (Ta- karo, Krieger, Song, Sharify, & Beaudet, 2011).

Rural environments have traditionally been considered nat- ural and more healthful than urban environments. However, the built environment also influences rural areas. For example, “factory farms” or concentrated animal feeding operations (CAFOs) cause significant air and water pollution, but are exempt from enforcement of provisions of the Clean Air Act pending further study. Particulate emissions, for example, have been found to be three times higher than permitted levels at some factory farms, and thousands of pounds of ammonia may be produced on the worst days. In addition, hydrogen sulfides have been found to exceed acceptable levels for other indus- tries and are often worse than in many cities (Environmental Integrity Project, 2011).

both natural and built environments affect human health. (Joey Chan/ Pearson Education. Inc)

M04_MARY9591_06_SE_C04.indd 85 06/09/14 6:08 PM

86 unit 2 influences on Population health

The built environment also influences human health- related behavior. For example, the proximity of tobacco outlets in residential areas has been associated with success or failure of tobacco cessation initiatives (Reitzel et al., 2011), and a pre- ponderance of small grocery stores in urban neighborhoods has been related to higher BMIs and greater prevalence of obe- sity. Similarly, moving from a rural to an urban area has been shown to result in lower BMIs, possibly due to greater avail- ability of healthy food choices (Gibson, 2011).

The presence of parks and recreation areas in the built en- vironment influences health-related physical activity levels in the population, and parks with supervised activity classes have been shown to promote physical activity more than parks without such programs (Parra et al., 2010). Unfortunately, many such programs are being eliminated as a result of city, county, and state budget cuts. A number of studies have dem- onstrated the link between access to physical activity venues in the built environment and engagement in physical activ- ity. For example, James and colleagues (2013) found that ele- ments of the built environment were associated with physical activity levels and body mass index (BMI) (James et al., 2013). Similarly, greater density of fast-food restaurants in a com- munity is associated with increased BMI, particularly for low-income residents (Reitzel et al., 2014). The presence of parks also influences physical activity, and public parks have been suggested as avenues of escape from stress for victims of natural disasters (Rung, Broyles, Mowen, Gustat, & Sothern, 2011).

Urban sprawl is another feature of the built environment that has drawn considerable attention in recent years. Urban sprawl has been defined as “a pattern of uncontrolled development around the periphery of a city,” (Resnick, 2010, p. 1853) and is characterized by low population density, loss of open spaces,

aspects of the built environment strongly influence health-related behaviors such as physical activity. (Monkey Business Images/Shutterstock)

FOCusED AssEssmENT Lead Exposure risk

• Do you or family members use products from other countries that may contain lead (pottery, medicines, spices, food, candy)?

• Do you serve food in leaded crystal, pottery, or pewter dishes?

• Do you or members of your family chew on nonfood items (e.g., dirt, paint chips)?

An affirmative answer to any of these questions suggests the need for blood lead testing.

Adapted from: New York State Department of Health. (2009). Lead exposure risk assessment questionnaire for children. Retrieved from http://www.health. state.ny.us/environmental/lead/exposure/childhood/risk_assessment.htm; Texas Department of State Health Services. (2011). Risk assessment for lead exposure: Parent questionnaire. Retrieved from http://www.dshs.state.tx.us/lead/ pdf_files/pb_110_parent_questionnaire.pdf

• Do you live in or regularly visit a house or building built before 1978 with chipped or peeling paint or current or recent renovation?

• Have you ever lived outside of the United States?

• Is anyone you know (family member, neighbor’s child, child’s playmate) being treated for lead poisoning?

• Do any jobs or hobbies of family members involve exposure to lead?

• Do you live near an active lead smelter or battery recycling plant or other industry that may release lead into the environment?

• Do you live near a heavily traveled road or highway?

M04_MARY9591_06_SE_C04.indd 86 06/09/14 6:08 PM

chaPter 4 environmental influences on Population health 87

automobile dependence due to low connectivity between des- tinations, air and water pollution, and limited opportunities to walk or bicycle to work or school. Other characteristic features of urban sprawl include poor land use mix, limited activity cen- ters and downtown areas, “leapfrogging” development, and em- ployment dispersion.

Urban sprawl can be counteracted by smart growth, which has been defined as a “policy framework that promotes an ur- ban development pattern characterized by high population density, walkable and bikeable neighborhoods, preserved green spaces, mixed use development (i.e., development projects that include both residential and commercial uses), available mass transit, and limited road construction” (Resnick, 2010, p. 1853).

Smart growth has been resisted by some entities for a variety of reasons. These include possible decreases in property values, diminished affordability of housing, restrictions on property owners on their use of their land, and the potential to increase, rather than decrease, urban sprawl as new planned communi- ties are built. In addition, smart growth may disrupt existing communities and displace low-income minority residents from center city areas (Resnick, 2010).

Mixed-use development refers to the extent to which ur- ban development creates areas that combine residential and commercial endeavors. Poor land use mix has a long histori- cal tradition in the United States, mandating segregated land use for residential and commercial purposes. Leapfrogging development is the practice of developing distant parcels of land while skipping over those closer to developed areas. Both types of arrangements result in the necessity for people to commute to work or shopping areas and increase motor vehicle traffic while decreasing opportunities for physical activity through walking and bicycling. Urban sprawl wastes available land and converts valuable agricultural land to other uses as well as increasing energy use and contributing to pollution.

All of the characteristic features of urban sprawl lead to increased resource use. The extent of resource use is concep- tualized in terms of humanity’s ecological footprint, which has been defined as the amount of environmental resources in terms of productive land or water required by a popula- tion to support a current lifestyle (World Wildlife Federa- tion, n.d.). An ecological footprint is usually measured in hectares per person (one hectare is 10,000 square meters or 2.47 acres). Worldwide, the current ecological footprint is 2.7 hectares per capita, but only 2.1 hectares can be regen- erated each year, suggesting that we are outpacing our re- sources. The ecological footprint of industrialized nations is even greater. Earlier in this chapter, we referred to the need for sustainable development. In this context, a sustainable or ecological community is one with an acceptable ecological footprint. For further information on determining your own ecological footprint, see the External Resources section of the student resources site.

The Social Environment Throughout this book, we discuss the effects of several el- ements of the social environment on the health of popu- lations. For example, Chapter 5 discusses the cultural aspects of the social environment, and Chapter 6 addresses the economic aspect. In this chapter, we will focus on four aspects of the social environment as they affect health: so- cial capital, social policy, energy consumption, and waste management.

sOCIAL CAPITAL. A basic definition of social capital was presented in Chapter 1 . The World Bank (2011) conceptual- ized social capital as “the institutions, relationships, and norms that shape the quality and quantity of a society’s social interac- tions” (para 1). Social capital is derived from relationships that make resources available to members of a group and depends on the overall level of resources available to the group. These relationships may involve both horizontal and vertical associa- tions and are facilitated by an enabling social and political envi- ronment. Horizontal relationships are social networks of people that increase their productivity by facilitating cooperation and coordination. Interactions with your classmates that facilitate assimilation of educational concepts (e.g., study groups) are ex- amples of horizontal relationships. Vertical relationships may also provide social capital. For example, the expertise of your nursing faculty may also facilitate your learning. The culture of a nursing program that promotes open interaction between faculty and students is an example of an enabling environment.

The social capital available to a population or to a segment of the population has been shown to be related to population health status, independent of the economic status of the indi- vidual or family. For example, higher economic-level neighbor- hoods have been associated with lower obesity risk for adults. Similarly, a study in Brazil indicated that people in the richest residential areas had a healthy life expectancy more than twice as high as that of slum dwellers (Szwarcwald, de Mota, Dama- cena, & Pereira, 2011).

Resources, in the context of social capital, include those available to individual members of the group as well as to the group as a whole. Because of the relationships among group members, resources available to one member become available to others. The extent of social capital in a community or popu- lation group depends on the resources available to the group as well as the relationships that permit access to those resources.

Communities with high levels of social capital have also been characterized by cohesion and collective efficacy. The ex- tent of social capital in a community or population group may also be affected negatively by community or neighborhood characteristics. These negative effects also have health-related implications. For example, overall neighborhood poverty has been associated with higher cardiovascular disease risk for women, and neighborhood crime rates and segregation have been linked to cancer risk in both men and women (Freedman, Grafova, & Rogowski, 2011).

M04_MARY9591_06_SE_C04.indd 87 06/09/14 6:08 PM

88 unit 2 influences on Population health

Some authors, however, note the potential for disadvantages to social capital. These disadvantages lie in the group norms and in the relationship of the group to the outside world. Group norms can, in some instances, promote “antisocial capital”— that is, social capital put to inappropriate uses. Examples given include social norms and behaviors related to drug rings, nep- otism, cronyism, and crime. Neighborhood crime rates have been linked to health-related behaviors such as physical activity, particularly among youth (Moore et al., 2010).

Another area for consideration is the differential effect of social capital on some subgroups within the population. For example, young people in the community may not have ac- cess to some elements of community social capital. As an- other example, homeless individuals are denied access to community social capital when they are prohibited from us- ing public facilities such as parks. With respect to interac- tions with the larger society, some authors have warned that an emphasis on building social capital within groups and communities may be used as an excuse not to redistribute economic resources to address structural inequalities in ac- cess to resources.

sOCIAL POLICy. Social policy also has multiple effects on the environment and on human health and health- related behaviors. Policies may relate directly to environmental conditions or to behaviors that affect the environment. For example, smoke-free policies for multiunit housing may prevent tobacco smoke exposure. Approximately 40 million Americans live in multiunit housing in which smoke is easily transmitted among units. Landlords have resisted initiation of smoke-free policies for a variety of reasons. Chief among these is an expectation that smoke-free policies will lead to higher vacancy and turnover rates. In actual fact, however, in units with smoke-free policies, vacancy rates increased by only 11% compared to an expected 54%, and turnover rates were less than 4% compared to an anticipated 50%. Other reasons for not instituting smoke-free policies in rental properties include difficulties in enforcement, anticipated tenant objections, and loss of rental market share (Cramer et al., 2011).

Policies related to smoking in the workplace are also an is- sue with respect to environmental health. The National Center for Chronic Disease Prevention and Health Promotion (2011) reported an increase from zero to 26 in the number of states that prohibit smoking in the workplace, bars, and restaurants from 2000 to 2010, and nearly half of U.S. residents live in smoke-free jurisdictions. Unfortunately, more than 88 million nonsmok- ers over 3 years of age continue to be exposed to second-hand smoke. The Healthy People 2020 objective is to increase the prev- alence of smoke-free workplace, bar, and restaurant laws to all states. In addition to decreasing exposure of nonsmokers to sec- ond-hand smoke, such laws assist smokers in cessation efforts, change social norms regarding smoking, and decrease hospital- izations related to heart disease and asthma.

At the national level, the EPA has promulgated a wide va- riety of social policies with regulatory enforcement to reduce

environmental health risks. Two prominent examples are the Clear Air Act of 1970 and the Clean Water Act of 1972. The EPA (2011c) estimates that the Clean Air Act will pre- vent more than 230,000 premature deaths in 2020 through its enforcement of emission standards related to industry and transportation. Several amendments have been made in the legislation since its enactment, the most recent being regula- tions regarding the emission of greenhouse gases discussed earlier. The precursor to the Clean Water Act was passed in 1948 as the Federal Water Pollution Control Act, but was sub- stantially reorganized in 1972 and labeled the Clean Water Act in 1977. This act regulates wastewater and sets standards for contaminants in surface water (EPA, 2011f). The EPA also develops policy in a variety of other areas of environmental concern, including waste management, radon exposure, acid rain, lead and other heavy metal exposures, climate change, pesticide exposures, and so on.

The EPA (2010a) has developed a set of five strategic goals for 2011 to 2025. These goals and related objectives are pre- sented in Table 4-3•. Similar environmental-policy-making bodies may also operate at local and state levels. At the interna- tional level, WHO provides a focus for global health initiatives and policy development.

Other types of social policies also affect human health. For example, minimum wage policies have been shown to affect access to health. States with higher minimum wage laws also tend to have a lower risk of unmet health needs among low- skilled workers. Such findings refute contentions that mini- mum wage laws might actually decrease access to care due to lowered numbers of workers hired, fewer hours worked to eliminate the need to provide health insurance benefits, or reductions in available benefits (McCarrier, Zimmerman, Ralston, & Martin, 2011). Many other social policies also affect health, from enactment of seat belt legislation to food labeling laws. Political influences on health and the role of population health nurses in policy formation are discussed in more detail in Chapter 9 .

ENErGy CONsumPTION. Energy consumption is anoth- er aspect of the social environment to be considered. Energy consumption, which plays a large part of the human ecological footprint discussed earlier, arises out of social mores and stand- ards of living. Total energy use in the United States during 2012 was 95 quadrillion British thermal units (Btus), nearly three times the energy use in 1950. Less than 10% of 2012 energy con- sumption resulted from residential and commercial use, 20.5% from industrial use, and nearly 27% from transportation (U.S. Energy Information Administration [EIA], 2013a). Results of the Residential Energy Consumption Survey indicate that per- household residential energy use in the United States decreased from 1980 to 2009, but that each household still used an average of 90 Btus per year. In 2013, less than 10% of energy consump- tion came from renewable energy sources (EIA, 2014).

In large part, reductions in home energy consumption are related to use of more energy-efficient appliances and heating

M04_MARY9591_06_SE_C04.indd 88 06/09/14 6:08 PM

chaPter 4 environmental influences on Population health 89

and cooling systems as well as housing units with more energy- conserving features. For example, in 2009, 58% of homes sur- veyed had multipane windows and 80% of new homes built after 2000 had energy-efficient windows. Similarly, 39% of house- holds used an Energy Star refrigerator and 36% had an Energy Star clothes washer. On the other hand, more homes (40%) use DVRs rather than VCRs and DVD players. DVRs consume more energy than VCRs or DVD players. In addition, 75% of homes now have computers and 35% have two or more comput- ers. Another 50 million homes have three or more televisions, adding to the level of home energy consumption (EIA, 2011).

Manufacturing or industrial energy consumption declined by nearly 17% from 2002 to 2010, but still accounted for 14 quadrillion Btu in 2010 (EIA, 2013b). All forms of energy consumption are contributing to rapid depletion of natural resources, and there is a serious need to develop alternative forms of energy production.

Some alternative energy sources, however, pose envi- ronmental health hazards themselves. For example, deple- tion of oil resources has motivated the development of new methods of natural gas extraction, which make natural gas a more cost-effective alternative fuel than in the past. The ex- traction process, called “fracking,” uses chemicals that leak into groundwater supplies and are known to cause damage to lungs, liver, kidneys, blood, and the brain (Finkel & Law, 2011). As was seen in the aftermath of the tsunami and flood- ing of nuclear reactors in Japan, use of nuclear power has other potential health-related risks. Similarly, conversion of food products, such as corn, to fuel alternatives minimizes their availability as food supplies for humans and domestic animals. Wind and solar power may be more healthful as

well as renewable energy sources, but their long-term health effects are not yet known. Population health nurses need to stay current on the research on the health effects of various energy sources and educate the public and policy makers to make informed decisions. In addition, nurses can be instru- mental in promoting energy conservation.

WAsTE mANAGEmENT. The final aspect of the social en- vironment to be addressed is the issue of waste management. Categories of waste to be considered include solid waste, haz- ardous waste, chemical waste, heavy metals, and biological waste. Solid waste consists of paper products, glass, metal, plas- tics, rubber and leather, textiles, wood, and other wastes, which include food scraps, yard trimmings, and other organic wastes. According to the U.S. Census Bureau (2011a), U.S. residents generated nearly 250 million tons of solid waste in 2008, an in- crease of 65% over 1980. Approximately one third of the solid waste generated in 2008 was recovered by recycling, compost- ing, or burning as an energy source. Another 135 million tons were discarded to landfills and other sites.

Hazardous waste is defined as “waste that is dangerous or potentially harmful to our health or the environment. Hazard- ous wastes can be liquids, solids, gases, or sludges. They can be discarded commercial products, like cleaning fluids or pes- ticides, or the by-products of manufacturing processes” (EPA, 2011i). Hazardous wastes are of concern in terms of their dis- posal and in terms of transportation from one place to another. In 2007, the United States generated more than 32 million tons of hazardous waste, 655,000 tons of which were transported posing risk for major exposures due to accidents in transit (U.S. Census Bureau, 2011c).

TABLE 4-3 EPA strategic Goals and related Objectives

strategic Goal related Objectives Goal 1: Taking action on climate change and improving air quality

Address climate change by reducing greenhouse gas emissions and assisting the public to deal with effects of climate change. Improve air quality by reducing the extent of toxic pollutants. Restore ozone layer, protecting the public from ultraviolet radiation. Reduce unnecessary radiation exposure, minimizing exposure and dealing with exposures that occur.

Goal 2: Protecting America’s water Reduce human exposure to contaminants in drinking water, shellfish, fish, and recreational water. Protect and restore watersheds and aquatic ecosystems.

Goal 3: Cleaning up communities and advancing sustainable development

Promote sustainable and livable communities by promoting smart growth, land reclamation, and emergency preparedness. Preserve land by decreasing waste generation, recycling, and effective waste management. Restore land by cleaning up and restoring contaminated land and responding to toxic releases. Strengthen health and environmental protection on Indian lands.

Goal 4: Ensuring the safety of chemicals and preventing pollution

Ensure chemical safety and reduce chemical exposures. Promote pollution prevention.

Goal 5: Enforcing environmental laws Implement environmental law with vigorous enforcement and use of sanctions.

Data from: Environmental Protection Agency. (2010a). FY 2011–2011 EPA strategic plan: Achieving our vision. Washington, DC: Author.

M04_MARY9591_06_SE_C04.indd 89 06/09/14 6:08 PM

90 unit 2 influences on Population health

Hazardous wastes are primarily generated by human ac- tivities, and may be biological, chemical, or metal. Biological hazardous wastes occur when harmful bacteria and other bio- logical agents are discharged into water supplies or contaminate foods. Chemical hazardous wastes are generated by a variety of industrial processes and frequently contaminate water supplies. Use of personal products such as cleansing agents in the home may also lead to generation of hazardous waste. Metal contami- nation of water supplies or land may also occur as a result of industrial processes or home use of products that contain heavy metals such as lead, arsenic, and so on. For example, in 2009, the prevalence of elevated blood lead levels (BLLs) in U.S. adults was 6.3 per 100,000 employed persons. Control strategies have resulted in a decreased prevalence of lead poisoning in adults, however. For example, the prevalence of elevated blood lead levels declined by more than 50% from 1994 to 2009 (Division of Surveillance, Hazard Evaluation, and Field Studies, 2011).

Toxic chemical waste releases actually decreased by 15% from 2003 to 2008, but total industrial releases in 2008 still totaled more than 3,861 million pounds. The greatest releases

occurred from metal mining, followed by electric utilities (U.S. Census Bureau, 2011b). Agriculture also produces chemical wastes related to pesticides and fertilizers that contaminate water supplies through runoff. As we noted earlier, ammonia production at factory farms is also of concern.

In the past, many toxic hazardous wastes were stored or dumped in a variety of places that permitted their release into air and water. During the 1970s, the health implications of these hazardous waste sites were recognized prompting the development of the Superfund program; Superfund is the EPA program initiated to clean up these hazardous waste sites. It was established under the Comprehensive Environmental Re- sponse, Compensation, and Liability Act of 1980 and permits EPA cleanup of sites placed on the National Priorities List, to compel parties responsible for hazardous waste dumping to engage in cleanup or compensate EPA for cleanup activities. Since the passage of the legislation, tens of thousands of sites throughout the nation have been cleaned up (EPA, 2011g). For further information on remaining Superfund sites, see the External Resources section of the student resources site.

Biological wastes are created by humans, animals, and in- sects, as well as by decomposing plant matter. Biological wastes become hazardous to human health when they contain pathogens that contaminate water and food supplies. In devel- oped countries, most human biological wastes are controlled through sewage treatment systems. In other parts of the world, however, sanitation is rudimentary and the consequent risk of exposure to fecal pathogens is high. Animal and insect drop- pings are also sources of many communicable diseases. For ex- ample, the presence of mouse droppings in the environment increases the risk of hantavirus exposure. Similarly, flies, cock- roaches, and other insects contaminate food and water sup- plies. Population health nurses can help to educate populations for control of biological wastes and prevention of food and wa- ter contamination by biological agents.

Interactions Among Environmental components Although we have discussed the natural, built, and social envi- ronments as if their effects on health are independent of one another, they are actually intimately related. For example, in- dustrial and human wastes deposited into the ocean from the built environment have polluted waters and altered the marine food chain. Overfishing of coastal waters has, in turn, led to an increasing dependence on farmed fish, which may have higher levels of contaminants than wild fish, thereby increasing the potential for human health effects. Similarly, ozone levels that contribute to air pollution peak during traffic rush hours (part of the built environment) and with increasing temperatures during the day (the natural environment). Surprisingly, ozone levels may be worse in less densely populated areas due to in- creased vehicle use as a result of urban sprawl.

Elements of the natural environment also interact with hu- man development, human behavioral factors, and elements of

Pollution affects everyone's health. (Jules Selmes/Pearson Education, Inc.).

M04_MARY9591_06_SE_C04.indd 90 06/09/14 6:08 PM

chaPter 4 environmental influences on Population health 91

the social environment to contribute to health problems. For instance, the effects of severe heat waves are associated with increased age, decreased socioeconomic status, poor housing quality, and lack of air conditioning, as well as with the use of alcohol and some medications. Another example of the inter- actions between built and natural environments lies in the ag- ing water systems in most U.S. cities, leading to breakdowns and contamination of natural water supplies.

We noted before the effects of the built environment on hu- man health-related behaviors such as walking. Community de- sign also affects the natural environment. Urban development, for example, increases the amount of impervious surfaces that do not absorb rain water, leading to greater storm water vol- ume and runoff, which have the potential to contaminate water sources or increase flood risk in residential areas. The built en- vironment also affects levels of social capital through its effects on opportunities for people to congregate and interact with each other. For example, communities with walkable, mixed- use neighborhoods tend to exhibit higher levels of social capital than automobile-dependent ones.

Social environmental changes such as the move to smaller, nuclear families requires more housing, uses more natural re- sources, and creates a larger ecological footprint. These effects, as well as those of global climate change in the natural environ- ment, are anticipated to result in major social upheavals such as water wars and environmental refugees (Pappas, 2011).

Population Health Nursing and Environmental Influences on Health Because of their consistent presence in the community, popula- tion health nurses are some of those most likely to become aware of environmental health problems, yet they are often unprepared to recognize and deal with them. Protection of the environment is one of the essential functions of public health, and the participa- tion of population health nurses in this function is critical. Popu- lation health nursing activity related to environmental health issues occurs at individual/family client and population levels.

Standards and competencies for occupational and environ- mental health nursing practice have been developed and are discussed in Chapter 23 . In addition, a number of national ini- tiatives support the role of nursing with respect to environmen- tal health issues. The first of these initiatives was an offshoot of the Agency for Toxic Substances and Disease Registry (ATSDR). ATSDR, part of the Superfund legislation passed in 1980, was cre- ated to prevent or minimize public exposure to hazardous sub- stances. In 1994, ATSDR established the Environmental Health Nursing Initiative to promote research, collaboration, and edu- cational opportunities related to environmental health. The ATSDR initiative was designed to promote a more active role for the nursing profession in addressing environmental health with a goal of making environmental health “an integral component of nursing practice, education, and research” (ATSDR, n.d.).

To that end, the initiative has developed a series of education resources and training programs and roundtable discussions around nursing involvement in environmental health.

In 1995, the Institute of Medicine report, Nursing, Health, and the Environment (Pope, Snyder, & Mood, 1995), promul- gated four general competencies for nursing with respect to en- vironmental health. The first of these competencies addressed knowledge related to mechanisms for environmental exposure, prevention and control strategies, and the need for evidence- based approaches to dealing with environmental issues. The second competency dealt with the ability to take an environ- mental exposure history and make appropriate referrals for health care services as well as informing the public regarding environmental hazards. The third competency underscored the need for advocacy to support environmental justice in resolv- ing environmental health problems, and the fourth reflected knowledge and use of legislative and regulatory processes to address environmental conditions that jeopardize health.

In 2010, the Alliance of Nurses for Healthy Environments joined the American Nurses Association (ANA) to incorporate a standard related to environmental health in ANA’s revised Nursing: Scope and Standards of Practice. The standard ad- dresses competencies for both the basic registered nurse and graduate-prepared nurses (Gilden, 2010). For further informa- tion on the competencies, see the External Resources section of the student resources site.

Population health nurses can use the population health nursing model to address environmental health problems. Use of the model focuses on assessment, intervention planning, and evaluation of environmental interventions.

Assessing Environmental Health Influences The first step in ameliorating environmental health problems is an assessment of the factors contributing to them and their ef- fects on human health. In addition to identifying environmen- tal factors in the community that may affect health, population health nurses assess the population for factors that may in- crease the risk or severity of the health effects of environmental conditions. Factors in each of the determinants of health cat- egories may be addressed.

BIOLOGICAL DETErmINANTs. Biological determinants such as age, genetics, and existing health problems may increase a population’s risk of environmentally caused health problems. For example, children’s higher metabolic rate increases the rate of absorption of toxins, and very young children are closer to the floor, where air pollutants, in particular, accumulate. In ad- dition, the rapid rate of growth and cell differentiation in chil- dren fosters genetic alteration and carcinogenesis. Older adults, because of changes in their cardiovascular, renal, pulmonary, and immune systems, are less able to detoxify environmental toxins and, consequently, have a higher risk of adverse health effects. The population health nurse would determine the age composition of the population as it affects risk for and presence of health problems related to environmental factors.

M04_MARY9591_06_SE_C04.indd 91 06/09/14 6:08 PM

92 unit 2 influences on Population health

Existing genetic and physiologic conditions may also increase the potential for health effects of environmental factors. For exam- ple, levels of environmental toxins that might not harm an adult may be harmful to the fetus in a pregnant woman. A higher preva- lence of chronic respiratory conditions, such as asthma, increases the adverse health effects of plant pollens and air pollution.

Population health nurses also assess population groups and individual clients for evidence of environmentally caused dis- ease. Air pollution, for example, affects the respiratory system primarily, but may also produce cardiovascular, central nervous system, or hematopoietic effects. Air pollution also irritates the eyes and mucous membranes of the respiratory system. Water pollution can affect the gastrointestinal system, skin, liver, and reproductive, hematopoietic, lymphatic, cardiovascular, and genitourinary systems. Pesticides can adversely affect the cen- tral nervous system and produce kidney damage, a variety of cancers, and chromosomal changes. Radiation can cause skin cancer, visual impairment, cataracts, and genetic mutations, as well as lung and other cancers. Lead poisoning damages the central nervous system as well as the gastrointestinal sys- tem and can impair growth and development. Other metals and hazardous chemicals may cause cancers or central nervous system, gastrointestinal, and metabolic damage. High levels of noise not only compromise human hearing but can also con- tribute to gastrointestinal, dermatologic, central nervous sys- tem, cardiovascular, and psychological problems. Finally, built environments that hinder physical activity contribute to obe- sity, osteoporosis, and depression. Some of the effects of these environmental hazards are presented in Figure 4-2•. PsyCHOLOGICAL DETErmINANTs. Psychological deter- minants within the population may influence behaviors that contribute to environmental risk or affect the consequences of environmental conditions for members of the population. For example, stress may increase smoking behavior, leading to greater levels of smoke exposure for both smokers and non- smokers. Conversely, environmental conditions may affect the mental health of the population. For example, persistent rain may lead people to stay indoors and lead to a higher incidence of depression. Certainly, environmentally caused disasters have significant psychological effects on the population.

ENvIrONmENTAL DETErmINANTs. Population health nurses would also assess the environmental conditions that may affect the health of the population. What is the extent of air and water pollution? To what extent do weather conditions affect health? What features of the built environment contrib- ute to health or ill health?

sOCIOCuLTurAL DETErmINANTs. Sociocultural de- terminants such as occupation, income, and educational levels; cul- tural beliefs, behaviors, and attitudes; and social and environmen- tal policies influence environmental conditions that affect health. Occupational settings give rise to multiple opportunities for ex- posure to environmental hazards, and population health nurses should assess the potential for exposure to hazardous environmental

conditions created by local occupations and industries. A related issue is the extent of recreational pursuits that entail exposure to toxins. Other social factors, such as socioeconomic status, may in- fluence exposure to environmental hazards. For example, children living in housing of lower economic value are at higher risk for lead poisoning or injury resulting from home safety deficiencies. Simi- larly, social capital available to the population may affect their abil- ity to address environmental risk factors. Educational levels influ- ence the population’s knowledge of environmental issues and their awareness of strategies to prevent environmentally caused health problems or recognition when those problems exist.

Cultural attitudes toward the environment may also influ- ence concern for environmental issues and the population health nurse would assess public awareness of environmental concerns and willingness to take relevant actions to prevent or ameliorate problems. The population health nurse would also examine policies related to environmental issues and the ex- tent to which they promote or impede environmental health. Closely aligned with policies is the existence of special interest groups that may resist social policies that promote and protect environmental health. For example, economic costs have been used to argue against implementation of clean air regulations in some industries. What groups within the population support or resist policies aimed at promoting environmental health and what is the basis for their support or resistance?

BEHAvIOrAL DETErmINANTs. Certain personal behav- iors prevalent in the population may interact with elements of the physical environment to cause or exacerbate health problems. Smoking, for example, increases lead absorption levels for both smokers and their children. Similarly, reliance on biomass fuels for cooking and heating creates indoor air pollution. Recreation- al activities are also affected by environmental factors. For exam- ple, after-school sports and after-work physical activity at times of peak ozone levels increase the potential for respiratory health effects. Similarly, swimming and other water-related recreational activities increase the potential for exposure to microorganisms and chemical agents when water is contaminated.

Population health nurses would also assess the extent of be- haviors within the population that prevent environmental pol- lution and environmental health effects. What is the attitude to and extent of recycling in the population? To what extent do members of the population limit energy consumption or conserve water? What protective measures do members of the population take to prevent environmental exposures (e.g., use sunscreen, wear hats, fence swimming pools)?

HEALTH sysTEm DETErmINANTs. Finally, factors related to the health care delivery system may contribute to or exacerbate environmental health problems. For example, screening for lead levels in high-risk children and adults does not always occur when indicated. Health care providers in gen- eral have little knowledge of the manifestations or treatment of many environmentally caused diseases. The focused assessment on page 94 provides tips to assist you in your assessment of en- vironmental health issues.

M04_MARY9591_06_SE_C04.indd 92 06/09/14 6:08 PM

chaPter 4 environmental influences on Population health 93

Figure 4-2 Human Health effects of environmental Conditions

Ear • Impaired hearing

Metabolic/Endocrine System • Metabolic acidosis • Pituitary tumor • Thyroid tumor

Hematopoietic/Lymphatic System • Anemias • Hematopoietic cancers • Hemolysis • Immune suppression

Gastrointestinal System • Abdominal pain • Bowel cancer • Cirrhosis • Esophageal cancer • Esophagitis • Gastritis • Hepatitis • Liver cancer • Mucous membrane irritation

• Nausea • Pancreatic cancer • Peritoneal cancer • Salivary gland cancer • Stomach cancer • Ulcer • Vomiting

Genitourinary System • Acute & chronic renal failure • Adrenal tumor • Bladder cancer

• Kidney damage/ cancer • Prostatic cancer

Integumentary System • Acneform dermatitis • Alopecia • Contact dermatitis • Discoloration

• Folliculitis • Hyper/hypopigmentation • Skin cancer • Ulceration

• Immunologic sensitization • Lymphatic cancers • Marrow depression

Eye • Blindness • Cataracts

• Impaired visual acuity • Irritation

Central Nervous System • Ataxic gait • Behavior change • Brain tumor • CNS depression • Cranial or peripheral neuropathy • Developmental disability • Fatigue • Hallucination • Headache

• Impaired mental function • Impaired psychomotor function • Increased intracranial pressure • Irritability • Memory impairment • Neurasthenia • Psychosis • Seizures • Tremors

Cardiovascular System • Chest pain • Heart disease • Hypertension

• Impaired exercise tolerance

Respiratory System • Asphyxia • Asthma • Chronic lung disease • Emphysema • Granulamatous disease • Impaired exercise tolerance • Irritation • Laryngeal cancer

• Lung cancer • Mesothelioma • Mucous membrane irritation • Nasal ulceration • Pharyngeal cancer • Pneumonitis • Pulmonary fibrosis • Sensitization

Reproductive System • Breast cancer • Congenital abnormalities • Genetic mutation • Low birth weight

• Neonatal death • Prematurity • Spontaneous abortion • Sterility • Testicular cancer

Musculoskeletal System • Bone cancer • Osteoporosis

General • Obesity • Depression

Some environmental assessment data can be obtained pri- marily by observation in the home or community. For example, elements of the built environment such as traffic safety hazards or recreational opportunities are easily observed. Data related to environmental health effects may be available from local health departments or environmental protection agencies or from state agencies. Information on human behaviors that con- tribute to environmental health problems (e.g., smoking) is best

obtained by asking family members or in community surveys. Information on environmental policy can be obtained from lo- cal government, environmental protection agencies, and local businesses and industries. Other elements of environmental as- sessment are addressed in relevant chapters in this book (e.g., community assessment in Chapter 15 and school and occupa- tional settings in Chapters 22 and 23 , respectively), as well as in assessment tools included on the student resources site.

M04_MARY9591_06_SE_C04.indd 93 06/09/14 6:08 PM

94 unit 2 influences on Population health

Planning to Address Environmental Health Issues Population health nurses assess for environmental hazards present in the community, the factors contributing to them, and the health effects that result. They then use this informa- tion to plan interventions, in conjunction with others in the population, to address environmental health problems affect- ing the population. These interventions can address promo- tion, prevention, resolution, and restoration.

PrOmOTION. With respect to promotion, population health nurses can advocate for environments that promote health and healthful behaviors. For example, they can col- laborate with other segments of the population to foster built environments that promote physical activity. Similarly, they can advocate for environments in which access is provided to healthful and nutritious foods at reasonable prices.

PrEvENTION. A significant portion of population health nurses’ efforts, with respect to environmental health, will relate to prevention efforts. Prevention strategies may focus on pre- vention of environmental degradation or prevention of human exposure to adverse environmental conditions. These activities may include education of the public regarding prevention as well as advocacy for environmental policies that protect the environment or minimize human exposures. For example, the population health nurse can educate members of the public for energy conservation while advocating for the development of new energy resources and industrial processes that can mini- mize energy consumption and decrease emission of greenhouse gases, reducing the effects of global warming. Nurses can ini- tiate recycling campaigns within the community or in health care facilities. They can also educate the public regarding vector

control measures that do not jeopardize human health (e.g., care in use of rodenticides or pesticides).

Prevention within the built environment would include the development of well-designed communities that minimize ur- ban sprawl, limit resource use, promote mixed land use and the development of social capital, and foster healthy behaviors such as walking and bicycling. In addition, the contributions of the built environment to degradation of the natural environ- ment could be minimized by investing in more effective wa- ter systems that make use of newer technological approaches that are more effective and more environmentally friendly. For example, use of waterless toilets, recycling, and rainwater har- vesting can conserve water and make it available for human needs (Natural Resources Defense Council, 2012). Population health nurses can advocate for water treatment systems that do not damage the natural environment and yet provide safe wa- ter for human consumption. In addition, they can educate the population with respect to water conservation, use of drought tolerant landscaping, and other measures to conserve water. They can also educate clients on inexpensive water treatment measures when more technologically advanced systems are not available (e.g., in underdeveloped countries or on a camp- ing trip).

Developing countries that will not be able to initiate water treatment systems in the near future can encourage point- of-use water treatment systems that incorporate use of dilute solutions of sodium hypochlorite (laundry bleach), solar dis- infection by means of ultraviolet light projected through clear plastic bottles or bags, and safe water storage in narrow-mouth containers that require pouring or the use of a spigot to prevent recontamination of the water by dipping. Use of such systems will require access to the needed supplies and public motiva- tion to offset the added costs in terms of time and money.

FOCusED AssEssmENT Assessing Environmental Influences on Population Health

• What barriers exist to improving environmental conditions?

• What is the potential for eliminating hazardous environmental conditions? What is the potential for limiting human exposure if hazardous environmental conditions cannot be eliminated?

• What actions will be required to address environmental health concerns within the population?

• Does the health care system contribute to environmental health hazards? If so, how?

• Is the health care system adequate to address environmentally caused diseases in the population?

• Are health care providers adequately prepared to recognize and treat environmentally caused diseases in individual clients?

• What natural, built, and social environmental conditions have the potential to influence the health of the population? How do these conditions affect health? What is the extent of their influence on health at the present time?

• What segments of the population are most likely to be adversely affected by environmental conditions? Why?

• What factors contribute to the presence and influence of environmental conditions within the population?

• To what extent do environmental conditions arise from or are influenced by individual behavior (e.g., smoking, recycling, water conservation)?

• What are the attitudes of members of the population to environmental health issues? What priority is given to resolution of environmental health issues?

M04_MARY9591_06_SE_C04.indd 94 06/09/14 6:08 PM

chaPter 4 environmental influences on Population health 95

TABLE 4-4 Prevention measures for Populations, Individuals, and Families related to selected Environmental Concerns

Environmental Concern Population Individual/Family

Radiation Educate the public on the hazards of radon exposure and preventive measures.

Educate the public on the hazards of radon exposure and preventive measures.

Engage in political activity to promote building stan- dards that safeguard occupants in areas with high levels of natural radiation.

Encourage spending most of one’s time in higher lev- els of the home.

Educate public about the hazards of overuse of diag- nostic X-rays.

Discourage overuse of diagnostic X-rays.

Engage in political activity to promote and enforce safety standards for nuclear reactors. Educate the public about the hazards of exposure to ultraviolet radiation.

Encourage adequate cleaning of door seals on micro- wave ovens and maintenance of safe distance while microwave is in operation. Discourage sunbathing. Encourage use of sunscreen and protective clothing when outdoors.

Promote availability of smoking cessation services. Discourage smoking in home; refer for smoking ces- sation assistance.

Lead and heavy metals Encourage communities to remove lead-based paint from older homes. Advocate for funds for lead remediation of older homes.

Encourage families to remove lead-based paint from older homes.

Encourage covering surfaces on which paint is peeling. Encourage families to wash small children’s hands as well as toys to remove lead-contaminated dust. Encourage close supervision of small children.

Encourage policy makers to set and enforce stan- dards for solid waste sites to prevent metal contami- nation in waters.

Encourage calcium intake to limit lead absorption. Encourage families to use cold water to drink and cook with and to allow the tap to run for a few minutes.

(Continued )

Public education and social support will be required for all of these initiatives, and many of them will require political ad- vocacy as well. For example, there is a need for additional lead poisoning prevention legislation, funding for programs, and public education to foster identification of risk groups and in- tervention to reduce exposure risks. Similarly, developers and community development agencies will need to be convinced of the need for smart growth and for provision of affordable mass transit located near schools, homes, and workplaces in those communities already affected by urban sprawl. Popula- tion health nurses can be actively involved in all of these ac- tivities. For example, they may organize local residents to work with developers to plan mixed-use communities and commu- nity designs that promote fitness and exercise. Such strategies can be employed in the design of new communities, but are also appropriate to the redevelopment of older existing com- munities. Additional prevention activities by population health nurses directed at promoting environmental health for individ- uals/families and for populations are presented in Table 4-4•. rEsOLuTION. Resolution-related activities also reflect care of individuals and families as well as population groups. Popu- lation health nursing interventions with individuals and their

families would be geared to identifying and resolving existing health problems caused by environmental conditions. For ex- ample, population health nurses might be involved in screen- ing for elevated lead levels or for hearing loss. They might also make referrals for testing of water supplies for clients who are concerned about potential contamination. When possible en- vironmentally caused health conditions are identified, popula- tion health nurses might make referrals for medical diagnosis and treatment as needed. They might also make referrals for assistance with eliminating environmental hazards. For exam- ple, the nurse might be aware of lead-based paint in dwellings in some parts of town. He or she can screen young children in the area for elevated blood lead levels (BLLs) and make referrals for treatment for children with positive test results. The nurse might also make a referral for assistance in removing lead- based paint from the homes of affected children. Finally, the nurse might monitor children’s responses to therapy and the potential for continued exposure to lead.

At the population level, population health nurses might pro- mote targeted screening programs to identify the prevalence of risk factors in the community. Population health nurses can also encourage policy makers to adopt targeted screening prac- tices for appropriate populations in the community.

M04_MARY9591_06_SE_C04.indd 95 06/09/14 6:08 PM

96 unit 2 influences on Population health

TABLE 4-4 (continued)

Environmental Concern Population Individual/Family Noise Promote noise abatement ordinances. Encourage families to limit noise in the home.

Encourage use of ear protection in high-noise areas. Infectious agents Educate the public on the need for immunizations. Promote routine immunization for all ages.

Encourage policy makers to provide low-cost immunization services.

Encourage good hygiene, particularly handwashing.

Promote enforcement of regulations for food process- ing and food handlers.

Encourage washing fruits and vegetables before eating. Encourage adequate cooking and refrigeration of food.

Advocate for adequate sanitation, waste disposal, and water treatment.

Encourage susceptible individuals to boil water for cooking and drinking in areas with unsafe water.

Insects and animals Advocate for development and enforcement of pet immunization and leash laws.

Encourage immunization of family pets. Discourage exotic pets and educate owners regarding hazards and prevention.

Advocate for ordinances controlling insect-breeding areas.

Refer for assistance in eliminating insects, rats, and other pets from the home. Encourage use of insect repellant and protective clothing when outdoors.

Plants Promote elimination of poisonous plants from recre- ation areas.

Eliminate poisonous houseplants.

Educate the public about poisonous plants. Eliminate poisonous plants from yards. Eliminate other hazardous plants (e.g., poison ivy, plant allergens) from home environment. Encourage close supervision of small children.

Poisons Educate the public on hazards of household chemi- cals and medications.

Educate families on proper use, storage, and disposal of household chemicals and medications. Encourage close supervision of children.

Advocate for legislation to limit use of hazardous chemicals in home and industry.

Encourage proper disposal of hazardous wastes.

Advocate for effective hazardous waste disposal services.

Air pollution Promote legislation to prevent air pollution. Encourage limiting physical activity on days with high air pollutant levels.

Promote incentives for carpooling. Encourage carpooling. Advocate for legislation to develop and enforce safety standards for home-heating devices.

Discourage use of space heaters in poorly ventilated areas.

Promote building standards that ensure adequate ventilation.

Encourage frequent cleaning or replacement of heater and air-conditioning filters. Encourage opening doors and windows to permit air exchange.

Advocate replacement of hazard-producing industrial processes.

Encourage replacement of asbestos insulation as needed.

Advocate legislation mandating CO monitors in resi- dential units.

Encourage installation of CO monitors in home. Educate for use of hazardous household products with adequate ventilation.

Water pollution Promote development and enforcement of legislation to prevent water pollution.

Encourage use of bottled water by high-risk persons in areas with heavily polluted water.

Promote replacement of hazard-producing industrial processes.

Encourage use of fewer polluting products.

Promote filtration of water sources for new pathogens, etc.

Educate about water purifying techniques as needed.

Energy consumption Advocate for policies that conserve resources, promote smart growth, and limit urban sprawl.

Educate regarding interventions to conserve electricity, water, natural gas, etc.

Advocate for recycling programs. Promote recycling.

M04_MARY9591_06_SE_C04.indd 96 06/09/14 6:08 PM

chaPter 4 environmental influences on Population health 97

TABLE 4-5 resolution measures for Individuals, Families, and Populations related to selected Environmental Concerns

Environmental Concern Population Individual/Family Radiation Monitor incidence of health problems caused by

radiation. Promote access to diagnostic and treatment facilities. Monitor longevity to determine effects of treatment in groups of people affected.

Look for signs of health problems that may be caused by radiation among clients and members of their families. Refer for diagnosis and treatment as needed. Monitor effectiveness of treatment.

Lead and heavy metals Promote access to screening services. Promote compliance with Medicaid lead-screening guidelines for children. Promote adequate reimbursement for lead-screening services. Monitor incidence of heavy metal poisoning. Promote access to diagnostic and treatment facilities. Monitor prevalence of complications due to heavy metal poisoning.

Screen for elevated blood levels of heavy metals in persons at risk.

Observe for signs of heavy metal poisoning. Refer for diagnosis and treatment as needed. Monitor effects of treatment.

Noise Promote access to hearing-screening services. Promote access to diagnostic and treatment services.

Screen for hearing loss in persons at risk. Refer for diagnosis and treatment as needed. Monitor effects of treatment.

Infectious agents Promote access to screening services for infectious diseases. Monitor incidence of communicable diseases.

Screen for selected communicable diseases in high- risk persons. Observe for signs of communicable diseases.

Insects and animals Promote access to treatment for animal bites. Monitor the incidence of diseases caused by insects or animals. Promote access to diagnostic and treatment services for diseases caused by insect or animal bites.

Educate families about first aid for insect and animal bites. Observe for signs and symptoms of diseases caused by insects or animals. Refer for medical assistance as needed.

Plants Educate the public about poison control activities. Promote community support of poison control centers.

Inform families of poison control center activities. Refer families for poison control center services as needed. Refer for treatment of allergies and other conditions caused by plants.

Poisons Educate the public about first aid for poisoning. Monitor the incidence of accidental poisoning. Promote access to poison control services.

Educate families about first aid for poisoning. Observe for signs and symptoms of poisoning. Refer families for poison control services as needed.

Air pollution Advocate development and enforcement of legislation to reduce pollutant emissions. Promote access to diagnostic and treatment services.

Observe for signs and symptoms of diseases caused by air pollution. Refer for diagnosis and treatment as needed.

Water pollution Promote legislation to control water pollution. Promote access to diagnostic and treatment services for water-related diseases.

Observe for signs and symptoms of water-related diseases. Refer for diagnosis and treatment of water-related diseases.

Political activity by population health nurses might also be needed to influence health policy makers to provide adequate access to diagnostic and treatment facilities for people with health problems caused by environmental conditions. Or a nurse might campaign for stricter standards for pollutant emis- sions in air and water. Table 4-5• provides additional examples of resolution measures that might be taken to improve environ- mental health in families and population groups.

rEsTOrATION. Population health nurses may need to work with individuals or families to prevent recurrence or complica- tions of environmentally caused health problems. For example, a nurse might assist a family to find housing where exposure to lead is not a problem. Or the nurse might provide parents

with referrals for assistance in coping with the mental effects of long-standing lead poisoning in their children. Another resto- ration measure might involve suggestions for decreasing noise levels in the home to prevent further impairment of hearing.

Restoration activities might also be needed to deal with envi- ronmental problems at the aggregate or group level. An example might be political activity to mandate standards that prevent the recurrence of a leak at a nuclear power plant or to pass a bond issue to renovate a water treatment plant and prevent recon- tamination of drinking water with sewage. Advocacy for funds to remove lead hazards from older homes or legislation man- dating lead removal in rental units are other possible population health nursing interventions related to restoration. Advocacy for continued funding of Superfund clean-up activities is another

M04_MARY9591_06_SE_C04.indd 97 06/09/14 6:08 PM

98 unit 2 influences on Population health

TABLE 4-6 restoration measures for Populations, Individuals, and Families related to Environmentally Caused Health Conditions

Population Individual/Family Monitor effects of environmental changes on incidence of environmen- tally caused conditions.

Monitor for long-term effects of environmentally caused conditions.

Promote access to services for members of the population affected by environmentally caused conditions.

Promote adjustment to the long-term effects of environmentally caused conditions. Refer families to personal or environmental health services to deal with consequences of adverse environmental conditions.

Advocate environmental policies to prevent recurrence of environmental health problems.

Promote changes in environmental conditions or minimize subsequent exposure to prevent recurrence of environmentally caused disease.

population-level restoration intervention. Table 4-6• pres- ents several restoration interventions related to environmental health in the care of individuals/families and populations.

Evaluating Environmental Health Measures Population health nurses are also involved in evaluating the effectiveness of environmental control measures. Evaluation would focus on the effectiveness of promotion, prevention, resolution, and restoration measures related to individuals, families, and population groups. For example, the nurse might monitor blood lead levels of children in housing with lead- based paint to determine whether preventive measures have

prevented initial elevation. For those children who already have elevated blood lead levels, evaluation would focus on the effects of chelating agents in reducing blood levels and the preven- tion of symptoms of lead poisoning. Evaluation of restoration measures would be aimed at the effectiveness of abatement pro- cedures in preventing blood lead levels from rising again after treatment. Similar approaches to evaluation of promotion, pre- vention, resolution, and restoration interventions could be used for each of the environmental health problems addressed in this chapter. Evaluation at the aggregate level would focus on the ex- tent to which national objectives for environmental health have been achieved as well as on the effectiveness of specific promo- tion, prevention, resolution, and restoration interventions.

Janice Wu, a community health nurse, is visiting a new client in a nursing home in an inner-city area in Los Angeles. As she en- ters the nursing home, she notices that several of the residents are doing calisthenics in the yard. Some of the residents are sit- ting on the sidelines and appear quite short of breath. When Janice checks to make sure they are all right, they tell her that they usually have a hard time breathing when they exercise on smoggy days like today. The residents say that they usually try to continue their exercises because it is one of the few activities

that get them out of the building. They also enjoy the social as- pects of the exercise sessions. Many of them state that they have always been active and want to maintain their strength and mo- bility as long as possible. They express fears of being bedridden and unable to care for themselves.

After Janice is sure that all of the residents will be all right, she goes on to see her client. When she enters the building, she notices that it is quite hot inside, even though all the windows and doors are open. Although it is only 10 a.m., it promises to

CAsE sTuDy

Population health nurses are in a prime position to identify en- vironmental influences on health and to initiate measures to fos- ter health promoting environments. They assess factors related to each of the six categories of determinants of health arising from natural, built, and social environments and collaborate

with others to plan and implement environmental strategies re- lated to health promotion, illness and injury prevention, prob- lem resolution, and health restoration. They are also involved in the evaluation of the effectiveness of interventions in modifying environmental factors that influence population health.

CHAPTEr rECAP

Environmental Advocate

M04_MARY9591_06_SE_C04.indd 98 06/09/14 6:08 PM

chapter 4 environmental Influences on population health 99

be one of L.A.’s scorching summer days. After seeing her cli- ent, Janice talks to the director about the heat in the building. The director tells her that the building is always hot and that the air conditioning has never worked properly. The last time the service people came to fix the air-conditioning unit, they said it could not be repaired and would have to be replaced. The nursing home is run by a large national corporation, and the director says she has been told they will have to wait until the next budget year (October) before money will be available for a new air conditioner. Fortunately, the heating system is separate, so there will be heat when the colder weather starts.

The director says that staff members have been particularly careful about maintaining hydration in the residents during the hot weather, but many of the residents seem fatigued and listless with the heat.

1. What hazards are present in the natural, built, and social environments in this situation? What health effects, if any, are these hazards causing?

2. What levels of intervention are warranted in this situation? What might Janice do to intervene?

Agency for Toxic Substances and Diseases Registry. (n.d.). The ATSDR environmental health nursing initiative. Retrieved from http://www.atsdr. cdc.gov/EHN/

AIRNow. (2010). Air Quality Index (AQI)—A guide to air quality and your health. Retrieved from http://www.airnow.gov/index.cfm?action=aqibasics.aqi

American Lung Association. (2011). State of the air 2011. Retrieved from http:// www.stateoftheair.org/2011/assets/SOTA2011.pdf

Bell, E. (2011). Readying health services for climate change: A policy framework for regional development. American Journal of Public Health, 101, 804–813. doi:10.2105/AJPH.2010.202820

Centers for Disease Control and Prevention. (n.d.). Tips for preventing heat- related illness. Retrieved from http://www.bt.cdc.gov/disasters/extremeheat/ heattips.asp

Centers for Disease Control and Prevention. (2009). CDC policy on climate change and public health. Retrieved from http://www.cdc.gov/ climatechange/pubs/Climate_Change_Policy.pdf

Centers for Disease Control and Prevention. (2011a). CDC 2011 estimates: Findings . Retrieved from http://www.cdc.gov/foodborneburden /2011-foodborne-estimates.html

Centers for Disease Control and Prevention. (2011b). Drinking water week 2011. Morbidity and Mortality Weekly Report, 60, 517.

Chomel, B. B., & Sun, B. (2011). Zoonoses in the bedroom. Emerging Infectious Diseases, 17, 167–171. doi:10.3201/eid1702101070

Cramer, M. E., Roberts, S., & Stevens, E. (2011). Landlord attitudes and behaviors regarding smoke-free policies: Implications for voluntary policy change. Public Health Nursing, 28, 3–12. doi:10.1111/j.1525-1446.2010. 00904.x

Division of Foodborne, Waterborne, and Environmental Diseases. (n.d.). CDC and the safe water system. Retrieved from http://www.cdc.gov/safewater/ PDF/SWS-Overview-factsheet508c.pdf

Division of Foodborne, Waterborne, and Environmental Diseases. (2011a). Botulism caused by consumption of commercially produced potato soups stored improperly—Ohio and Georgia, 2011. Morbidity and Mortality Weekly Report, 60, 890.

Division of Foodborne, Waterborne, and Environmental Diseases. (2011b). Vital signs: Incidence and trends of infection with pathogens transmitted commonly through food—Foodborne Diseases Active Surveillance Network, 10 U.S. sites, 1996–2010. Morbidity and Mortality Weekly Report, 60, 749–755.

Division of Parasitic Diseases and Malaria, (2011). Raccoon roundworms in pet kinkajous—Three states, 1999 and 2010. Morbidity and Mortality Weekly Report, 60, 302–305.

Division of Surveillance, Hazard Evaluation, and Field Studies. (2011). Adult blood lead epidemiology and surveillance—United States, 2008–2009. Morbidity and Mortality Weekly Report, 60, 841–845.

Environmental Integrity Project. (2011). Hazardous pollution from factory farms: An analysis of EPA's National Air Emissions Monitoring study. Retrieved from http://www.environmentalintegrity.org/documents /HazardousPollutionfromFactoryFarms.pdf

Environmental Protection Agency. (2010a). FY 2011-2011 EPA strategic plan: Achieving our vision. Washington, DC: Author.

Environmental Protection Agency. (2010b). Sources of pollutants in the ambient air. Retrieved from http://www.epa.gov/apti/course422/ap3.html

Environmental Protection Agency. (2011a). Air pollution emissions overview. Retrieved from http://www.epa.gov/airquality/emissns.html

Environmental Protection Agency. (2011b). Air quality trends. Retrieved from http://www.epa.gov/airtrends/aqtrends.html

Environmental Protection Agency. (2011c). Clean Air Act. Retrieved from http://www.epa.gov/air/caa/

Environmental Protection Agency. (2011d). Drinking water contaminants. Retrieved from http://water.epa.gov/drink/contaminants/index.cfm

Environmental Protection Agency. (2011e). Endangerment and cause or contribute findings for greenhouse gases under Section 202(a) of the Clean Air Act. Retrieved from http://www.epa.gov/climatechange/endangerment.html

Environmental Protection Agency. (2011f). Summary of the Clean Water Act. Retrieved from http://www.epa.gov/regulations/laws/cwa.html

Environmental Protection Agency. (2011g). Superfund—Basic information. Retrieved from http://www.epa.gov/superfund/about.htm

Environmental Protection Agency. (2011h). Sustainability : Basic information. Retrieved from http://www.epa.gov/sustainability/basicinfo. htm#sustainability

Environmental Protection Agency. (2011i). Wastes—Hazardous waste. Retrieved from http://www.epa.gov/osw/hazard/

Environmental Protection Agency. (2012). Radiation protection: Health effects. Retrieved from http://www.epa.gov/rpdweb00/understand/health_effects.html

Finkel, M. L., & Law, A. (2011). The rush to drill for natural gas: A public health cautionary tale. American Journal of Public Health, 101, 784–785. doi:10.2105/AJPH.2010.300089

RefeRences

M04_MARY9591_06_SE_C04.indd 99 08/09/14 4:04 PM

100 unit 2 influences on Population health

Freedman, V. A., Grafova, I. B., & Rogowski, J. (2011). Neighborhoods and chronic disease onset in later life. American Journal of Public Health, 101, 79–86. doi:10.2105/AJPH.2009.178640

Gibson, D. M. (2011). The neighborhood food environment and adult weight status: Estimates from longitudinal data. American Journal of Public Health, 101, 71–78. doi:10.2105/AJPH.2009.187567

Gilden, R . (2010). Environmental health scope and standards of prac t ice . Ret r ie ved f rom http : / /envirn .org/pg/groups/3755/ environmental-health-scope-and-standards-of-practice/

Global Health Council, (2009). Improving global health with clean water and sanitation. Retrieved from http://www.globalhealth.org/images/pdf/ publications/200903_fact_sheet_clean_water.pdf

Isakower, I. (2011). The impact of GHG regulations. Retrieved from http:// blog.energytomorrow.org/2011/02/the-impact-of-ghg-regulations. html?gclid=CMmfzuj2kKoCFSE_gwodJT2Xzg

James, P. J., Troped, P. J., Hart, J. E., Joshu, C. E., Colditz, G. A., Brownson, R. C., . . . Laden, F. (2013). Urban sprawl, physical activity, and body mass index: Nurses’ Health Study and Nurses’ Health Study II. American Journal of Public Health, 103, 369-375. doi: 10.2105/AJPH.2011.300449

Joseph, J. T., Roy, S. S., Shams, N., Visitainer, P., Nadelman, R. B., Hosur, S., …, Wormser, G. P. (2011). Babesiosis in Lower Hudson Valley, New York, USA. Emerging Infectious Diseases, 17, 843–847.

Kovats, S. (2006). Climate change: Vector-borne diseases. In P. Wilkinson (Ed.), Environmental epidemiology (pp. 160–172). New York: McGraw-Hill Education.

Levy, B., S., & Sidel, V. W. (2011). Water rights and water fights: Preventing and resolving conflicts before they boil over. American Journal of Public Health, 101, 778–779. doi:10.2105/AJPH.2010.194670

Mathies, F., Bickler, G., Marin, N. C., & Hales, S. (Eds.). (2008). Heat health action plans: Guidance. Retrieved from http://www.euro.who.int/__data/ assets/pdf_file/0006/95919/E91347.pdf

McCarrier, K. P., Zimmerman, F. J., Ralston, J. D., & Martin, D. P. (2011). Associations between minimum wage policy and access to health care: Evidence from the Behavioral Risk Factor Surveillance System, 1996– 2007. American Journal of Public Health, 101, 359–367. doi:10.2105/ AJPH.2006.108928

McDonald, L. (Ed.). (2004). Florence Nightingale public health care. Waterloo, ON: Wildfrid Laurier University Press.

Mendez, D., Alshanqeety, O., Warner, K. E., Lantz, P. M., & Courant, P. N. (2011). The impact of declining smoking on radon-related lung cancer in the United States. American Journal of Public Health, 101, 310–314. doi:10.2105/AJPH.2009.1892250

Michael, A., & Beaglehole, R. (2009). The global context for public health. In R. Beaglehole & R. Bonita (Eds.), Global public health: A new era (2nd ed., pp. 1–22). Oxford, UK: Oxford University Press.

Moore, J. B., Jilcott, S. B., Shores, K. A., Evenson, K. R., Brownson, R. C., & Novick, L. F. (2010). A qualitative examination of perceived barriers and facilitators of physical activity for urban and rural youth. Health Education Research, 25, 355–367. doi:10.1093/her/cyq004

Murphree, R., Warkentin, J. V., Dunn, J. R., Schaffner, W., & Jones, T. F. (2011). Elephant-to-human transmission of tuberculosis, 2009. Emerging Infectious Diseases, 17, 366–370. doi:10.3201/eid1703101668

National Aeronautics and Space Administration, Earth Observatory. (n.d.). Global warming. Retrieved from http://earthobservatory.nasa.gov/Features/ GlobalWarming/page2.php

National Association of State Public Health Veterinarians. (2011). Compendium of measures to prevent disease associated with animals in public health settings, 2011. Morbidity and Mortality Weekly Report, 60(RR-4), 1–23.

National Center for Chronic Disease Prevention and Health Promotion. (2011). State smoke-free laws for worksites, restaurants, and bars—United States, 2000–2010. Morbidity and Mortality Weekly Report, 60, 472–475.

National Center for Emerging and Zoonotic Infections, (2010). Human rabies— Virginia, 2009. Morbidity and Mortality Weekly Report, 59, 1236–1238.

National Center for Emerging and Zoonotic Infections, (2011). Update on human Salmonella typhimurium infections associated with aquatic frogs—United States, 2009–2011. Morbidity and Mortality Weekly Report, 60, 628.

National Weather Service. (2011a). 2010 cold-related fatalities. Retrieved from http://www.weather.gov/om/hazstats/cold10.pdf

National Weather Service. (2011b). 2010 heat-related fatalities. Retrieved from http://www.weather.gov/om/hazstats/heat10.pdf

National Weather Service. (2011c). Summary of natural hazard statistics for 2010 in the United States. Retrieved from http://www.weather.gov/om /hazstats/sum10.pdf

National Weather Service. (2011d). Weather fatalities. Retrieved from http:// www.weather.gov/om/hazstats.shtml

Natural Resources Defense Council. (n.d.). Bringing safe water to the world. Retrieved from http://www.nrdc.org/international/safewater.asp

Natural Resources Defense Council. (2012). Water facts. Retrieved from http:// www.nrdc.org/water/sanitation/files/sani.pdf

New York State Department of Health. (2009). Lead exposure risk assessment questionnaire for children. Retrieved from http://www.health.state.ny.us/ environmental/lead/exposure/childhood/risk_assessment.htm

Occupational Safety and Health Administration. (2013). Non-ionizing radiation. Retrieved from https://www.osha.gov/pls/oshaweb/owadisp. show_document?p_table=STANDARDS&p_id=9745

OMB Watch. (2010). As Senate defeats challenges to climate finding, EPA faces additional trials. Retrieved from http://www.ombwatch.org/node/11070

Pappas, G. (2011). Pakistan and water: New pressures on global security and human health. American Journal of Public Health, 101, 786–788. doi:10.2105/AJPH.2010.300009

Parra, D. C., McKenzie, T. L., Ribeiro, I. C., Hino, A. A. F., Dreisinger, M., Coniglio, K., …, Simoes, E. J. (2010). Assessing physical activity in public parks in Brazil using systematic observation. American Journal of Public Health, 100, 1420–1426. doi:10-2105/AJPH.2009.181230

Pope, A. M., Snyder, M. A., & Mood, L. H. (Eds.). (1995). Nursing, health, and environment: Strengthening the relationship to improve the public's health. Washington, DC: National Academy Press.

Prüss-Üstün, A., & Corvalán, C. (2006). Preventing disease through healthy environments: Toward an estimate of the environmental burden of disease. Geneva, Switzerland: World Health Organization.

Raymond, J., Wheeler, W., & Brown, M. J. (2011, January 14). Inadequate and unhealthy housing, 2007 and 2009. Morbidity and Mortality Weekly Report, 60(Suppl.), 21–27.

Reitzel, L. R., Cromley, E. K., Li, Y., Cao, Y., Dela Mater, R., Mazas, C. A., …, Wetter, D. W. (2011). The effect of tobacco outlet density and proximity on smoking cessation. American Journal of Public Health, 101, 315–320. doi:10.2105/AJPH.2010.191676

Reitzel, L. R., Regan, S. D., Nguyen, N., Cromley, E. K., Strong, L. L., Wetter, D. W., & McNeill, L. H. (2014). Density and proximity of fast food restaurants and body mass index among African Americans. American Journal of Public Health, 104, 110–116. doi: 10.2105/AJPH.2012.301140

Resnick, D. B. (2010). Urban sprawl, smart growth, and deliberative democracy. American Journal of Public Health, 100, 1852–1856. doi:10.2105/ AJPH.2009.182501

M04_MARY9591_06_SE_C04.indd 100 06/09/14 6:08 PM

chapter 4 environmental Influences on population health 101

Rezick, J. S., & Fee, E. (2011). Voices from the past. American Journal of Public Health, 101, 1050–1053. doi:10.2105/AJPH.2010.300022

Rung, A. L., Broyles, S. T., Mowen, A. J., Gustat, J., & Sothern, M. S. (2011). Escaping to and being active in neighborhood parks: Park use in a post disaster setting. Disasters, 35, 383–403. doi:10.1111/j.0361-3666.2010.01217.x

Schools divert trash at football games. (2011, April). The Nation's Health, 17. Szwarcwald, C. L., de Mota, J. C., Damacena, G. N., & Pereira, T. G. S. (2011).

Health inequalities in Rio de Janeiro, Brazil: Lower health life expectancy in socioeconomically disadvantaged areas. American Journal of Public Health, 101, 517–523. doi:10.2105/AJPH.2010.195453

Takaro, T. K., Krieger, J., Song, L., Sharify, D., & Beaudet, N. (2011). The breathe-easy home: The impact of asthma-friendly home construction on clinical outcomes and trigger exposure. American Journal of Public Health, 101, 55–62. doi:10.2105/AJPH.2010.300008

Texas Department of State Health Services. (2011). Risk assessment for lead exposure: Parent questionnaire. Retrieved from http://www.dshs.state.tx.us/ lead/pdf_files/pb_110_parent_questionnaire.pdf

UC Davis Veterinary Medicine. (n.d.). PREDICT: Building a global early warning system for emerging diseases that move between animals and people. Retrieved from http://www.vetmed.ucdavis.edu/ohi/predict/index.cfm

U.S. Agency for International Development. (2007). Best practices in social marketing safe water treatment solution for household water treatment: Lessons learned from Population Services International Field Programs. Washington, DC: Author. Retrieved from http://pdf.usaid.gov/pdf_docs /PNADI479.pdf

U.S. Agency for International Development. (2011). Predict. Retrieved from http://www.healthmap.org/predict/

U.S. Census Bureau. (2011a). Statistical abstract of the United States—Table 373. Municipal solid waste generation, materials recovery, combustion with energy recovery, and discards: 1980–2008 (p. 229). Retrieved from http://www .census.gov/compendia/statab/2011/tables/11s0373.pdf

U.S. Census Bureau. (2011b). Statistical abstract of the United States— Table 377. Toxic chemical releases and transfers by media: 2003 to 2008 (p. 231). Retrieved from http://www.census.gov/compendia/statab/2011/tables/11s0377.pdf

U.S. Census Bureau. (2011c). Statistical abstract of the United States—Table 381. Hazardous waste generated, shipped, and received by state and other areas (p. 233). Retrieved from http://www.census.gov/compendia/statab/2011/ tables/11s0381.pdf

U.S. Department of Health and Human Services. (2012). 2012 Environmental justice strategy and implementation plan. Retrieved from http://www.hhs. gov/environmentaljustice/strategy.pdf

U.S. Department of Health and Human Services, (2014). Environmental health. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/ overview.aspx?topicId=12

U.S. Energy Information Administration, (2011). What’s new in our home energy use? Retrieved from http://www.eia.gov/consumption/residential/ reports/2009overview.cfm

U.S. Energy Information Administration, (2012). Residential Energy Consumption Survey data show decreased household energy consumption per household. Retrieved from http://www.eia.gov/todayinenergy/detail. cfm?id=6570#

U.S. Energy Information Administration. (2013a). Energy in brief: What are the major sources and users of energy in the United States? Retrieved from http:// www.eia.gov/energy_in_brief/article/major_energy_sources_and_users.cfm

U.S. Energy Information Administration. (2013b). Manufacturing Energy Consumption Survey (MCES). Retrieved from http://www.eia.gov/consumption/ manufacturing/reports/2010/decrease_use.cfm?src=‹Consumption-f2

U.S. Energy Information Administration. (2014). Primary energy consumption by source. Retrieved from http://www.eia.gov/totalenergy/data/monthly/ pdf/sec1_7.pdf

U.S. Geological Survey, (2014). Source and use of water in the United States, 2005. Retrieved from http://water.usgs.gov/edu/wateruse-diagrams.html

Watts, S. (2003). Disease and medicine in world history. New York: Routledge. West, L. (2014).Global warming leads to 150,000 deaths every year. Retrieved

from http://environment.about.com/od/globalwarmingandhealth/a/gw_ deaths.htm

World Bank. (2011). What is social capital? Retrieved from http://web.worldbank .org/WBSITE/EXTERNAL/TOPICS/EXTSOCIALDEVELOPMENT/EXTT SOCIALCAPITAL/0,,contentMDK:20185164~menuPK:418217~pagePK:14 8956~piPK:216618~theSitePK:401015,00.html

World Health Organization. (2011). Environmental health. Retrieved from http://www.who.int/topics/environmental_health/en/

World Health Organization & United Nations Children’s Fund. (2014). Progress on drinking water and sanitation, 2014 update. Retrieved from http://apps. who.int/iris/bitstream/10665/112727/1/9789241507240_eng.pdf

World Wildlife Federation. (n.d.). Ecological footprint. Retrieved from http:// wwf.panda.org/about_our_earth/teacher_resources/webfieldtrips/ ecological_balance/eco_footprint/

Yumul, G. P. Jr., Cruz, N. A., Servando, N. T., & Dimalanta, C. B. (2011). Extreme weather events and related disasters of the Philippines, 2004–08: A sign of what climate change will mean? Disasters, 35, 262–282. doi:10.1111/j.0361-3666.2010.01216.x

M04_MARY9591_06_SE_C04.indd 101 08/09/14 7:39 PM

chaPter

5 Cultural Influences on Population Health

ableism

acculturation

assimilation

complementary and alternative medicine

cultural competency

culturally congruent care

cultural imposition

culture

culture-bound syndromes

discrimination

ethnicity

fatalism

health culture

health literacy

individual religiosity

integrative medicine

linguistic competence

nationality

organizational culture

pluralism

prejudice

race

racism

social religiosity

stereotyping

worldview

xenophobia

Key Terms

Learning Outcomes

After reading this chapter, you should be able to:

1. Differentiate among culture, race, nationality, and ethnicity.

2. Discuss direct and indirect influences of culture on health and health care.

3. Describe cultural competence.

4. Identify barriers to cultural competence.

5. Conduct a cultural assessment of an individual, family, group, or health system.

6. Design, implement, and evaluate culturally competent care and health care delivery systems.

M05_MARY9591_06_SE_C05.indd 102 06/09/14 6:09 PM

103

Helper Woman

Like many nurses of her generation, Elinor Delight Gregg went against the expectations of her family to pursue a career in nursing. As the youngest daughter, Elinor was expected to stay at home to care for aging parents, and at one point actually interrupted her career to care for her increasingly debilitated father. Elinor’s early career encompassed positions in a variety of different fields, including industrial nursing, as Assistant Superintendent of Nurses at Cleveland City Hospital, as Superintendent of Infant’s Hospital in Boston, and as a Red Cross Nurse in Europe during World War I (Pflaum, 1996). After the war, she completed postgraduate work in public health nursing at Simmons College (van Betten & Moriarty, 2004).

In 1922, Elinor accepted a position as a Red Cross Nurse on loan to the Bureau of Indian Affairs and was assigned to the Pine Ridge and Rosebud Reservations in South Dakota. In an era when the focus in the Bureau was on assimilation into the mainstream society, Elinor displayed a level of cultural sensitivity that led to her adoption as a member of the Sioux with the name “Helper Woman.” Throughout her 2-year tenure on the reservation, she focused on trying to improve the living conditions of the residents as well as their access to health care. In one report, she wrote:

“This report sounds as if my mind were more occupied with social problems than with nurs- ing activities. After all, what is done effectively in nursing lines depends so much on the proper adjustment to the existing social structures that the thorough knowledge of the social structure should come first” (quoted in Pflaum, 1996, p. 100).

In addition to providing direct care in a clinic in her home, she traveled the reservation noting the needs of the population and agitating among supervisors in Washington, DC, for appropriate medi- cal and nursing personnel. As a result of her work on the reservation, Elinor was made Supervisor of Public Health Nursing for the Bureau of Indian Affairs and spent the remainder of her career travel- ing to reservations across the country assessing needs and recruiting qualified nurses to address those needs. During her tenure in the Bureau, the size of the health workforce increased by 600%. Even in retirement, Elinor continued her advocacy for the needs of ethnic populations through volun- teer work at a free clinic serving the Hispanic population in Santa Fe, New Mexico (Pflaum, 1996).

A d

vo ca

cy N

ow Meeting the Needs of an Ethnic Population Hollywood, California, is often equated with wealthy movie stars, but there is a growing ethnic popu- lation in the area as well. In fact, one local area is officially known as Koreatown, with 23% of its population of Korean descent. Members of this community, like other ethnic groups, often experience culture shock when encountering scientific health care systems. Problems encountered are as widely varied as language barriers, lack of ethnic food choices in hospital menus, and the inability to have family members present. Recognizing the effects of these issues on the health of the population, Hollywood Presbyterian Medical Center created a Korean Care Center (KCC) which later became the Asian Pavilion dedicated to meeting the needs of clients from multiple Asian countries. The KCC em- ploys bilingual nurses who speak Korean and provides culturally appropriate food choices as well as access to Korean television and newspapers. In addition, the center provides an environment in which family can engage in their traditional roles in the care of ill members. In fact, nursing staff are asked to identify a family member as a patient care partner during the client’s hospital stay (Magda, 2010).

Efforts to modify health care services to meet the needs of ethnically diverse clients do not have to be as extensive as those initiated by Hollywood Presbyterian Medical Center. What actions might be taken in health care systems with which you are familiar to better meet the needs of these populations?

A d

vo ca

cy T

h en

M05_MARY9591_06_SE_C05.indd 103 06/09/14 6:09 PM

104 Unit 2 influences on Population health

W hy study culture? The most obvious answer, of course, is to enable us to provide effective care for the increasingly diverse populations that we serve. There are, however, other reasons as well. Each of us is the product of a cultural background that in- fluences, often unconsciously, our thoughts, beliefs, values, at- titudes, and behaviors. When we are unaware of the influences of culture on our own behaviors, we are less able to recognize how our attitudes and behaviors influence others. The more we know about culture in general, and our own culture in par- ticular, the better able we are to modify our interactions with others to provide effective care. In addition, as nurses, we are immersed in a biomedical culture; the influences of which are again often unrecognized. Awareness of the influences of the biomedical culture on our practice can assist us to modify ele- ments of that culture that impede effective health care. Finally, as nurses, we generally work with health care institutions and organizations that have their own distinct cultures. If we are to work effectively within these organizations, we must conform to the cultural expectations others have of us. Similarly, recog- nition of organizational culture and its influence on practice can help us modify health care systems to better meet the needs of clients from diverse cultural backgrounds.

The principles of cultural assessment and cultural compe- tence can be applied in client care situations as well as profes- sional interactions within nursing and between nursing and other disciplines. Throughout this chapter, we will examine cultural principles as they relate to traditional ethnic cultures, the dominant U.S. culture, biomedical culture, and organiza- tional culture.

Basic Concepts Related to Culture and Health Culture is often equated with ethnicity, nationality, or race. As we saw above, however, groups other than ethnic minorities or national populations are influenced by culture. Similarly, cul- ture may cut across racial or ethnic groups. For example, both White nurses and nurses of color are imbued with the culture of nursing, which cuts across racial boundaries. Similarly, Arab Muslims and African American Muslims subscribe to similar aspects of culture derived from their adherence to Islam, but display other cultural beliefs and behaviors unique to their ethnic heritage. As an example of the interaction of race and ethnicity, the population categories included in the most recent census subdivided racial categories of Black and White into subcategories of Black/Hispanic, Black/non-Hispanic, White/ Hispanic, and White/non-Hispanic, combining features of race and ethnicity to create more informative categories.

Culture has been described as “a system of symbols and meanings that members of a group use to make sense of their world” (Green, 2010, p. 28). In other words, culture is the way that people think about their world and interact with it. For our purposes, culture is defined as the ways of thinking and

acting developed by a group of people that permit them to in- teract effectively with their environment and to address con- cerns common to the human condition. A group’s worldview, which shapes culture, is their way of looking at their universe and their relationship to that universe.

Ethnicity, on the other hand, is defined as “belonging to a common group with shared heritage, often linked by race, nationality and language” (Edmonton Seniors Coordinating Council, n.d.). An ethnic group usually has a relatively homo- geneous social culture. Ethnicity is self-defined and may be influenced by one’s personal, social, and political experiences. Ethnicity is also a fluid concept and may change over time or with the situation. For example, I generally perceive myself as American, but in some contexts, I would describe myself in terms of my largely German heritage. Nationality usually re- fers to one’s country of birth, but may also refer to a country adopted for permanent residence. Again, nationality may cut across ethnic and racial designations. For example, citizens of the United States consider themselves Americans (nationality), but include members of all three racial groups (White, Black, and Asian) as well as multiple ethnicities (e.g., German Ameri- cans, Irish Americans, African Americans).

Hmong residents in the United States maintain their cultural heritage with traditional New Year’s costumes and celebrations. (Photo by Mary Jo Clark)

M05_MARY9591_06_SE_C05.indd 104 06/09/14 6:09 PM

chaPter 5 cultural influences on Population health 105

Race is an artificial categorization of people based on ge- netic inheritance and such physical characteristics as skin color, blood type, hair color and texture, and eye color or shape. Much of the demographic and other information used for planning health care delivery services (e.g., census data, morbidity, and mortality data) is categorized on the basis of race. The five categories currently used by the Office of Man- agement and Budget (OMB) for national data purposes are Black or African American, White, Asian, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander. The OMB also collects ethnicity data related to Hispanic or non-Hispanic origin. In a 2009 report, however, the Institute of Medicine (IOM) recommended the expansion of data catego- ries to include the OMB racial and ethnic designations along with “granular ethnicity” data and information about preferred language and English proficiency in the population. Granular ethnicity refers to more in-depth exploration of ethnicity as, for example, Puerto Rican or Cuban, rather than merely Hispanic (Ulmer, McFadden, & Nerenz, 2009).

Societal or ethnic culture is most often learned within the family, but is also transmitted in one’s day-to-day interactions with other members of the group. Biomedical and professional cultures, on the other hand, are learned in the context of spe- cific educational preparation and through interactions with others in professional practice. Similarly, the organizational culture of the workplace is transmitted through both formal and informal mechanisms in the workplace (e.g., through for- mal orientation programs and through everyday interactions with supervisors and coworkers).

Culture is not static and is undergoing constant change even if that change is very slow. The culture of a specific group is influenced by interactions within and outside the group and is constantly being renegotiated and redefined in different con- texts. For example, migration from one’s country of origin to another country usually results in profound changes in culture as a result of interactions between members of the cultural group and those of the dominant culture. The aspects of cul- ture that influence the behavior of members include values, be- liefs, and customs or behaviors. The interrelationship of these factors has been conceptualized as a pyramid. Values serve as the broad foundation or base of the pyramid and are the com- ponent of culture that is the least amenable to change. Beliefs rest on the foundation of values and are somewhat more open to change. Finally, customs or behaviors flow from beliefs and form the apex of the pyramid. Customs and behaviors with a cultural basis are much more easily modified than either beliefs or values (Hulme, 2010).

Even though culture affects virtually every aspect of life, its influence is largely unconscious. The influence of culture is rarely consciously noted, unless one purposefully undertakes a study of one’s own culturally determined behavior. This is why nurses need to become aware of their own cultural beliefs, bi- ases, and behaviors in order to understand their influence on interactions with clients and with members of other health care disciplines.

Some authors have noted that culture is an individual concept as well as a group phenomenon. In addition, culture is a facet of organizations. The culture of any particular group is unique. Although several cultures may exhibit certain commonalities, no two cultures, like no two individuals, are exactly alike. The beliefs and behaviors that constitute a particular culture arise from the unique constraints faced by a given group of people in dealing with problems common to humanity. These unique situational constraints are the source of cultural variation among groups of people. For example, the arid nature of the southwestern United States has led to water conservation practices among residents of the region that would not be seen in other parts of the country. Similarly, although the cultures of nursing and medicine have some commonalities, they also have many distinct differences. Likewise, the organizational culture of one health care institu- tion may differ markedly from that of another institution even though both exist for the same basic purpose.

Even within a cultural group, there is considerable varia- tion among group members. Each individual exhibits a unique blending of various cultures to which he or she belongs. Some authors note that culture is “taken up selectively” by indi- viduals within a group, with adherence to some aspects of the typical culture and nonadherence to others. Intracultural vari- ability exists within cultural groups because culture is not the only factor that influences behavior and because people engage in interactions with others outside the cultural group and re- spond differently to circumstances based on those interactions. Not only do members of a particular group vary with respect to adherence to the behavioral aspects of culture, but they may also not be homogenous even with respect to genetic traits. Af- rican Americans, for example, represent a gene pool of more than 100 different genetic strains, making for a great deal of variation within the group (Campinha-Bacote, 2009).

Variability also occurs within professional cultures. A par- ticular nurse, for example, may not always believe or act in ways typical of nursing’s culture. Similarly, not all members of an ethnic population exhibit the beliefs and behaviors typical of the group. Adherence to the values and behaviors of a particu- lar culture is influenced by the extent of one’s acculturation. Acculturation is a process by which people react to contact with another culture, adopting some features of the new cul- ture, while retaining elements of their own culture, to develop a new composite culture (Acculturation, n.d.). Acculturation involves the acquisition of at least some of the beliefs, values, and behaviors of another culture (Hulme, 2010). Acculturation usually occurs because such adaptation is required for survival in a new environment. For members of ethnic groups, accul- turation is usually considered in terms of their acquisition of beliefs, values, and behaviors typical of the dominant societal culture, and members of a given cultural group may exhibit various levels of adherence to the beliefs, values, and behaviors of that group. Some people, for example, maintain a traditional cultural stance, adhering strongly to the culture of their family of origin. Others are bicultural, and are equally at home in tra- ditional and dominant cultures.

M05_MARY9591_06_SE_C05.indd 105 06/09/14 6:09 PM

106 Unit 2 influences on Population health

Acculturation is not only seen in movement from ethnic cultural traditions to those of the dominant culture, but is also reflected in the degree to which gay and lesbian individu- als subscribe to the mores of those subcultural groups. Finally, some people may be marginal in their cultural affiliations, with little interaction with either a culture of origin or the dominant culture. Many homeless individuals may be considered cultur- ally marginalized.

Acculturation also takes place in other venues. Your nurs- ing education, for example, is designed to promote your ac- culturation to the nursing profession and its unique culture. In the same way, you are becoming acculturated to the overall biomedical culture. You will also need to become acculturated to a certain extent to the health care institution or agency that employs you, if you are to be successful there. In all of these examples, acculturation may have both positive and negative effects. Assimilation is a process similar to acculturation, but goes even further. Assimilation involves complete acceptance of the values, beliefs, customs, behaviors, and so on of another

cultural group (Hulme, 2010). In other contexts, assimilation may be conceived of as “going native.”

Additional concepts that relate to cultural considerations include pluralism, stereotyping, cultural imposition, discrimi- nation, and cultural competence. Pluralism involves the pres- ence of multiple distinct entities or groups within a society. These distinct groups may be the result of differences in cul- ture, ethnicity, nationality, religion, or other characteristics (Hulme, 2010). Stereotyping is defined as an “exaggerated over-generalization” about a group of people based on limited knowledge (Campinha-Bacote, 2009). Stereotyping often re- sults from a tendency to react to people on the basis of what one thinks is typical of a group with which they are associated. One is tempted to apply what one knows about a given culture to all of the members of the culture in spite of the intracultural variation discussed earlier. Knowledge of some facets of a cul- ture may be used as a starting point for intercultural interac- tions, but should not be acted upon until its accuracy has been validated with the individual client.

Cultural imposition is an expectation that others will con- form to the dictates of one’s own culture. Expecting hospital- ized clients to bathe at times convenient to hospital routine is an example of imposing health care culture on clients whose own behaviors may be quite different. Discrimination involves being treated differently than others based on some perceived trait or characteristic or membership in a particular group. At the health care organizational level, discrimination may take the form of “institutional racism,” which has been described as “collective failure of an organization to provide an appropriate and professional service to people because of their color, cul- ture, or ethnic origin” (as quoted in Hulme, 2010, p. 275). We will explore some of the health-related effects of discrimination later in this chapter.

Cultural competence, on the other hand, is a positive re- sponse to the cultural diversity encountered in today’s health care system. Cultural competency has been defined as

A developmental process in which individuals or institutions achieve increasing levels of awareness, knowledge, and skills along a cultural competence continuum. Cultural competence involves valuing diversity, conducting self-assessments, avoid- ing stereotyping, managing the dynamics of differences, ac- quiring and institutionalizing cultural knowledge, and adapting to diversity and cultural contexts in communities. (Office of Minority Health [OMH], 2013a, p. 139)

Characteristics of cultural competence and strategies for promoting culturally congruent health care encounters will be addressed in more detail later in this chapter.

Culture and Health Culture, whether it is that of an ethnic group, the dominant society, a professional discipline, or health professionals as a group, has both positive and negative health consequences. For example, the dominant U.S. culture values cure of disease, often through the use of expensive technology. This cultural

Traditional music enables some cultural groups to maintain their heritage. (Abbitt/Fotolia)

M05_MARY9591_06_SE_C05.indd 106 06/09/14 6:09 PM

chaPter 5 cultural influences on Population health 107

value results in extensive expenditures for costly high- technology therapies and little attention to health promotion and illness prevention needs. At the same time, the dominant culture values an attractive physical appearance, which may lead people to engage in more exercise activities than they would if uninfluenced by this value.

Ethnic/Societal Culture and Health Ethnic minority cultures and the dominant societal culture have both direct and indirect effects on health. Direct effects stem from specific culturally prescribed practices related to diet and food or to health and illness. For example, all cultures have prescribed practices intended to promote health and prevent illness or to restore health when illness occurs. Similarly, all cultures have particular dietary practices that influence nutri- tional status and, thereby, the health status of their members. For example, the typical diets of many ethnic minority groups are basically healthful, but some dietary practices (e.g., the pre- ponderance of fried food in the southern United States) have negative health effects. Similarly, the prevalence of fast food and “super sizing” in the dominant culture contributes to obe- sity and other adverse health effects.

Ethnic and societal cultures also affect health indirectly. Some of these indirect effects result from cultural definitions of health and illness, acceptability of health care programs and providers, and cultural influences on compliance with suggested health or illness regimens. Cultural definitions of health and illness determine what kinds of health problems are considered worthy of attention and what conditions are likely to be disregarded. If, for example, certain behaviors that are perceived as evidence of mental illness by health profes- sionals are considered normal in the client’s culture, then the client is unlikely to take any action to deal with those behav- iors. Similarly, minor illnesses may be ignored if health is de- fined in terms of one’s ability to work or to perform other social roles. In general, people are likely to disregard any type of condition that is not defined as illness in their own culture. This cultural propensity can lead to serious health consequences.

Cultural factors may also determine the acceptability of both health programs and health providers. For example, cul- tures that eschew scientific medicine in favor of healing based on faith in God may view immunization programs as inimical to their beliefs. In other cultures, health care providers may be considered lower-class persons not to be associated with, effec- tively preventing people from taking advantage of many health opportunities.

Cultural factors often determine whether clients will comply with recommendations when they do seek professional help. Culture gives rise to certain expectations regarding treatment. If health care providers’ recommendations are too far removed from these expectations, the provider loses credibility, and the client is unlikely to comply with those recommendations. For example, in the dominant U.S. culture, clients have come to

expect health care providers to address most health problems with prescription medications. When no prescription is pro- vided, even though the health problem doesn’t really require medication, clients may be dissatisfied with care and fail to follow through on other more appropriate recommendations, such as dietary changes, weight loss, and so on.

Biomedical Culture and Health Health culture has been defined as “a system that attempts to explain and treat sickness and to maintain health. Health cul- tures are a component of the larger culture or tradition of a people and may be a popular or folk system or a technical or scientific one” (Health culture, n.d.). As this definition implies, health cultures exist within ethnic cultures as well as within the biomedical health care system, although many health care pro- viders do not realize that their actions are often dictated by a biomedical culture.

Biomedical culture is characterized by several prominent features, including mind–body dualism, conceptualizations of disease versus illness, and a focus on cure over care (Crowley- Matoka, Saha, Dobscha, & Burgess, 2009). Mind–body dualism refers to the generalized belief in the biomedical system that the mind and body are separate entities, with the physical body taking priority over issues related to the mind. In addition, biomedical culture tends to focus on disease, the visible mani- festations of ill health noted in anatomical and physiological changes. An illness focus, on the other hand, emphasizes the social context of ill health and its effects on clients’ lives in ad- dition to physical signs and symptoms. Finally, biomedical cul- ture revolves around strategies for the cure of physical diseases rather than on the care of the individual who is experiencing it. These characteristic features differ markedly from the con- ceptualizations of ethnic health cultures and may contribute to difficulties in intercultural interactions.

Like ethnic and dominant societal cultures, the overall bio- medical culture and the cultures of professional health disci- plines and organizations may have both positive and negative influences on the health of population groups. The emphasis on the provider as an authority and the client as subordinate that pervades the biomedical culture may lead clients to forgo health care in an effort to control their own lives and health or to fail to accept responsibility for health actions on their own behalf. Unfortunately, health professionals often fail to recog- nize the influence of the biomedical culture and the dominant societal culture on their practice, and may see biomedicine as having been “purged” of cultural influences by its reliance on objective scientific evidence.

Authors in the health professions and other disciplines give a variety of examples of the cultural rituals and artifacts em- bedded in the biomedical culture. For example, the use of the hospital gown in biomedically oriented hospitals is a ritual that conveys the dependence of the client on the institution and their loss of autonomy with respect to even their own apparel. Similar rituals include meals served at specific times whether

M05_MARY9591_06_SE_C05.indd 107 06/09/14 6:09 PM

108 Unit 2 influences on Population health

clients are hungry or not and the need to schedule an appoint- ment to receive services in most biomedical organizations. These cultural rituals within the biomedical and health profes- sional communities are primarily based on dominant cultural values of efficiency and time consciousness.

The biomedical culture in the United States has also been characterized by vacillation between risk taking and risk avoid- ance. There is a tendency to want to try new things, such as experimental therapies, mixed with distrust of new ideas. Negative health effects can result from either perspective. For example, clients may be pressured to agree to new treatments with undetermined efficacy. Conversely, providers may resist implementation of evidence-based practice guidelines.

Culture may also have adverse effects on the health profes- sions themselves. For example, some nurse authors have cited the lack of cultural sensitivity in the NCLEX-RN exam as a contributing factor in the dearth of nurses representative of ethnic minority groups and in the exacerbation of the nurs- ing shortage. In addition, the cost of preparing for and taking the examination itself may disadvantage minority nurses. This may be particularly true for nurses prepared in other countries whose programs may not include some of the content tested on the examination. Even within the United States, nurses edu- cated in Puerto Rico are successful on Puerto Rican advanced practice certification examinations, but have difficulty with na- tional certification examinations due to language and cultural differences.

Ethnic Diversity in the United States As we noted earlier, one of the primary reasons for becoming knowledgeable about culture and its effects on health lies in the ethnic and cultural diversity of the clients that we serve. Beyond the period of early colonization of North America by settlers primarily from England, the United States has al- ways been ethnically and culturally diverse. Even in the early colonial periods, there were cultural differences in the groups that settled here. For example, many of the first settlers were members of specific religious groups seeking religious free- dom that brought their own cultures with them. Later immi- grant groups came from other Western European countries, particularly Ireland and Germany, and from other parts of the world as well. Although possessed of their own distinct cul- tures, these groups had more in common than many later im- migrant groups.

Today, the United States is more ethnically and culturally diverse than ever before. For example, the Latino/Hispanic population, constituted 12.5% of the total U.S. population in 2002, but had increased to 15.7% of the population by 2009, and is expected to comprise 17.7% of the population by 2015. In 2009, African Americans constituted 12.9% of the popula- tion, and Asians comprised another 4.5% of the population. In addition, there were 3.1 million Americans of American

Indian or Alaskan Native descent and more than 578,000 na- tive Hawaiians and Pacific Islanders compared to more than 244 million White Americans. Each of these groups is expected to increase at a greater rate than the White population between 2010 and 2015 (U.S. Census Bureau, 2013f, 2013g). Much of the change in population composition in the United States is a result of natural increase through birth, but a significant portion of it results from international migration (U.S. Census Bureau, 2013a). In 2010, for example, slightly over 12% of the U.S. population was foreign born (U.S. Census Bureau, 2013c).

Even these figures do not give a full picture of the extent of diversity in the population because of the different ethnicities represented within each of these large groups. For example, in 2009, 20% of the U.S. population spoke a language other than English at home, ranging from 35.4 million Spanish speakers to speakers of various European languages and multiple Asian lan- guages, to those who speak Arabic or a variety of Native Ameri- can languages. There is great variation even within groups that speak the same language. For example, Arabic speakers may include people from Egypt, Iraq, Jordan, Lebanon, Morocco, Palestine, and Syria among others (U.S. Census Bureau, 2013d). Similarly, the Hispanic population includes people from Spain, Mexico, Puerto Rico, and a variety of Central and South Ameri- can countries, each with its own unique culture and different health problems and service needs.

Even among the Anglo population of the United States, there are distinct cultural groups. For example, dietary patterns among Southern Whites may differ significantly from those of Caucasian groups in other areas of the country (e.g., Mid- western German Americans or Italian Americans in the north- east). Diversity also exists within cultural groups with respect to other population characteristics. For example, as an aggre- gate group, Asian Americans had higher mean family incomes than their White, Black, or American Indian/Native Alaskan counterparts in 2009, and lower rates of poverty than all groups except White Americans (U.S. Census Bureau, 2013e). On the other hand, there are considerable differences in income among different Asian subgroups. This is particularly true for foreign-born ethnic populations among whom 10.5% of house- holds had annual family incomes below $15,000 in 2010 com- pared to only 7% of native-born residents (U.S. Census Bureau, 2013c). European immigrants are less likely than their Asian or Latin American counterparts to have low family incomes (U.S. Census Bureau, 2013b).

The United States is not the only country to experience cul- tural diversity, yet diversity may be even less well recognized in other nations than in the United States. For example, a group of Japanese nursing students visiting the United States to study social and health care cultures were amazed to note the cultural diversity present there. When they were asked about cultural diversity in their own country, they indicated that there was no diversity. They were unable to recognize the cultural diversity posed by the Ainu, the original population of Japan, and the large resident Korean population as well as the wide variety of foreign visitors to Japan.

M05_MARY9591_06_SE_C05.indd 108 06/09/14 6:09 PM

chaPter 5 cultural influences on Population health 109

Assessing Cultural Influences on Health and Health Care As noted earlier, population health nurses must incorporate cultural concepts into the care of individuals and their families as well as the development and implementation of health care programs for population groups. In addition, nurses must be able to function effectively within the biomedical, professional, and organizational cultures in which they work and modify those cultures to improve population health care. To accom- plish these tasks, nurses must have knowledge of the cultural groups with which they interact. Such knowledge is derived from a cultural assessment, including assessment of the group to determine typical beliefs, values, and behaviors, and assess- ment of individual members of the group in terms of their ad- herence to those beliefs, values, and behaviors.

Principles of Cultural Assessment Four basic principles should guide the study of a culture. First, view the culture in the context in which it developed. As noted earlier, cultural practices arise out of a need to meet common human problems in a particular human setting. That setting must be considered in exploring culture.

Second, examine the underlying premise of culturally de- termined behavior. What was the intended purpose for the behavior when it originated? Does the behavior still fulfill this purpose? When one knows the underlying reason for behaviors that seem strange, the behaviors may not seem quite so strange after all. Third, the nurse examines the meaning of behavior in the cultural context. The meaning of certain behaviors from the perspective of the nurse may be very different from the be- havior’s meaning to others. Using the previous example of the hospital gown, its original purposes were to minimize spread of microorganisms via clothing brought in from the outside, pro- mote ease of access to clients for therapeutic procedures, and prevent ruin of clients’ personal clothing by blood and other substances. With the advent of washing machines, however, the first and third purposes are really no longer relevant in many situations. In fact, given the rate of nosocomial infection in hospitals, wearing one’s personal clothing might actually be safer than wearing a hospital gown. Similarly, when faced with the potential meaning attached to the practice from a client perspective of dependence and loss of autonomy, is the advan- tage of the hospital gown to providers outweighed by its dis- advantages in the provider–client relationship? Using another example, the dominant U.S. cultural values of independence and self-sufficiency make sense in the light of the historical development of the United States, but do they still serve their underlying purpose in the context of an increasingly interde- pendent global society?

Finally, there is the need to recognize intracultural varia- tion. Not every member of any given cultural group displays all of the beliefs and behaviors typical of that culture. As we saw earlier, subgroups within a cultural group may exhibit different

behavior patterns. Or individuals may be more or less adherent to the beliefs, values, attitudes, and behaviors typically expected by members of the culture. Not all Mexican Americans, for ex- ample, will demonstrate a belief in the “evil eye.” Similarly, not all perinatal providers believe that an enema is a necessary part of preparation for birth. Another term used to denote the de- gree of adherence or nonadherence to elements of a culture is heritage consistency, or the degree to which one conforms to one’s cultural heritage. Although this concept was obviously developed in relation to ethnic cultural heritages, it is equally applicable to the “tribal culture” of nursing or biomedicine. Principles of cultural assessment are summarized above.

Obtaining Cultural Information How does one become knowledgeable about a culture? Perhaps the best way to begin is to recognize the influences of culture on one’s own life and behavior. Personal insights regarding culture will enable the nurse to recognize and accept cultural beliefs and behaviors that may differ from his or her own. Once familiar with his or her own cultural heritage, the nurse can begin to read literature related to other cultures of interest. In reading, the community health nurse should examine the qual- ifications of the authors writing. Was the book or article writ- ten by a member of the culture? Is it based on empirical data derived from research, on personal experience with a particular culture, or on stereotypes? Information about a culture from the perspective of nonmembers of the culture can also be in- structive. For example, some of the sociological and social an- thropological research on professional cultures can assist us to see the elements of culture that are embedded in biomedicine or in nursing practice that we might not have identified when viewing them from inside the culture.

A second means of acquainting oneself with a culture is to interview colleagues who are members of that culture. Ex- plore with them their concepts of health and illness and at- titudes and practices affecting health. Discover how these concepts may differ from those held by previous generations or other members of their family. Health care professionals, by virtue of their knowledge of health matters, are likely to have achieved a greater degree of acculturation and conformity with the dominant U.S. culture with respect to health practices

Principles of Cultural Assessment • View all cultures in the context in which they developed.

• Examine underlying premises for culturally determined beliefs and behaviors.

• Interpret the meaning and purpose of behavior in the context of the specific culture.

• Recognize the potential for intracultural variation.

Highlights

M05_MARY9591_06_SE_C05.indd 109 06/09/14 6:09 PM

110 Unit 2 influences on Population health

than nonprofessionals from the same group. These individu- als, however, usually remain a valid source of information re- garding cultural health beliefs and practices. Such strategies are also effective in understanding the “culture” of other groups, such as members of the gay, lesbian, bisexual, and transgender (GLBT) populations (see Chapter 20 ).

You can also use this strategy of interviewing members of a culture when newly employed or considering employment in a particular health care organization. Talk about the orga- nizational culture with people who are already members of the organization. How are clients viewed? How are employ- ees viewed? How are employees expected to interact with each other? With clients? If the organizational culture seems to be too alien to your own personal culture, you may not want to work there. Clients’ perspectives on the biomedical culture can also be enlightening. How do they perceive some of the atti- tudes and behaviors typical of the culture? Do these percep- tions enhance or impede effective health care delivery?

Another effective way to become familiar with a particular culture is to spend time living within it. For example, prospective nursing students may be encouraged to engage in volunteer work or to shadow practicing nurses to explore the culture of nursing as a career option. Similarly, one might spend time living within an ethnic cultural group. This approach, however, is not always fea- sible. Alternatives include home visits to families within the group to observe daily living in the cultural context and questioning cli- ents and families regarding health-related beliefs and practices. Another possible approach is observing activities and interactions at health facilities and community or religious functions.

When assessing another culture directly, whether it is an ethnic cultural group or the organizational culture of a health care institution, the population health nurse should follow a few general guidelines. First, look and listen before asking questions or taking action. Observation aids in asking perti- nent and timely questions and forestalls actions that may be inappropriate. Second, explore how the group feels about being

studied. Explain that your reasons for studying the culture are practical and do not arise out of idle curiosity. Third, dis- cover any special protocols. Should one speak to a local leader or agency supervisor before beginning to observe a group? Is there a council or leadership group who should grant permis- sion for participation in group activities? Fourth, foster human relations, putting them before the need to obtain information. Information will not assist the nurse to provide care or func- tion effectively in a work setting if he or she alienates members of the group. Social amenities are important in many cultures and should be attended to before the “business” of information gathering begins in earnest. In fact, information about social amenities is part of the data needed by the nurse.

Many people, in exploring another culture, look for differ- ences from their own culture. The nurse, however, should also look for cultural similarities to use as a foundation in aiding clients to accept and use health care services. Cultural differ- ences should be accepted as normal.

Locate group leaders and respected residents, those con- sidered wise, “ordinary” group members, and clients who can converse knowledgeably about the culture. Critics of tradi- tional aspects of the culture may also be interviewed to provide a balanced picture.

Participate as well as observe. The nurse must assess each cul- tural situation as it occurs to determine whether participation or observation is the more appropriate activity. Participation conveys an openness to cultural differences and a willingness to engage in culturally prescribed activities rather than ridicule them. Some activities, however, are closed to outsiders, and the population health nurse’s participation would not be welcomed.

When exploring another culture, the nurse should also con- sider the feelings of group members about questions asked. The nurse should ascertain what types of questions are acceptable or offensive in a particular culture. For example, U.S. Peace Corps volunteers in India found it difficult to adjust to frequent questions about their salary or how much their clothes cost. Such questions were perfectly acceptable in Indian society, but considered impolite or “nosy” in the United States. Similarly, there may be certain questions that can safely be asked within the biomedical culture. For example, some physicians may re- spond readily to questions about a particular element of their practice or the plan of care for a client, whereas others would perceive questions as threatening to their authority. The same may be true in the employment setting, where certain ques- tions are acceptable and others are not.

A little forethought as to the phrasing and timing of questions can prevent serious mistakes. Ask questions positively with- out implying value judgments. For example, “I notice you put garlic on a string around the baby’s neck; can you tell me what it’s used for?” is far more acceptable than “Why in the world do you hang garlic around the baby’s neck?” Nurses might ask the same questions themselves and gauge their own emotional reaction to the questions. A nurse can also try out questions on colleagues who are members of the culture being explored. Sug- gested modes of cultural exploration are summarized below.

Modes of Cultural Exploration • Become conversant with your own culture and its influences

on your life.

• Review the existing literature on beliefs, values, and behaviors of specific cultural groups.

• Interview colleagues who are members of the cultural group in question.

• Immerse yourself in the culture to be studied.

• Observe members of specific cultural groups.

• Interview members of cultural groups, particularly group leaders.

• Interview other persons who are conversant with the culture.

Highlights

M05_MARY9591_06_SE_C05.indd 110 06/09/14 6:09 PM

chaPter 5 cultural influences on Population health 111

Cultural Assessment Data General areas to be considered in a cultural assessment based on the population health nursing model include factors related to biological, psychological, physical, environmental, sociocul- tural, behavioral, and health system determinants.

Biological Determinants Biological considerations in cultural assessment include those related to maturation and aging, genetics, and physiologic function. Each of these areas will be explored with respect to ethnic cultures and the dominant U.S. culture. Where appro- priate, aspects of biomedical and professional cultures and organizational culture are also discussed.

MATURATION AND AgINg. Cultural groups may dis- play different attitudes toward age. For example, the dominant U.S. culture is oriented toward youth, and youth is valued over age. A significant proportion of the gross domestic product is expended each year on trying to look, feel, and act young. In many traditional ethnic cultures, on the other hand, older per- sons tend to be highly respected and influential within the fam- ily and the social group.

Biomedical and organizational cultures may also display differential attitudes toward age. For example, many health care providers believe that because older clients are nearing the end of their lives health promotion interventions will have little effect and are unwarranted. Research, however, indicates that health promotion activities with the elderly can have profound, positive effects on health status and self-care capacity. As we will see in Chapter 19 , ageism and stereotypes of the elderly significantly affect the type of health care services provided to older clients. Similarly, age may be viewed differently in differ- ent organizational cultures. How are older employees treated in the organization? Is their expertise valued, or are they ex- pected to move aside in favor of younger employees?

In addition to the attitudes of the cultural group toward ag- ing and people of different age groups, the population health nurse would want to consider the age composition of the cul- tural group because this information will help identify po- tential age-related health concerns. For example, if a large percentage of the cultural group is young children, different types of services will be required. Similarly, if a large portion of the workforce in the organization is close to retirement age, consideration needs to be given to finding replacements. This is currently a problem for health care professions in general and nursing in particular.

gENETIC INHERITANCE. Considerations related to ge- netics would be more relevant in the assessment of ethnic cul- tural groups than for biomedical or organization cultures. Gen- erally, ethnic groups differ with respect to several genetically determined physical characteristics, such as body build and structure, skin color, enzymatic variations, and susceptibility to disease (Spector, 2012).

Physical differences based on genetic inheritance in some ethnic groups have implications for nursing, and nurses need to be conversant with these physiologic variations. For ex- ample, different ethnic groups may experience enzymatic variations such as the lactose intolerance of many Asian and Native American groups. Similarly, “normal” skin color var- ies widely between groups based on the amount of melanin typically found in the skin. Campinha-Bacote (2009) described the need to assess skin from a “melanocentric” perspective, based on the amount of pigment in the skin, rather than a Eu- rocentric perspective based on what is considered normal for light-complected people of European ancestry. She suggested several basic considerations in assessing skin, including: (a) es- tablishing a baseline color by asking or comparing with family members, (b) observing the skin in direct sunlight rather than artificial light, (c) observing areas with the least pigmentation, (d) palpating, rather than observing, for evidence of rashes, and (e) comparing the skin in corresponding areas when possible.

Genetic inheritance may also play a part in the types of health problems commonly seen in members of some ethnic groups. For example, African Americans and people of Kurdish and Sephardic Jewish descent experience higher rates of glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, an enzyme deficiency that causes red blood cell hemolysis, than members of other groups (Dugdale & Mason, 2010). Similarly, data from the 2009 National Patient Information Reporting System (NPIRS) indicate that diabetes prevalence was 77% higher in non-Hispanic Blacks, 66% higher in Hispanics, and 18% higher in Asian Americans than among non-Hispanic White adults (Centers for Disease Control and Prevention [CDC], 2011). Knowledge of the prevalence of these diseases in certain population groups can promote accurate diagnosis and treatment. Ethnic groups may also vary in their capacity to metabolize drugs, resulting in the need to adjust dosages to accommodate these differences (Purnell, 2012). There may also be differences among groups with respect to their susceptibility to adverse health effects of environmental hazards.

PHySIOLOgIC FUNCTION. Considerations related to physiologic function are the third aspect of biological determi- nants of health addressed in a cultural assessment. Areas to be considered include health problems prevalent in a particular group (beyond those with a genetic component discussed above) and attitudes to body parts and functions. Population health nurses should be familiar with the kinds of health problems ex- perienced by a particular ethnic cultural group. This permits the development of health delivery programs to meet specific needs in the population. At the same time, such knowledge may lead to stereotyping and inappropriate individual diagnosis and treat- ment within the biomedical culture. Uncertainty about a clinical diagnosis on the part of a professional provider may lead him or her to rely on probability to make a diagnosis. Knowing that a certain ethnic group has a high prevalence of a specific condi- tion may lead to a diagnosis of that condition, when the symp- toms are actually the result of some other disease.

M05_MARY9591_06_SE_C05.indd 111 06/09/14 6:09 PM

112 Unit 2 influences on Population health

ATTITUDES TOWARD BODy PARTS AND PHySIOLOgIC FUNCTIONS. There may be considerable difference in the attitudes toward body parts and physiologic functions among ethnic cultural groups and between these groups and the dominant U.S. culture. For example, Muslims are extremely modest and may be reluctant to bare their bodies to health care providers, particularly a provider of the opposite gender (Wehbe-Alamah, 2008). In India, it is common for women to bare their midriff, but in village society in many parts of the country, baring the shoulders is considered indecent. Similarly, the head is considered sacred in many Asian cultures (Purnell, 2012), and touching the head of another may be considered threatening or insulting.

Clothing and exposure of different body parts is an area of culture that may change drastically over time. It was not so very long ago when women wore floor-length skirts, and to show even as much as an ankle was considered “fast” behavior in the dominant U.S. culture. Today, short skirts or shorts and bare legs and midriffs are common among youth in the United States and other parts of the world, but may be shocking to older people, even within the dominant culture. Among many Muslim groups, modest women are expected to be completely covered, including their hair and face, but the style of dress varies among Muslim groups (Wehbe-Alamah, 2008).

Different ethnic cultural groups also have different atti- tudes toward specific physiologic functions. In many cultures, menstruating women are considered unclean and are expected to remove themselves from the flow of daily life. In the previ- ous century in the United States, menstruation was sometimes viewed as a time of weakness and vulnerability in the dominant culture, and women were expected to rest and not engage in strenuous activity during their menstrual periods. Today, most menstruating women continue their normal life activities.

Breast-feeding, urination, defecation, and sexual activity are other bodily functions that are viewed differently by different cultural groups.

Many members of the dominant U.S. societal culture are embarrassed to see women breast-feeding in public, yet this is a commonly accepted practice in many ethnic cultural groups. Similarly, urinating, defecating, and spitting in public are prac- tices that are generally frowned upon in “polite” U.S. society, but may be common, or even necessary, in places without pri- vate sanitation facilities. Groups may also differ with respect to the position assumed for defecation or cleansing themselves afterward. For example, most American homes are equipped with sit-down flush toilets. Even in some areas in rural Amer- ica that still use “outhouses,” a seating area is provided. In other countries, such as Japan and India, even some modern toilets are designed for squatting rather than sitting. Similarly, most people in the United States would use toilet paper to cleanse themselves after urinating or defecating. This practice, however, is considered very unsanitary by those in other cul- tures (e.g., rural India) who wash themselves with water using the left hand. The left hand is then considered contaminated and is not used for clean activities such as eating. Similarly, many Muslims eat only with the right hand and will not accept something offered with the left hand (Wehbe-Alamah, 2008).

Different groups also differ with respect to the types of touch that are permissible in public and who may touch whom. In the dominant U.S. culture, kissing and holding hands is per- missible between men and women, but may be less so in cer- tain settings and situations (e.g., in church). In other cultural groups, such intimate behaviors are not condoned between members of opposite genders, but may be acceptable between members of the same gender without connoting a same-sex sexual orientation.

FOCUSED ASSESSMENT Biological Determinants in Cultural Assessment

• Do members of the cultural group display genetically determined physical features or physiologic differences?

• Do group members display differences in normal physiologic values (e.g., hematocrit, height)?

• What genetically determined illnesses, if any, are prevalent in the cultural group?

Physiologic Function

• What physical health problems are common within the cultural group?

• What are the cultural attitudes to body parts and physiologic functions? How do these attitudes affect health and health care delivery?

Maturation and Aging

• What is the age composition of the cultural group?

• What attitudes toward age and aging are prevalent in the culture? How do these attitudes affect health and health care?

• At what age are members of the culture considered adults?

• Are there cultural rituals associated with coming of age?

Genetics

• What is the gender composition of the cultural group? Are there differences in the cultural value given to one gender over the other?

• Does gender play a role in the acceptability of health care providers?

M05_MARY9591_06_SE_C05.indd 112 06/09/14 6:09 PM

chaPter 5 cultural influences on Population health 113

In the biomedical culture, providers usually think nothing of baring whatever body part needs to be examined or treated. Often, there is scant concern for clients’ modesty and the em- barrassment that results. Although nurses are taught to respect clients’ privacy and to protect their modesty during proce- dures, often the pace of the work setting leads nurses to forget these “amenities.” Similarly biomedical culture often under- takes invasive procedures (e.g., shaving the head for surgery) that may have very negative connotations in other cultures. Tips for a focused assessment of biological factors in cultural assessment are included on page 112.

Psychological Determinants Areas to be considered in assessing psychological determinants of health related to culture include the extent of and typical sources of stress experienced by members of the group, the importance of group versus individual goals, attitudes toward change, and attitudes toward mental health and mental illness. An additional area for exploration is that of culture-bound syn- dromes. The importance of culture in relation to mental health is highlighted by findings that treatment programs specifically designed for certain ethnic groups have better outcomes than generalized mental health programs.

ExTENT AND SOURCES OF STRESS. The extent of stress experienced by the cultural group affects the health status of its members. As we will see later, stressful interactions with the dominant culture in the form of prejudice and discrimination affect health both directly and indirectly. Members of ethnic cultural groups may also experience stress related to intergen- erational conflict as some generations become more accultur- ated to the dominant culture while others attempt to retain traditional cultural orientations. Similarly, some members of the gay, lesbian, bisexual, and transgender cultures may expe- rience rejection or estrangement from family because of their sexual identity or orientation. Membership in the biomedical culture can itself be a source of stress given the life-and-death decisions that are sometimes required of members of this cul- tural group. Similarly, members of professional cultures may experience stress and frustration in situations in which they are unable to achieve desired outcomes for their clients. This stress may be exacerbated by the relative loss of control of one’s own practice that has accompanied the move to manage systems of health care.

INDIvIDUAL vERSUS gROUP gOALS. Cultural groups differ with respect to the priority given to individual goals ver- sus those of the larger group, and may be characterized as ei- ther collectivist or individualist societies. Collectivist societies emphasize the good of the group, harmonious relationships, traditional values, and group loyalty. Individualist societies are characterized by the primacy of individual needs over those of the larger group. In individualist societies, people expect to be able to make and act on their own decisions independent of influence or coercion by others. Although these perspectives

might also be considered part of the sociocultural determinants of health, they are included under psychological determinants because of their potential for adverse effects on the psychologi- cal health of members of a cultural group when there is conflict between individual and group goals.

The dominant U.S. culture is highly individualistic. Many traditional ethnic cultures, on the other hand, have a collectiv- ist perspective. For example, in many Asian and Latino cultural groups, family goals take precedence over the personal goals of members. Many Native American tribal cultures are commu- nity oriented, and illness may be perceived as resulting from estrangement from the community. For these reasons, family and community members are important participants in health and illness care in many Latino and Native American groups, as well as among Muslims (Center for Health and Healing, n.d.; Green, 2010; Wehbe-Alama, 2008).

Medicine as a culture has some elements of collectivism. For example, the previous taboo against advertising medical services and the reluctance to criticize the medical practice of others might be seen as attempts to protect the professional group. Certainly, much political activity undertaken by medi- cal groups has collectivist underpinnings in promoting the welfare of the medical profession. Nursing, on the other hand, although also a collectivist culture, has worked more often for the benefit of the collective society than for the profession it- self. A move away from individualism in medicine can also be seen in the dwindling number of independent practitioners and the expansion of group practice and managed care.

ATTITUDES TOWARD CHANgE. Group attitudes toward change also influence the psychological environment and health care for members of cultural groups. The dominant U.S. culture is positively oriented toward change, which is frequently la- beled “progress.” Biomedical culture tends to vacillate between the desire for change and the tendency to stick to traditional forms of care. In the biomedical culture, change is often linked to technological advances, and more particularly, to public knowledge of and demand for care based on those advances. One of the interesting areas of change in biomedical culture that is occurring primarily in response to public demand is the incorporation of what were once considered traditional “folk” health practices, now termed complementary and alternative medicine (CAM). We will discuss CAM in more detail later in this chapter.

The culture of nursing is also characterized by a certain de- gree of ambiguity with respect to attitudes toward change. On the one hand, nursing is attempting to move toward evidence- based practice. On the other, many nurses are unwilling to give up practices that have not demonstrated therapeutic effective- ness or that are no longer practical in the current health care system because they learned to provide care that way. Nursing education has been criticized for its willingness to “jump on ev- ery bandwagon that comes by,” but cannot agree on a single mechanism for entry into the profession. Changes in nurs- ing education often lack a sound basis in student and societal

M05_MARY9591_06_SE_C05.indd 113 06/09/14 6:09 PM

114 Unit 2 influences on Population health

needs and evidence of the effectiveness of specific educational activities.

Ethnic cultural groups vary with respect to their eagerness to engage in change, but many tend to hold to traditional ways of doing things. Attitudes toward change also differ within cul- tural groups (and within professional groups, as well), based on the level of acculturation to the dominant culture.

Closely allied to group attitudes toward change are culturally based attitudes of resignation and acceptance. In many areas of the world, notably underdeveloped countries but also among the poor of the developed world, people have little access to the means to change the circumstances of their lives. Over many years or generations, people in such groups may become re- signed and develop fatalistic attitudes. Widespread resigna- tion within a cultural group can hinder health promotion and disease prevention initiatives, and may even affect willingness to seek care for existing health problems. For example, cancer fatalism has been associated with unwillingness to participate in screening activities in general (Baron-Epel, Friedman, & Lernau, 2009) and breast cancer screening in particular (Clark & Natipagon-Shah, 2008). Fatalism is defined as the belief that one’s fate is fixed and that personal efforts can do little to affect that fate (Fatalism, n.d.). Population health nurses working with members of other cultural groups should determine the effects that fatalistic beliefs have on health behaviors.

PREvALENCE AND PERCEPTIONS OF MENTAL HEALTH AND ILLNESS. Cultural groups also differ in their definitions of what constitutes mental health and mental illness and their attitudes toward mental illness. For example, in some groups, symptoms that would be construed as mental illness in the biomedical culture are considered normal behavior or a fact of life. In addition, cultural groups often differ with respect to the extent of mental illness present in the population.

In many cultural groups, including segments of the domi- nant U.S. culture, mental illness carries an unpalatable stigma, leading members of the group to avoid seeking care. Mental ill- ness may also be seen as a stigma for the family as well as for the individual involved. Chinese Americans, for example, may experience strong stigma attached to mental illness (Yeung et al., 2010). Asian Indian families have been known to hide family members with mental illness in the home to avoid social stigma against the family. Some American families may abandon men- tally ill/disabled family members in public institutions. Among Islamic cultures, mental illness may be perceived as punishment or a test of one’s faith (Ciftci, Jones, & Corrigan, 2013). In the dominant U.S. culture, those with a history of mental illness or substance abuse may encounter difficulty with employment or election to public office, among other social effects. Among some cultural groups, mental illness may be perceived as posses- sion by an evil spirit or failure to honor good spirits, warranting religious intervention rather than psychotherapy. Psychological distress may be concealed or expressed psychosomatically due to perceptions of stigma attached to mental illness. Other cul- tural groups are more tolerant of mental health problems.

In the dominant U.S. culture, and even in the biomedical and professional cultures, mental illness also continues to carry a stigma, although much progress has been made in this area. The degree of stigma varies with the type of condition and is less severe for problems like depression than for chronic men- tal health problems, such as schizophrenia, in which bizarre behavior may be displayed.

Some ethnic cultural groups may recognize a variety of emotional conditions that are not documented in the Diagnos- tic and Statistical Manual (DSM-5), which serves as the com- pendium of mental illness in the biomedical culture. These conditions are often referred to as culture-bound syndromes. The general diagnosis of culture-bound syndrome has, how- ever, been added to later versions of the DSM-IV and defined as recurrent patterns of behavior or symptoms that lie outside the biomedical system.

Culture-bound syndromes are conditions involving behav- ioral, affective, and cognitive symptoms that manifest within a specific culture and represent behaviors different from those expected in the culture (Singh Balhara, 2011). Although unique to a given culture, similar conditions may occur, with some variations, in other cultural groups. For example, dhat, is an Asian Indian culture-bound syndrome that involves weakness, loss of vitality, sexual dysfunction, and loss of virility attributed to loss of bodily fluid through urine, nocturia, or masturbation. Other variants of dhat are found in China, Europe, Russia, and the Americas (Singh Balhara, 2011). Amok is another ex- ample of culture-bound syndromes found in Malaysia. Amok involves a period of brooding followed by a sudden violent out- burst. Nerviosismo is a culture-bound syndrome noted in Latin America and the Caribbean. It is characterized by somatiza- tion, anxiety, dizziness, emotional lability, and difficulties with sleeping and concentrating, and is believed to be brought on by stress (Hulme, 2010).

Care should be taken in attributing symptoms of emotional distress or unusual behavior to culture-bound syndromes without exploring other possible causes. Several authors note that culture-bound syndromes can only be understood in the context of the cultures in which they occur and that therapy often depends on the “deep grammar” or underlying circum- stances resulting in disease (Yang, Tranulis, & Freudenreich, 2009). Assuming that symptoms experienced by a client from another culture represent a culture-bound syndrome may pre- vent accurate diagnosis of underlying mental health problems (Green, 2010). Rather, it may be more appropriate to accept the client’s explanation of the underlying issues and combine con- ventional and traditional therapies in addressing their cause.

Culture-bound syndromes are not unique to ethnic cul- tural groups, but may also be seen in the dominant U.S. and biomedical cultures. For example, anorexia nervosa is a rec- ognized illness in Western cultures, particularly in the United States, that is not seen in many other cultural groups and has been described as a culture-bound syndrome (Isaac, 2013). Its incidence in U.S. women may reflect the cultural pressure to be thin (National Alliance on Mental Illness, 2013). Similarly,

M05_MARY9591_06_SE_C05.indd 114 06/09/14 6:09 PM

chaPter 5 cultural influences on Population health 115

seasonal affective disorder, a form of depression recognized by the biomedical culture and believed to be caused by diminished light in winter, is seen in some Western cultures (e.g., in the United States), but not in others.

Population health nurses should also assess the prevalence of specific mental illness diagnoses in the population as well as the extent of use of mental health services. For example, it has been estimated that 17% of Asian Americans may experi- ence psychiatric illness at some point in their lives, but that their use of formal mental health system services is low. Often, informal support systems are sought instead (Spencer, Chen, Gee, Fabian, & Takeuchi, 2010). Other authors have suggested that Asian Americans do seek health providers’ assistance with mental health issues but are often undiagnosed due to failure of providers to recognize symptoms reported as evidence of men- tal health problems (Yeung, et al., 2010).

As we have seen, psychological determinants related to cul- ture may have profound effects on the health of population groups. Tips for a focused assessment of psychological deter- minants in cultural assessment are provided below.

Environmental Determinants Cultural groups differ in their perceptions of relationships be- tween people and their environment. The dominant U.S. cul- ture seeks mastery over the environment. Many traditional ethnic cultures, on the other hand, seek harmonious relation- ships with the external physical environment. For example, tra- ditional African American cultural groups have often perceived a need for cooperation with a powerful natural environment in order to promote survival. Similarly, some cultural groups also view seasonal changes as directly affecting human health and behavior. Again, seasonal affective disorder is an example rec- ognized in the biomedical culture.

Other aspects of relationships to the external environment include perceptions of space and time. With respect to time,

some cultural groups, such as the dominant culture in the United States and African American culture, are future ori- ented, whereas others are past or present oriented. Many Asian cultures, for example, attach great importance to the past and are considered past oriented. Native American and Latino groups, on the other hand, tend to be oriented to the present moment (Spector, 2012). Both past- and present-oriented cul- tural groups may have difficulty in long-range planning for fu- ture events or may not be attuned to preventive health care.

Other perceptions related to time may also be of importance in planning nursing care for individual clients or for population groups. Care of a Muslim client, for example, may need to be planned to prevent interference with specified times for prayer (Wehbe-Alamah, 2008). At the group level, effective health pro- grams targeted to Jewish clients or Seventh-day Adventists would not be scheduled on Saturday. Similarly, many cultural groups have fluid concepts of time that make appointment-based health care delivery, a biomedical cultural norm, less effective.

Cultural groups also have differing attitudes to space. Most population health nurses in the United States subscribe to European American notions of acceptable personal space in certain situations. Preferred distance between people in European American culture can be described as follows:

• Public distance: greater than 12 feet • Social distance: 4 to 12 feet • Personal distance: 1.5 to 4 feet • Intimate distance: within 1.5 feet (Spector, 2012)

European Americans are frequently uncomfortable when their perceived personal space is invaded by another person. Among other cultural groups, however, there is considerable varia- tion in what is perceived as one’s personal space, leading to the potential for discomfort and conflict.

One final consideration with respect to the physical envi- ronment relates particularly to immigrant and refugee groups.

FOCUSED ASSESSMENT Psychological Determinants in Cultural Assessment

• Do members of the cultural group exhibit attitudes of resignation and fatalism? If so, what effect does this have on the use of health care services?

• What attitudes toward mental health and illness are held by members of the cultural group? Is there stigma attached to mental illness for the individual? For the family?

• Does the group recognize any culture-bound syndromes? If so, what are they? What are their characteristic features?

• Does the culture have an individualist or collectivist perspective?

• How do members of the cultural group prioritize individual, family, and group welfare and goals?

• What is the extent of stress experienced by members of the cultural group? What are the usual sources of stress? How do group members typically cope with stress?

• Is there intergenerational conflict within the cultural group that contributes to stress?

• How do members of the cultural group perceive change? How do they adapt to change?

M05_MARY9591_06_SE_C05.indd 115 06/09/14 6:09 PM

116 Unit 2 influences on Population health

The change in their physical environment may lead to a vari- ety of health problems not encountered in their homelands. For example, the heavy traffic patterns in most U.S. cities have contributed to traffic fatalities among Hmong children whose parents are not accustomed to having to teach traffic safety. Similarly, exposure to a variety of household cleaning products common in U.S. households has led to a number of acciden- tal poisonings among refugees. In addition, research has indi- cated that refugee children may experience elevated blood lead levels several months after coming to the United States due to the need to find housing in older run-down areas with a high degree of lead contamination. Tips for assessing elements of the physical environmental dimension of culture as they affect health are presented above.

Sociocultural Determinants Cultural elements related to the sociocultural determinants of health can have profound effects on health and health-related behaviors. Each cultural group has norms that govern the in- teraction of its members. Considerations to be addressed in assessment include cultural values, relationships with the su- pernatural, interpersonal roles and relationships, relationships with health care providers and the larger society, socioeco- nomic status, and life experiences such as those related to sexu- ality and reproduction, coming of age, marriage, immigration, and death.

vALUES. As we noted earlier, the values held by a cultural group are some of the elements most resistant to change. Cultural groups may differ significantly on the value attached to certain conditions and differences in strongly held values between group members and the dominant culture may give rise to difficulties. Data from the World Values Survey of 79 nations from 2005 to 2008 indicated that cultural values differ along two main dimensions. The first is the traditional/secular- rational dimension, which denotes differences between cultures in which religion is very important and those that have a more secular view of the world in which religion is less important. Other related values tend to vary along traditional/secular lines. For example, groups with more traditional values tend to em- phasize deference to authority and traditional family values.

Groups with a secular-rational values orientation tend to value self-determination and rationality (Inglehart & Welzel, n.d., 2010).

The second major dimension on which values vary among cultural groups is the survival/self-expression dimension. In this dimension, according to the theory posed by Inglehart and Welzel (2010), societies that have major concerns with basic survival tend to emphasize values that support survival, such as order, economic security, and conformity. On the other hand, in societies in which survival is more or less taken for granted, higher value is placed on self-expression, subjective well-being, and quality of life. These values are accompanied by modifi- cations in other areas of life such as more permissive parent- ing, fostering of tolerance for diversity, and so on (Inglehart & Welzel, n.d., 2010).

For example, the dominant culture, including the biomedi- cal culture, strongly values being on time. Appointments are made for specific times and clients are expected to arrive at that time or earlier. This value, however, frequently does not seem to apply to providers themselves, who may keep clients wait- ing to be seen for significant periods of time. Examples of other values that may differ among cultural groups or between mem- bers of these groups and the dominant culture are those related to autonomy and self-sufficiency, work ethic, dignity of life, importance of family, and the need for education or health- related activities.

The population health nurse explores with members of the culture the areas of strongly held values. Often this is done through observation since people may be unable to adequately articulate values in conversation.

RELATIONSHIPS WITH THE SUPERNATURAL. Human psychological health is often intertwined with spiritual health, particularly among many ethnic cultural groups. Even in the dominant societal culture, spiritual interventions, such as prayer, are commonly invoked in health promotion and resto- ration. Attitudes and behaviors with respect to the supernatural world are often exhibited in the form of religious affiliation and magical practices.

Religiosity, the belief or participation in religious ob- servances, is conceptualized as having two aspects: social

FOCUSED ASSESSMENT Environmental Determinants in Cultural Assessment

• What is the orientation of the cultural group to time?

• What changes in their physical environment have members of the cultural group experienced? What influence do these changes have on the health status of the group?

• How do members of the cultural group perceive their relationship to the environment?

• How do members of the cultural group perceive personal space?

M05_MARY9591_06_SE_C05.indd 116 06/09/14 6:09 PM

chaPter 5 cultural influences on Population health 117

religiosity and individual religiosity. Social religiosity reflects the extent to which members of the population affiliate with religious organizations and spend time in religion-oriented ac- tivities. Individual religiosity addresses individual beliefs in a God and the importance of God and religious observance in one’s life (Okulicz-Kozaryn, 2010). These two aspects of religi- osity may also be referred to as extrinsic and intrinsic religios- ity (Abdel-Khalek, 2009).

The influences of religion and spiritual beliefs may be seen in five areas. First, specific religious beliefs or practices may influence health, either positively or negatively (Rabinowitz, Mausbach, Atkinson, & Gallagher-Thompson, 2009). Second, religious groups may be involved in the provision of health care. In addition, participation in organized religious activities may contribute to a sense of belonging (Okulicz-Kozaryn, 2010). Religious beliefs may also act as a source of personal support in times of adversity, and religiosity has been associated with

better life satisfaction and mental health (Abdel-Khalek, 2009; Okulicz-Kozaryn, 2010). Finally, the type and quality of interactions between religious leaders and the health care system can profoundly influence the acceptability and use of health care services.

Biomedical culture tends to separate health care and religion or spirituality as distinct and unrelated fields, despite evidence that religious practices may enhance well-being. There is grow- ing recognition, however, that spirituality may play a signifi- cant role in clients’ well-being. In fact, the National Cancer Institute (2012) has recommended spiritual assessment of clients with cancer. This assessment has been adapted in the Focused Assessment below to assess religious and spiritual in- fluences on population groups.

Religious belief and magic are closely intertwined in some cultures. In other cultures, magic is conceived as antithetical to religion and as an act against God (Greenwood, 2009). Magical effects may be conceptualized as resulting from sympathetic magic or analogical thinking. Sympathetic magic may be based on two perspectives: homeopathic magic or contagious. In homeopathic magic, effects occur based on associations of similarity in which a desired effect can be achieved by imita- tion (Greenwood, 2009). In rural Appalachia, for example, scissors may be placed beneath the mattress of a woman in la- bor to “cut” or reduce her pain. The basic concept is that “like causes like.” In contagious magic, effects result from contact. For example, an object in contact with a person is believed to absorb the attributes of that person. For example, a pair of a laboring woman’s husband’s pants might be placed on the bed- post to impart his strength to her.

In analogical thinking, reasoning is based on similarities per- ceived between one thing and another in the view of the person making the analogy (Greenwood, 2009). Analogical thinking is the basis for some religious rituals. For example, baptism with water is symbolic of being cleansed of one’s sins, the analogy

Religion is an important aspect of a group’s culture. (Eray/Fotolia)

FOCUSED ASSESSMENT Population Spiritual Assessment

• To what extent are adverse events (e.g., serious illness, natural disaster) likely to result in a loss of faith in the population?

• What conflicts, if any, exist between religious beliefs and health care practices?

• To what extent do religious beliefs and spirituality contribute to healthy behaviors?

• What views of death and afterlife are held by members of the population? How do these views affect their participation in health-related behaviors?

Adapted from: National Cancer Institute. (2012). Spiritual assessment. Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare /spirituality/Patient/page3

• What religious denominations are represented in the population?

• What beliefs or philosophies are prevalent in the population?

• How important are spiritual practices or rituals within the population?

• To what extent do members of the population view religion or spirituality as a source of support?

• To what extent does religion or spirituality contribute to a feeling of belonging among members of the population?

• To what extent do members of the population engage in prayer or meditation as a source of comfort or help?

M05_MARY9591_06_SE_C05.indd 117 06/09/14 6:10 PM

118 Unit 2 influences on Population health

being that as water washes dirt from the physical body, it also washes sins from the soul. Greenwood (2009), an anthropologist who has studied magic extensively, adds a third view of magic as “magical consciousness,” which is seen as expanded awareness of the world and participation through multiple connectedness be- tween persons, between persons and other features of the physi- cal world (e.g., animals), and between the living and the dead.

Belief in magic as a means of causing or curing disease is common in many traditional ethnic cultures, including African American, Italian, Native American, and Latino groups ( Spector, 2012). Magic may even be perceived as the origin of scientifically diagnosed illnesses. For example, when health care providers were unable to provide Thai clients and their fami- lies with an explanation for the development of schizophrenia, many family members attributed the disease to supernatural powers or black magic (Sanseeha, Chontawan, Sethabouppha, Disayavanish, & Turale, 2009).

Belief in and practices related to magical thinking are not only found among members of ethnic cultural groups. In the dominant culture, as well, many of us engage in “magical rituals” that com- fort us or give us confidence in tricky situations, like wearing your “lucky poker shirt.” Population health nurses would assess the place of magic in the belief system of a given population and the relationship of those beliefs to health and health-related behaviors.

FAMILy AND COMMUNITy RELATIONSHIPS. Cultur- ally defined roles and relationships are learned first within the family, and may differ by family type, age, and gender. The pre- dominant family form in U.S. societal culture remains the two- parent nuclear household, with loose relationships with kin in both parents’ families of origin. As we will see in Chapter 14 , however, this family form is being supplanted by a variety of other family forms, including single-parent families, nuclear dyads, extended families, and cohabiting couples. In many ethnic cultural groups, the extended family remains the pre- dominant family type, but in many countries this is changing as younger family members move away from the family of origin in search of employment opportunities.

Roles within the family are frequently defined by age, gen- der, and family position. In the traditional U.S. culture of the past, men were considered the family providers and women were responsible for care of the home and family, except in families that were dependent on women’s income to replace or supplement that of male family members. Gender role expec- tations in the dominant culture, however, have experienced a number of changes with women more often employed outside the home and men taking on more traditionally female tasks with respect to homemaking and child rearing.

In many traditional ethnic cultures, on the other hand, gen- der roles are more specifically defined. Men are often consid- ered the head of the family and the primary decision maker on major family issues. In other ethnic cultural groups (e.g., some Native American tribes), women are the primary deci- sion makers. Women’s traditional role is often defined in terms of childbearing and care of the home and family. Gender roles

may also entail strict separation of men from women except within the immediate family. In same-sex families, family roles may be shared by both partners or may be divided in ways that best meet the needs of the family.

Age may also play a role in family decision making. For ex- ample, in most cultural groups, including the dominant U.S. cul- ture, parents often make decisions related to their children. In the dominant culture, however, adolescents are often given more decision latitude regarding their own behavior than their coun- terparts in other cultural groups. Middle adults in the dominant culture may also find themselves in the position of making deci- sions for older parents. In some ethnic cultural groups, on the other hand, decision making is the province of family elders.

Children in many ethnic cultural groups are expected to respect and obey their parents without question. Children in the dominant U.S. culture, however, are generally given more latitude to question parents’ decisions or the rationale for those decisions. As we saw earlier, the dominant culture is youth ori- ented, and the elderly are not as well respected as may be the case in many ethnic cultural groups.

Family relationships may also be affected by illness or dis- ability among family members. In some cultures, ill or disabled family members may be hidden to escape social stigma for the family. In others, they may be overprotected and prohibited from developing to their full potential.

Relationships with extended family members also have many cultural aspects. As noted earlier, extended families in some cultural groups have often lived together in joint house- holds or in close proximity to other family members. Members of the GLBT population, on the other hand, may experience strained relationships with their families of origin and strive to create their own “families” with other individuals like them- selves. Transgendered women, in particular, may create a “sis- terhood” to replace or augment family ties.

Age and gender also influence roles within the biomedi- cal and health professional cultures. Traditionally, as a largely female profession, nurses were expected to be subservient to physicians, and only recently have nurses begun to be re- spected as equally expert providers of care. An interesting twist to this hierarchy is seen in the military health care culture, where respect and authority are based on rank, not profes- sional discipline. The influence of age in the biomedical and professional cultures is less forthright. Older professionals have greater experience than their younger counterparts, but in many instances, this advantage is offset by better education among younger practitioners.

COMMUNICATION AND LANgUAgE. Communication plays a significant role in interpersonal interactions within and between cultures. In assessing cultures, population health nurses attend to all types of communication, including oral and written communication, the language spoken, forms of nonver- bal communication and acceptable behavior, speed of speech and intonation, slang, and culturally inappropriate words, phrases, and topics.

M05_MARY9591_06_SE_C05.indd 118 06/09/14 6:10 PM

chaPter 5 cultural influences on Population health 119

The language spoken by members of ethnic cultural groups and group members’ facility with the language of the domi- nant culture, will affect intercultural interactions, particularly as they influence health. Differences in dialects within cultural groups may also impede communication. In the United States, 21% of the population over 5 years of age, speak a language other than English at home. Although many of these people also speak English, 8.5% of them speak English less than “very well” (U.S. Census Bureau, American Fact Finder, 2012). Non- English speakers are more likely than English speakers to have incomes below poverty level and less than a high school educa- tion. The Office of Minority Health (OMH, 2013a) defined lin- guistic competency as the ability to communicate effectively and convey information in ways that are easily understood by persons with limited English proficiency, low literacy or health literacy levels, or communication disabilities.

Patient and provider concordance with respect to language is important in providing culturally competent care. Language differences make for miscommunication and may compromise care and client outcomes resulting in increased disparities, in- equities, dissatisfaction, and inefficiency in health care deliv- ery systems (Tang, Lanza, Rodriguez, & Chang, 2011). Ideally, health care providers should be able to speak a client’s native tongue, but this is not always possible or practical. In such cases, interpreters or other linguistic services may be needed to assist with communication.

Linguistic services generally consist of four components: oral services, interpretation services, written services, and translation services. Interpretation services are used in the context of oral communication. Interpretation is not a word- for-word rendering of what is said, but involves conveying meaning for meaning. Translation, on the other hand, is the rendering of the written word in another language (Partner- ship for the Public’s Health, n.d.). Interpretation services are not always available in many health care settings due to their cost, yet research has shown that clients who receive interpre- tation services made more visits to providers, received more preventive services, and were given more prescriptions than those who needed, but did not receive, interpretation services.

It is hypothesized that ultimate health care costs may be de- creased enough, due to prevention and earlier intervention, to warrant the added cost of interpretation services.

Approaches to interpretation in health care settings range from the ideal of bilingual and bicultural providers to using family members as interpreters. Unfortunately, the lack of qualified bicultural providers and the cultural diversity encoun- tered in many health care settings often prohibits this solution to problems of interpretation. Even when providers speak the same language as the client, there may be difficulties related to dialect or socioeconomic status that make communication difficult. Health care agencies may also employ other bilingual staff who serve as interpreters. This approach is most effective, but also most costly, when staff are used exclusively for inter- pretation rather than being pulled away from other responsi- bilities to provide interpretation services. Another option is the use of outside interpreters or telephonic interpretation. These approaches usually need to be arranged in advance and so are not particularly useful in emergency situations. In addition, these services tend to be expensive, and the interpreter may not be conversant with medical terminology. Telephonic interpre- tation also has the disadvantage of the loss of communication through body language. Family members should be a last re- sort in meeting interpretation needs. Use of family members to interpret runs the risk of violating client confidentiality and creates the potential for family conflict or other adverse effects. Tips for assessing the need for interpretation services with a particular client are provided below.

Interpretation and translation are usually considered in terms of communication between providers and members of ethnic cul- tural groups. It is wise to keep in mind, however, that both inter- pretation and translation may be required to render biomedical terminology intelligible to clients and other members of the lay public. The Program for International Assessment of Adult Competencies (PIAAC) assesses health literacy ( ability to read and understand information), numeracy ( ability to calculate), and problem-solving skills in the United States and 22 other countries. The 2012 PIAAC data indicated that 16  countries had literacy levels higher than those in the United States,

FOCUSED ASSESSMENT Assessing Interpretation Needs

• When does the client prefer an interpreter?

• Can the client rephrase instructions to staff in the language of the dominant culture?

Data from: McLaurin, J. A. (2002). Assimilation, acculturation, and alternative medicines. MCN Streamline: The Migrant Health News Source, 8(6), 1–3.

• What language does the client speak at home?

• How long has the client been speaking the language of the dominant culture?

• What is the client’s level of literacy in the language of origin? In the language of the dominant culture?

• What types of things does the client read in each language?

M05_MARY9591_06_SE_C05.indd 119 06/09/14 6:10 PM

120 Unit 2 influences on Population health

and only 7 countries had lower scores. Since the assessment is only given in English, these scores vastly underrepresent lit- eracy levels among non-English-speakers. The U.S. scores were not significantly different from those derived from the National Assessment of Adult Literacy (ALL) in 2003–2008 (National Center for Education Statistics, 2012). Health literacy has been defined by the World Health Organization (WHO, 2009) as cognitive and social skills that motivate and enable people to

obtain, understand, and use health-related information to pro- mote their health.

Two Healthy People 2020 objectives related to health com- munication and information technology deal specifically with health literacy and communication with health care provid- ers. These objectives are summarized below. The first ob- jective, with its subobjectives, is developmental in nature, so there are no existing baseline data or established targets

ObjecTive

baSeliNe (YeaR)

TaRgeT

cURReNT daTa (YeaR)

daTa SOURce

HC/HIT-1 Improve the health literacy of the population

1.1 Increase the proportion of persons who report that their health care provider always gave them easy-to-understand instructions about what to do to take care of their illness or health

Developmental Developmental NDA Medical Expenditure Survey, AHRQ

1.2 Increase the proportion of persons who report that their health care provider always asked them to describe how they will follow the instructions

Developmental Developmental NDA Medical Expenditure Survey, AHRQ

1.3 Increase the proportion of persons who report that their health care providers’ office always offered help in filling out a form

Developmental Developmental NDA Medical Expenditure Survey, AHRQ

HC/HIT 2 Increase the proportion of persons who report that their health care providers have satisfactory communication skills

2.1 Increase the proportion of persons who report that their health care provider always listened carefully to them

59% (2007) 65% 61.9% (2010) Medical Expenditure Survey, AHRQ

2.2 Increase the proportion of persons who report that their health care provider always explained things so they could understand them

60% (2007) 66% 60.6% (2010) Medical Expenditure Survey, AHRQ

2.3 Increase the proportion of persons who report that their health care provider always showed respect for what they had to say

62% (2007) 68.2% 64.9% (2010) Medical Expenditure Survey, AHRQ

2.4 Increase the proportion of persons who report that their health care provider always spent enough time with them.

49% (2007) 54% 51.4% (2010) Medical Expenditure Survey, AHRQ

NDA = No data available. U.S. Department of Health and Human Services. (2013). Health communication and health information technology. Retrieved from http://www.healthypeople.gov/2020/ topicsobjectives2020/overview.aspx?topicid=18

Healthy People 2020

Selected Objectives Related to Cultural Competence

M05_MARY9591_06_SE_C05.indd 120 06/09/14 6:10 PM

chaPter 5 cultural influences on Population health 121

for accomplishment. As data collection systems are devel- oped, baseline data will be collected and appropriate targets determined.

There may also be difficulties in communication within the biomedical culture itself due to the different languages employed by many health care disciplines. For example, how well do members of other disciplines understand the language of nursing diagnosis? Similarly, health care professionals re- cruited internationally to address shortages in the United States may face a variety of communication difficulties with clients and other providers. These health care providers need to learn the language of the profession as employed in the United States as well as the conventions of interprofessional communica- tion, which may differ significantly from those of their coun- tries of origin. Language proficiency tests are not specific to the nursing profession and may not adequately assess English proficiency in a professional context. Communication difficul- ties are often exacerbated on the telephone and in reading and writing charts. Some of the problems that may occur include basic grammar, use of lay vocabulary and that of other profes- sionals, pronunciation difficulties, lack of understanding of different levels of interaction (formal, informal), and failure to recognize the variability of cultural norms among clients seen.

In addition to the words used, paralanguage variations may be important in communication between cultures. Paralan- guage includes the tone of voice, volume, and inflection typi- cally used in verbal communication (Purnell, 2012). For example, some cultural groups may use loud volume for urgent messages and repeat messages for emphasis. Others routinely use a louder voice and more rapid speech in ordinary conversa- tion than is common in some cultural groups. In the dominant U.S. culture, a loud voice may convey an emergency but may also be interpreted as anger.

Inflections also signal meaning in conversation. For exam- ple, in English, a question is indicated with an upswing in tone at the end of the sentence. In other languages, such as Marathi, an Asian Indian language, questions may be indicated by ap- pending a word to the end of the sentence or by means of an interrogative word at the beginning of the sentence (similar to English).

Nonverbal communication also varies among cultural groups. For example, nurses often rely on nonverbal cues to identify clients in pain; however, when the cues differ between the nurse’s and the client’s culture, effective pain relief may be compromised. Gestures are another element of nonverbal communication that may differ among cultural groups. For ex- ample, when you want someone to come closer to you in the dominant U.S. culture, you might crook your finger. In India, on the other hand, you would use a sweeping motion of the fingers toward you with the hand held prone. In yet other cul- tures, beckoning in any form is considered rude.

Another aspect of communication to be considered in a cul- tural assessment is the level of prescribed reticence within the group—the extent to which people are expected or willing to share private information. In the dominant U.S. culture, it is

not uncommon for people to tell much of their life story dur- ing a chance encounter in the grocery store. Yet, there are cer- tain things that one does not ask or tell. For example, it would be considered rude to ask a chance acquaintance how much money they make or whether they are sexually active. Yet, these kinds of questions are routinely asked by health care profes- sionals and may insult even members of the dominant culture if the reason for them is not carefully explained. Among many other cultural groups, there may be even greater reluctance to provide personal or family information, particularly when it relates to emotions.

RELATIONSHIPS WITH THE LARgER SOCIETy. The relationship between members of different cultural groups and the dominant society may also have significant effects on health status. Many people in the dominant U.S. culture dis- play xenophobia, an irrational fear of strangers (Spector, 2012), particularly those who are significantly different from oneself in appearance or behavior. When this fear centers on those of different sexual orientations, it is termed homophobia. Xeno- phobia, homophobia, and other negative reactions to persons of a cultural group may lead to racism, prejudice, and discrimi- nation. Racism is the belief that people can be classified on the basis of biophysical traits into groups that differ in terms of mental, physical, and ethical capabilities, with some groups be- ing intrinsically superior or inferior to other groups. Prejudice is the holding of negative attitudes or feelings toward members of another group. It is an internal perspective, and may or may not be acted upon. Discrimination, as we saw earlier, is a behav- ioral demonstration of racism or prejudice involving differen- tial treatment of an individual or group based on unfavorable attitudes toward the group. When discrimination is directed toward persons with a handicapping condition or disability, it is termed ableism.

Discrimination has been shown to have negative effects on health through both direct and indirect mechanisms. Dis- crimination by health care providers leads to inappropriate and ineffective care. Discrimination may be seen in response to members of ethnic cultural groups, but also in response to other individuals as well. For example, GLBT individuals re- port significant discrimination against them by members of the dominant U.S. society, as well as among health care providers. As noted earlier, the elderly and disabled populations may also face discrimination from the general public or from health care providers who believe certain health services (e.g., health pro- motion and illness prevention) are not warranted. Discrimina- tion may have indirect effects in terms of willingness to seek health care services or via the stress caused by exposure to culture-related discrimination or harassment.

Responses to negative experiences with the larger society can also have adverse effects on health. A large body of research has linked various forms of discrimination and even percep- tions of discrimination to the health status of multiple groups characterized by differences from the mainstream population (Juang & Alvarez, 2010; Pascoe & Smart, 2009). Perceived

M05_MARY9591_06_SE_C05.indd 121 06/09/14 6:10 PM

122 Unit 2 influences on Population health

discrimination against members of racial and ethnic minority groups by health care providers has also been reported (Sorkin, Ngo-Metzger, & De Alba, 2010).

Members of the biomedical culture also experience different relationships with the larger societal culture. In most ethnic cul- tures and in the dominant U.S. culture, health care providers are held in high esteem by the society in which they function. In the dominant U.S. culture, this can be seen in the incomes of physi- cians and in the trust placed in nurses. Nursing has not always been as highly valued as a profession, however. In the early days of the history of modern nursing, for example, nursing was seen as an occupation of lower-class women that most families would not want to see their daughters enter. This was also true on the Indian subcontinent as few as 40 years ago and may still be true in some parts of the world. Even in cultures in which nursing is esteemed, the profession may not be valued as highly as medi- cine. Although the status of nursing is changing within the bio- medical culture, nursing has not usually been as highly valued as medicine and some other health professional disciplines. In fact, nursing is still viewed in some settings and by some members of other professional disciplines as a handmaiden group.

SOCIOECONOMIC STATUS. The socioeconomic status of a cultural group also influences its health status. Gener- ally speaking, most members of the biomedical culture are of relatively high socioeconomic status. Even within this group, however, there is considerable variation, with physicians and dentists more often included in the upper to upper middle class and nursing and other health care disciplines considered to be middle- to lower-middle-class occupations. Members of many ethnic minority groups in the United States, on the other hand, tend to have relatively low socioeconomic status, but even that status varies among groups. For example, some Asian cultural groups enjoy relatively high educational and income levels, while others, particularly more recent immigrants and refugees, include large numbers of the poor or poorly educated. In gen- eral, members of the GLBT population tend to be fairly highly educated, but may have lower incomes than their “straight” counterparts due to the need to accept positions in organiza- tions that are accepting of their sexual orientation or identity.

Income, education, and the resulting lower socioeconomic status are some of the major contributing factors in health dis- parities noted in the United States. Health disparities are par- ticularly prevalent among immigrant and refugee populations, who tend to have lower education and economic levels than the general population. Chapter 6 presents a general discussion of poverty and health insurance and their influence on health dis- parities. Specific health disparities and their underlying causes are discussed in relevant chapters throughout this book. Popu- lation health nurses assess the typical socioeconomic status of the cultural groups with whom they interact. They also examine the effects of these factors on the health status of the population.

LIFE EvENTS. Cultural groups may differ significantly in the ways they address life experiences common to human

existence. Although all cultural groups deal with these common life experiences, cultural beliefs and behaviors related to them can vary considerably. Life experiences that will be addressed here include experiences related to sexuality and reproduction, coming of age, marriage, and death.

Sexuality and reproduction. Different cultures have differ- ing perspectives on and attitudes toward human sexuality and sexual activity. Some groups (e.g., fundamentalist Muslims and Christians) perceive sexual activity as inherently sinful and to be tolerated only within the bounds of marriage. Other groups are more tolerant of sexual activity outside of marriage, but may differ in terms of their application of this norm to men and women. For example, among some populations extramari- tal sexual activity is accepted for men but not women. “Good” women are not sexually experienced or knowledgeable and may not be willing to discuss sexual issues with their partners for fear of being thought a prostitute. These cultural attitudes place these women at risk for sexually transmitted diseases and cer- vical cancer since sexual beliefs have been found to influence willingness to obtain pap smears.

Attitudes toward homosexuality are another area that should be explored by the population health nurse engaged in a cultural assessment of a group of people. Homosexuality may be defined and perceived differently in some cultures than in the dominant U.S. culture. For example, Muslims and tradi- tional Christians and Jews generally consider homosexuality sinful. In some Asian cultures, homosexuality can be viewed as expressing disdain for societal norms that include expectations for marriage and children and brings shame to the family of the homosexual individual. China and Iran are particularly repres- sive of homosexual behavior, and such attitudes may accom- pany recent immigrants (Purnell, 2012). The dominant U.S. culture is generally homophobic and members of the GLBT populations experience considerable discrimination as we will see in Chapter 20 .

Cultural groups also vary with respect to attitudes and be- haviors related to contraception. In societies where child- bearing is an expectation, contraception is not approved and abortion is not permitted. Nonetheless, even in these cultures, there may be a variety of methods employed to induce abor- tion, some of which can be extremely dangerous. For example, poisoning with pennyroyal, a common abortifacient that is highly toxic, occurs periodically in the United States and else- where (Natural Medicines Comprehensive Database, 2012).

Many ethnic cultural groups also engage in a variety of be- haviors designed to prevent conception, some of which are based on traditional explanatory models for conception. For example, some African Americans believe that one is more apt to get pregnant if one has intercourse during menses and is “safe” at mid-cycle or that it is impossible to become preg- nant until one has had a menstrual period following deliv- ery of a baby. This latter belief may also be seen among some Italians (Purnell, 2012) and members of other cultural groups. Members of cultural groups may also engage in a variety of

M05_MARY9591_06_SE_C05.indd 122 06/09/14 6:10 PM

chaPter 5 cultural influences on Population health 123

behaviors to promote conception. Selected cultural beliefs and behaviors related to menstruation, conception, and contracep- tion are included in tables presented in the Further Information section of the student resources for this book.

All cultural groups have prescribed and proscribed be- haviors to be performed when pregnancy does occur, as well as during labor and delivery. Some authors have noted the relatively positive birth outcomes among immigrant women, particularly Latinas, compared to other low-income women, suggesting that healthful behaviors and social support arising out of cultural beliefs about pregnancy should be emulated by other groups.

Birth rituals occur in some form in all cultures. Birthing sys- tems usually prescribe a specific locale for the birth event to take place, as well as specific practices to be employed. Gener- ally speaking, the technocratic society of the United States and other developed nations advocates birth in a specialized locale, usually a delivery room within a hospital setting. Some authors have noted that this locale is designed to make the birth easy for the birth attendants rather than the mother. The second lo- cale specified for births is the woman’s local sphere. In many ethnic cultural groups, this is the home. Home births are a growing phenomenon in some segments of the dominant U.S. culture, as is the use of birthing centers. For members of other groups, birth should take place outside of the home because it is an unclean event and would contaminate the home.

Cultural groups also forbid some practices during preg- nancy and engage in a number of others to promote a posi- tive pregnancy outcome. For example, some ethnic cultural groups perceive pregnancy as a hot condition and, thus, refuse prenatal vitamins, a hot medication. In some cultures, part of the role of the traditional midwife or an older family member is to instruct the pregnant woman on the cultural taboos to be observed.

Biomedical culture is not exempt from birthing rituals, many of which have little scientific basis or evidence of effec- tiveness. For example, the practice of performing an episiotomy to keep the perineum from tearing has no scientific evidence of its efficacy and may be a function of the dominant U.S. cultural value for trying to speed up a natural process. Similarly, the routine practices of fetal monitoring and giving an enema prior to delivery have not demonstrated any difference in pregnancy outcomes. Advances in reproductive technology have made it possible for members of the GLBT population to have chil- dren and biomedical cultural birthing practices may need to be modified to accommodate same-sex parents or surrogate par- ents. Selected cultural beliefs and behaviors related to the peri- natal period are presented in the Further Information section of the student resources.

Coming of age. Some ethnic cultural groups have specific ceremonies that mark the movement of children into adulthood. For Jewish children, for example, the bar mitzvah for boys and the bat mitzvah for girls mark their entry into adult life. Similarly, in the southern United States, some groups still hold

debutante parties as a rite of passage for young girls. Initiation of dating may be seen as a coming-of-age ritual in some seg- ments of the dominant U.S. culture. In rural India, this change is typically signaled by a change in female clothing from a short dress or skirt and blouse to the traditional sari.

Female genital mutilation (FGM) is an extreme coming-of- age ritual for young girls in some cultural and religious groups in which portions of the female genitalia (clitoris and possibly the labia) are excised to promote chastity. Some authors sug- gest that immigrant women may be at greater risk for FGM in resettlement areas than in their country of origin due to attempts by the group to maintain their cultural identity. Al- though FGM is illegal in the United States and other countries, it does still occur. Population health nurses should be alert to the possible practice of FGM in client populations with whom they work because of the serious physical and psychological health effects, including infection and difficulties with fertility, pregnancy, and delivery.

Marriage. Some of the issues that may affect health include the typical age at marriage, who is considered an appropriate marriage partner, how marriages are contrived, and the roles and rights of the partners in marriage. In cultural groups where marriage takes place soon after a woman’s first menstrual pe- riod, the potential for complications of pregnancy increase. Conversely, in the dominant U.S. society, marriage is occurring at later ages, and women may be nearing the end of their child- bearing years when a first pregnancy occurs, which may also increase the risk of adverse maternal and infant outcomes.

Who is considered an appropriate spouse within the cul- tural group is also a consideration. In some societies, excessive consanguinity may result in a high prevalence of genetically determined diseases. In others, marriage to an “outsider” is not considered acceptable and may cause significant stress for the couple and their children. Finally, the nurse should consider the attitude of the cultural groups to same-sex couples. In the dominant U.S. culture, for instance, this is a current issue that is being hotly debated and cultural attitudes and family reac- tions to same-sex couples have been shown to create increased stress on the marriage and for the participants.

In the dominant U.S. culture, most marriages are “love matches,” but in other parts of the world and in some ethnic groups within the United States, marriages may still be ar- ranged by parents. Such marriages do not necessarily create negative health effects unless one party or the other resents be- ing forced to marry, which may lead to individual as well as family stress. Pressure to marry may also occur in some groups when a girl becomes pregnant out of wedlock, although such pressure is less likely to occur today with the increasing num- ber of single-parent families. Cultural attitudes toward divorce may also lead to stigma for couples who become divorced. Although this is not usually a problem in the dominant U.S. culture today, it may create family conflict in cultural groups that have a more traditional concept of the permanence of marriage.

M05_MARY9591_06_SE_C05.indd 123 06/09/14 6:10 PM

124 Unit 2 influences on Population health

Finally, the population health nurse would assess the roles and responsibilities expected of marital partners within the cul- tural group. Is the wife expected to be subservient to her hus- band? Is she allowed to own property in her own right? What are either partner’s rights in the event of abuse? Answers to all of these questions have implications for the physical and emo- tional health of the couple as well as other family members.

Death and dying. All cultural groups have beliefs and prac- tices related to death and dying that may vary considerably from those of other groups. Culture influences attitudes toward death and dying in a number of ways. One area of influence is the need for comfort experienced by the dying client. In those cultures in which death is seen as a normal part of life, there may be less need to comfort the dying and his or her family; conversely, in cultures in which death is feared, comfort may be needed and appreciated. Members of the biomedical culture, because of their focus on cure and promoting longevity, tend not to deal well with the concept of death and may need assis- tance in dealing with the death of a client or a loved one. They may also need to be encouraged to accede to clients’ requests to die with dignity and without heroic lifesaving measures. For the GLBT population, the right of the significant other to be pres- ent during hospitalization, particularly when death is imminent is an area that may require advocacy on the part of population health nurses.

The population health nurse should assess whether those he or she is dealing with have a cultural belief in an afterlife. Some non-Western religions, including Hinduism, believe in rein- carnation until the soul has achieved perfection and passes to Nirvana. Do religious beliefs regarding death and afterlife offer a source of comfort to clients and families, or do they engender fear and anxiety?

Culture also influences the selection and perception of health care providers when death is imminent. People from some cultures, including a growing body of mainstream Americans, believe that death should occur at home and are therefore unlikely to seek medical care for a dying client for fear that he or she will be removed from the home and placed in a hospital to die. For many people, going to the hospital means that death is inevitable.

Care of the body following death and funeral and burial practices are also influenced by culture, as are expectations regarding grief and mourning and practices to be observed during this period. Mourning is a cultural expression of grief following death, and mourning practices may vary from group to group.

Finally, culture influences communication regarding death, particularly with respect to children and their knowledge of and participation in the rites that accompany a death. Some groups are quite open in their communication about death; children may help with the care of the dying family member and partici- pate in funeral and grieving practices. Despite this participation, members of many cultural groups may resist telling the client or others regarding imminent death (Purnell, 2012).

Similarly, some cultural groups may resist the discussion or use of advance directives for fear that such a discussion implies a belief that death is near and may cause the ill client to lose hope. For these groups, discussion of death is avoided. Use of advance directives may also be resisted in some cultures be- cause of a perceived lack of need for them. For example, among African Americans, the family usually makes end-of-life deci- sions (Purnell, 2012).

Other questions relate to who should attend the dying client. The eldest son of a Chinese patient is often expected to be pres- ent with his dying parent, whereas in some Native American tribes, the maternal aunt is the more important figure. Some members of other tribes believe that the spirit cannot leave the body until family members are present.

Nurses should be familiar with the death rites of specific cul- tural groups so they can assist the family through their time of grief. Should the nurse wash and prepare the body, or is a fam- ily member responsible for this? Should personal belongings be left with the body or given to the family? The nurse should learn the answers to such questions when working with clients from other cultures. Death rites and the presence of family members may violate institutional policies in some health care settings, and nurses may need to function as advocates for cul- turally congruent care in these instances.

Members of many Native American tribes see the body as a “seed to be planted” and believe that the body must be disposed of in its entirety. Thus, family members may request amputated limbs to be kept until death and disposal of the body. They may also resist having an autopsy performed. Autopsy may also be resisted by members of some other cultural groups. In a simi- lar vein, members of some cultural groups may request the return of hair or nail clippings from hospitalized clients to pre- vent their use by witches. Disposal of the body can vary among cultures and may include burning, burial, or exposure to the elements.

Mourning can be very emotional in some cultural groups and very subdued in others and may last for varying periods of time. For instance, following 4 days of mourning, the Cheyenne and Quechan cease grieving, as do members of some other tribes. In some tribes, the name of the deceased is never spo- ken again, and memory of the deceased is actively suppressed. Among Hmong clans, mourning may last until the following New Year celebration (which usually occurs in late December).

Clothing may assume special meanings in relationship to death. The clothing of a deceased person is believed, in some cultural groups, to contain evil spirits. Family members of hos- pitalized clients should be encouraged to take clothing home until the client is discharged. If the client should die, the family may be reluctant to accept the deceased’s personal effects. In the dominant U.S. culture, family members are usually respon- sible for going through and disposing of the deceased person’s belongings, although who takes responsibility and how items are allocated vary considerably from family to family.

Clothing is also used to symbolize mourning, and mourn- ing garments are worn for varying lengths of time in different

M05_MARY9591_06_SE_C05.indd 124 06/09/14 6:10 PM

chaPter 5 cultural influences on Population health 125

cultures. The color of mourning can also vary. For example, black is the color of mourning for many cultures, includ- ing the dominant U.S. culture, but among the Hmong and Vietnamese, white signifies mourning and black is worn for weddings and other celebrations.

Non-Anglo cultural groups often celebrate death in a way that is foreign to many members of the dominant U.S. culture. The dominant culture, and particularly the biomedical culture, is more likely to try to defy death. In traditional African Ameri- can culture, death is perceived as a passage from one realm of

FOCUSED ASSESSMENT Sociocultural Determinants in Cultural Assessment

• What is the attitude of members of the dominant culture toward the cultural group? What is the attitude of members of the cultural group toward the dominant culture?

• To what extent are members of the cultural group subjected to or perceive prejudice, discrimination, hostility, or harassment?

Socioeconomic Status

• What is the attitude of members of the cultural group toward material wealth and possessions?

• What is the education level typical of members of the cultural group? What is the group’s attitude toward education?

• What is the socioeconomic status typical of members of the cultural group? What effect does socioeconomic status have on health and access to health care services?

Life Events

• What attitudes and beliefs do members of the cultural group hold toward sexuality?

• What are the attitudes of group members toward differences in sexual orientation and gender identity?

• What attitudes and practices related to conception and contraception are displayed by members of the cultural group?

• What are the attitudes, beliefs, and practices of the cultural group related to pregnancy, birth, and the postpartum period?

• Are there specific coming-of-age rituals within the cultural group? What are the health effects of these rituals and practices, if any?

• How is marriage perceived within the cultural group? At what age does marriage usually occur?

• Who is considered an appropriate spouse for a member of the cultural group? How are marriages contracted?

• What are the expected roles and responsibilities of couples? How are they expected to interact with other family members?

• What are the attitudes, beliefs, and practices of the group with respect to death?

• Is there a cultural belief in an afterlife? If so, what effect does this belief have on attitudes toward death and dying?

• What cultural practices are typical of the group in its care of dying members, mourning, and funeral rites?

Values

• What are the strongly held values of the group?

• In what ways do values affect health and illness within the group?

• What is the value given to health in the cultural group? What priority is given to health over other group values?

Relationships with the Supernatural

• What are the perceptions of members of the cultural group with respect to supernatural forces?

• What roles, if any, do supernatural forces have in health and illness?

• What are the religious affiliations of members of the cultural group? What are the major tenets of the religion(s)?

• What influence does religious affiliation or spirituality have, if any, on health care beliefs and practices?

• Do religious leaders have a role with respect to health and illness within the cultural group? If so, what is that role?

• Do magical influences play a part in health and illness within the cultural group?

Family and Community Relationships

• What are the gender roles expected within the cultural group?

• What roles are expected of family members in various positions (e.g., parent, child, elder)?

• What is the typical family structure within the cultural group? Has this structure changed with recent life events? If so, what are the health effects of change in family structure?

• Who is responsible for decisions within the family? Within the larger cultural group?

• What behaviors are expected in interactions with others within the cultural group? Outside the group?

• What is the primary language of the cultural group? What is the level of fluency with the language of the dominant culture among members of the group?

• What other forms of communication are employed by members of the cultural group?

• What is the level of prescribed reticence expected of members of the cultural group?

Relationships with the Larger Society

• What is the quality of interaction between the larger society and members of the cultural group?

M05_MARY9591_06_SE_C05.indd 125 06/09/14 6:10 PM

126 Unit 2 influences on Population health

life to another. Funerals are generally occasions for celebration despite the grief of family members left behind. As is true in the larger society, funerals and wakes are seen as a psychosocial mechanism that facilitates grieving. Funerals for many Latinos are evidence of their deep religious belief in an afterlife. Among the Hmong, funerals are very elaborate functions that may last for several days. As we have seen, beliefs and behaviors regard- ing death and dying vary among different cultures. Selected cultural behaviors related to death and dying and presented in the Further Information section of the student resources for this book. Tips for a focused assessment of sociocultural deter- minants in cultural assessment, including the consideration of life events, are provided on page 125.

Behavioral Determinants Culturally determined lifestyle patterns and related behaviors may also influence the health status of members of a cultural group. Aspects of the behavioral dimension to be addressed in a cultural assessment include dietary practices, other consump- tion patterns, and other health-related behaviors.

DIETARy PRACTICES. Apparel and dietary practices are some of the more obvious differences among ethnic cultural groups, with dietary practices having significant implications for health and illness. Some dietary practices have a religious ba- sis. For example, for both Jews and Muslims, pork is eschewed on religious grounds, and both groups follow strict butchering practices. Other religiously motivated dietary practices among Muslims relate to halal, permitted food and actions, and haram, prohibited food and actions (Katme, 2009). Muslims also fast during the month of Ramadan, eating and drinking nothing between sunrise and sunset. Among Orthodox Jews who keep kosher, separate utensils are used for preparing meat and dairy products, and these foods are not eaten together. In addition, only mammals with cloven hooves and fish with fins and scales are eaten (Keeping kosher: Jewish dietary laws, n.d.). Jains, a religious group found primarily on the Indian subcontinent, are strict vegetarians because of their beliefs in the sanctity of all life. For Jains and other cultural groups, including the domi- nant U.S. culture, food is a way of establishing community, particularly in a new place. Food may have religious connota- tions aside from specifically prescribed and proscribed foods. For instance, bread and wine are the staples of the Christian communion rite.

Among other ethnic cultural groups, food preferences and dietary practices are more a function of foods available than of religious beliefs and practices. For example, poverty and climate gave rise to the staple items of Southern Black diets. Immigration and acculturation to the dominant culture may have a negative effect on the healthier aspects of some tradi- tional diets. Ethnic cultural groups are not the only ones to experience changes in dietary patterns. For example, the move from home-cooked meals to fast foods in the dominant U.S. and other cultures contributes to the increasing prevalence of obesity. Patterns of food consumption have also changed, with

fewer meals eaten as a family group and more special family occasions celebrated with dinner in a restaurant than a celebra- tory home-cooked meal. Generally speaking, the health impact of these and other similar changes in dietary patterns is a nega- tive one.

In addition to considering the food preferences and meal patterns of a particular cultural group, the nurse may also want to assess the meaning of food (and specific food items) within the culture. Other considerations relate to what con- stitutes food for a cultural group (e.g., snails or hamburger, tomatoes or dandelion greens), who does the cooking and how, and the uses of food for specific health purposes. For example, corn is used for religious ceremonies in some Native American groups, and turkey is the traditional Thanksgiving meat in the dominant U.S. culture. With respect to cooking practices, some groups (e.g., some Asian cultures) use stir-fry methods that preserve vitamins; others (e.g., residents of the southern United States) eat a lot of fried foods that increase fat intake. Still other groups may boil vegetables until vitamins are lost. Finally, some foods (e.g., the classic chicken soup or Jell-O in the dominant U.S. culture), are used to promote or restore health.

OTHER CONSUMPTION PATTERNS AND HEALTH- RELATED BEHAvIORS. Other consumption patterns are also addressed in an assessment of behavioral determinants within a cultural group. Areas that the population health nurse might explore are the extent of tobacco use, alcohol consump- tion, attitudes toward and use of prescription and nonprescrip- tion medications, caffeine consumption, and so on. Additional considerations include use of safety precautions, leisure-time pursuits, and exercise.

Smoking and other forms of tobacco use are prevalent in many cultural groups, including the dominant U.S. culture. Other stimulants may also be used; for example, betel leaves are frequently chewed in some parts of India. Cultural groups also vary with respect to physical activity. For instance, large seg- ments of the dominant U.S. culture and many ethnic cultural

ethnic markets support cultural food preferences. (xuanhuongho/Fotolia)

M05_MARY9591_06_SE_C05.indd 126 06/09/14 6:10 PM

chaPter 5 cultural influences on Population health 127

groups do not engage in the recommended level of physical ac- tivity. Cultural fatalism may influence safety behaviors such as seat belt or helmet use.

Use of and attitudes toward alcohol are other areas in which cultural groups may vary. For example, French and Italian groups usually include wine with most meals, yet experience low prevalence of alcohol abuse. In other groups, however, where drinking alcohol is seen to be a sign of adulthood or manliness, alcohol abuse is more prevalent. Ease of access to controlled substances is an area of concern in the biomedical culture. Cultures also vary in their perceptions of alcohol and other substance abuse, with some cultures perceiving it as a disease (biomedical culture) and others as a character weakness (e.g., some fundamentalist religious groups).

Another area for assessment with respect to behavioral factors influencing the health of cultural groups is the use of health-related and safety practices. Among many immigrants, for example, the use of child car seats is limited due to the num- ber of children in the family and the cost of car seats. Members of the biomedical culture may also vary in the degree to which they engage in safety practices such as the use of gloves during routine procedures such as immunization.

Culturally determined behaviors and attitudes toward health-related behaviors can have a profound effect on a group’s health status. Tips for a focused assessment of behav- ioral considerations in cultural assessment are provided below.

Health System Determinants Factors related to health systems also affect the health of popu- lation groups. In assessing cultural groups, one would address health system factors related to perceptions of health and ill- ness and disease causation, the design of health systems, health care providers, and health care practices.

PERCEPTIONS OF HEALTH AND ILLNESS AND DISEASE CAUSATION. Cultural groups may differ signifi- cantly in their perceptions of what constitutes health and ill- ness and beliefs about what causes disease. To protect or restore health, one must be able to identify health and illness and devise interventions that address their causes. Based on their percep- tions of health and disease, cultural groups develop explanatory

models that address causation, symptomatology, pathological processes, the course of the disease, and appropriate treatment. For many Asians and some Latinos, health is a balance between hot and cold forces, and intervention is directed toward restor- ing that balance. Other groups view health as the ability to stay active and to participate in desired activities and functions.

For some groups, disease may have natural or supernatural causes. In keeping with common cultural beliefs in karma, fate, or God’s will, disease may be perceived as punishment for one’s own wrongdoing or that of one’s ancestors. A variety of beliefs about disease causation are also seen in the dominant U.S. cul- ture, where illness may be thought to occur as a result of ex- posure to cold, wrong living (e.g., drinking, sexual activity), pathogens, poor diet, and so on. In the past, in the biomedical culture, disease was perceived to have a discrete external caus- ative agent (e.g., a microorganism, exposure to environmental carcinogens). More recently, greater attention is being given to mind–body interactions in psychoneuroimmunology and to concepts of multiple causation.

Cultural groups may also develop complex disease taxono- mies or types and categories of diseases encountered in the pop- ulation. The International Classification of Disease (ICD-10) is the biomedical culture’s comparable classification system. Cultural conceptions of disease causation and treatment are discussed in more detail below.

HEALTH CARE SySTEMS. Health care is provided in sev- eral domains and each may be used to a different degree by members of different cultural groups or by individuals within those groups. These three domains include the professional, popular, and folk or alternative care domains. The profes- sional domain involves care by biomedical providers. The popular domain consists of health care engaged in by indi- viduals themselves or family members. This domain has been expanded considerably by the availability of health-related information on the Internet. The folk domain involves care by specialized members of the cultural group, usually after a period of apprenticeship. Each domain is characterized by explanatory models of health and illness, social roles for the players involved, and appropriate settings in which health care occurs (Gupta, 2010).

FOCUSED ASSESSMENT Behavioral Determinants in Cultural Assessment

• What is the effect of acculturation on dietary practices?

• What are the other consumption patterns of the cultural group (e.g., tobacco and alcohol use, caffeine consumption)?

• To what extent do members of the cultural group engage in health and safety behaviors?

• What dietary practices are typical of members of the cultural group? What are the preferred foods? How are they typically prepared? Are any foods proscribed?

• Do certain foods or dietary practices (e.g., fasting) have religious significance for members of the cultural group?

M05_MARY9591_06_SE_C05.indd 127 06/09/14 6:10 PM

128 Unit 2 influences on Population health

Use of health systems in any of the three domains is the re- sult of health-seeking behavior, which is a dynamic process of self-evaluation of symptoms, possible self-treatment, and seek- ing and acting on professional advice. Health-seeking behav- ior is greatly influenced by culture, and conventional providers need to consider each of these areas in interacting with clients from any cultural group. Areas for consideration include the meaning of the experience as viewed through a client’s cultural lens, use of popular and alternative therapies, the meaning of health advice within the context of the culture, and the result- ing effects on behavior (Gupta, 2010).

Considerations related to health care systems address the perceptions of members of the cultural group with respect to health care and the design and philosophical underpinnings of the health care system. Health systems may differ in their focus and their perspectives on individual responsibility for health and illness (Purnell, 2012). The biomedical culture and many health professional cultures focus heavily on curative practices. The dominant U.S. culture emphasizes restoration of health rather than health promotion and illness prevention, as seen in the level of funding provided for these various ac- tivities. The U.S. health system is generally focused on disease entities. Only recently has there been somewhat greater atten- tion paid to health promotion and illness prevention in the biomedical culture. Health and illness tend to be seen as indi- vidual or family responsibilities, with less attention to societal factors influencing health. Illness is often seen as the result of personal behaviors over which the client has considerable con- trol. As we saw in Chapter 1 , it is only relatively recently that attention has been given to the effects of social determinants of health.

Many ethnic cultural health systems, on the other hand, place significant emphasis on health promotion and illness prevention. Health is viewed holistically, and in some cultural groups, health and illness may have significant implications for the group or community in terms of both cause and resolution. Naturopathy, for example, is a health system that places special emphasis on illness prevention, and therapeutic interven- tions in this system often focus on promoting healthy lifestyles and facilitating the body’s natural ability to heal (American Association of Naturopathic Medicine, 2011).

Recent biomedical literature abounds with references to CAM. The National Center for Complementary and Alter- native Medicine (NCCAM, 2012c) defined complementary and alternative medicine as “a group of diverse medical and health care systems, practices, and products that are not gen- erally considered part of conventional medicine” (p. 2). Com- plementary medicine involves the use of CAM in conjunction with conventional medicine; alternative medicine systems use CAM in place of conventional therapy (NCCAM, 2012a). The term integrative medicine may also be used, denoting the in- tegration of these nonconventional practices into mainstream health promotion and treatment (NCCAM, 2013b).

NCCAM has identified several broad categories of CAM to include natural products, mind–body medicine, manipulative

and body-based practices, and other CAM practices (NCCAM, 2012b). Natural products include herbal remedies, vitamins, minerals, and other natural products, such as probiotics, live microorganisms that are similar to those found normally in the gastrointestinal tract. Mind–body medicine encompasses therapies that emphasize interconnections between the mind and the body and use of the mind to affect physical health. Some examples of mind–body practices include meditation, yoga, acupuncture, hypnotherapy, progressive relaxation, and tai chi. Manipulative and body-based practices include chiro- practic and other practices that may involve rubbing, press- ing, or manipulating the spinal column, muscles, or soft tissue. Other CAM practices involve such interventions as move- ment therapy, healing practices of traditional healers, manip- ulation of energy fields, (e.g., qigong or healing touch), and whole medicine systems. Whole medicine systems are com- plete theoretical systems outside of conventional medicine, such as homeopathy, Chinese medicine, and Ayurveda (NCCAM, 2012a). Shamanism is another alternative health

Tea and toast are a common popular remedy in mainstream U.S. culture. (Jannyjus/Fotolia)

M05_MARY9591_06_SE_C05.indd 128 06/09/14 6:10 PM

chaPter 5 cultural influences on Population health 129

system employed in some ethnic cultural groups. Each of these health care systems, including the biomedical or allopathic system, includes basic theoretical and philosophical concepts, perceptions of disease causation, and specific diagnostic and therapeutic practices. Table 5-1• describes salient features of some of these health care systems. For more information about categories of CAM, see the Further Information section of the student resources site.

A number of concerns have been raised regarding the in- creasing use of CAM in the United States, particularly regard- ing herbal preparations. These concerns deal with issues of regulation, standardization, quality, safety, and efficacy. Be- cause herbals are considered dietary supplements by the U.S. Food and Drug Administration (FDA), they must carry labels indicating that they are not intended for use to prevent or treat illness. Unfortunately, herbals are often used by the public for these purposes without FDA evaluation of their safety or ef- ficacy. In addition, there is no standardization regarding the strength of active ingredients or their biological activity, which often vary from batch to batch due to differences in plants and growing conditions. Quality is an issue in that preparations do not always contain what they are supposed to, possibly due to incorrect plant identification, contamination and adulteration, inability to disintegrate completely in the body, or misleading

product information. Safety is another area of concern. Herb- als are considered “natural substances,” so people may not be aware of their potential side effects, allergic reactions, or adverse events (NCCAM, 2012b). In addition, the safety of many herb- als for children and pregnant women has not been determined. Finally, although many herbals are the basis for many phar- maceuticals, there is limited information about the efficacy of many other herbs. One other area of concern is the potential for interaction with prescription medications and the fact that many clients who use CAM do not disclose that use to biomedi- cal providers (NCCAM, 2012b). Reasons given for nondisclo- sure include failure of the provider to ask, lack of importance, lack of understanding by providers, and fear that providers would disapprove of or discourage CAM use (IOM, 2005).

Complementary and alternative therapies may be used for health promotion, illness prevention, or curative purposes. An array of cultural approaches to health promotion, prevention, and treatment is included in the Further Information section of the student resources site. Many of the health promotion preventive strategies could also be used to prevent recurring health problems.

HEALTH CARE PRACTICES AND PRACTITIONERS. Each of the health care systems described in Table 5-1 makes use of a cadre of providers who function in accord with the pre- cepts of that system. There are also a few independent providers who do not subscribe to a particular system of care as the basis for their activities. Health care providers within cultural health systems vary with respect to how they enter their profession, the type of training they receive, their degree of specialization and focus of care, the health promotion and curative practices they employ, and the way in which they are viewed by members of the culture.

Health practitioners may come to their calling in several ways, including inheritance, family position, birth portents, revelation, apprenticeship, self-study, and formal education. Healing skills are sometimes believed to be passed down in families from generation to generation. One’s position within the family may also indicate special abilities, for instance, a sev- enth or ninth child or a child born after twins. Unusual occur- rences during pregnancy or at birth, such as being born with a “caul,” or amniotic membrane over the face, may also herald healing skills. Other practitioners may be called in a dream or vision or after recovering from a life-threatening illness them- selves. Others show an aptitude for healing and may be ap- prenticed to an experienced healer. A few practitioners learn their calling on their own because of personal interest. In the biomedical culture, professional health care providers receive specific training in their discipline, most often in a recognized institution for postsecondary education. Even within the bio- medical culture, however, there are variations in educational preparation for practice in a specific discipline (e.g., diploma, associate degree, and bachelor’s degree preparation for entry into the nursing profession versus post-baccalaureate educa- tion for physicians and dentists).

Herbal remedies are common in many cultures. (Photobee/Fotolia)

M05_MARY9591_06_SE_C05.indd 129 06/09/14 6:10 PM

130 Unit 2 influences on Population health

System Description

Ayurveda Source: India Basic Concepts: All matter is composed of five elements: ether, air, fire, water, and earth. Human beings are composed of body (dhatus—body tissues, malas—waste products, and doshas—physiologic elements) and soul (atma—soul or spirit, and nana—mood, cognition). Doshas are the embodiment of the five elements in the body: Vata dosha: composed of ether and air; controls functions of the central and sympathetic nervous systems; regulates feelings and emotions; prevalent after age 55 years Pitta dosha: composed of fire and water; controls heat production and metabolism, vision, skin texture; influences intellect and cheerfulness, anger, hate, and jealousy; prevalent from puberty to middle age Kapha dosha: composed of water and earth; influences strength, cell reproduction, memory, emotional bonding, greed, and envy; prevalent in childhood Individuals differ in the preponderance of each element in the body, giving rise to seven different “constitutions” that influence physical and behavioral aspects of the individual. Cause of Disease: Disease is caused by imbalance among elements of mind and body or ineffective functioning of one or more elements. Diagnosis: Diagnostic processes include observation, touch, questioning, assessment of pulses; examination of urine, stool, tongue, bodily sounds, eyes, skin, and total appearance; and assessment of digestive capacity, personal habits, and individual resilience. Treatment: Treatment entails four types of therapies: Shodan: cleansing by means of five panchakarma: intestinal cleansing, cleansing of the stomach and duodenum, medicinal enemas, medicinal nasal oils, and, occasionally, bloodletting Shaman: palliation through burning toxic wastes, fasting, yoga, lying in the sun, breathing exercises, and meditation Rasayan: rejuvenation through herbal remedies and dietary supplements Satwajaya: stress reduction, mental nurturing, and spiritual healing

Biomedicine (Allopathy) Source: Cartesian worldview of mind–body separation Basic Concepts: The body functions mechanically, based on complex physical and chemical interactions and independent of the influence of the mind. Cause of Disease: Disease causation is perceived from a mechanistic perspective, that is, changes in structure or function of the human “machine” in response to specific factors (e.g., microorganisms, fat intake, genetics) result in disease. Diagnosis: Diagnosis tends to rely on symptom presentation, invasive tests, and technological processes. Treatment: Treatment focuses on repair or replacement of bodily processes by means of pharmaceutical, immunological, and surgical interventions.

Chinese Medicine Source: Originated in China, but has spread throughout much of Asia Basic Concepts: The human body is composed of several vital substances: Qi (pronounced “chee”) is the body’s vital energy force, responsible for effective physiologic function. It forms the basis for the other bodily substances. Blood moistens and nourishes the body. Jing (essence) is a specific hereditary energy force contained in the kidney that determines constitution and regulates growth, development, and reproduction. Body fluids such as saliva, mucus, sweat, urine, and excretory fluids may be deficient or stagnant. Shen encompasses the mental, emotional, and spiritual aspects of the individual. Qi flows through a network of 12 principal meridians or channels within the body and can be adjusted through acupuncture. All life is composed of male and female aspects of yang and yin. Yin is related to the water element and has properties of moistness, coolness, and substance. Yang is related to fire and has properties of warmth, dryness, and lack of substance. Cause of Disease: Disease is caused by an imbalance between forces of yin and yang and among the five elements of wood, fire, earth, metal, and water. Yin/yang imbalance may be related to deficiency, stagnation, counterflow, or sinking Qi. Diagnosis: Diagnosis relies on two primary mechanisms: examination of the depth and quality of pulses in multiple locations, and examination of the color, shape, coating, and moistness of the tongue, which indicates the nature of imbalance between yin and yang.

TABLE 5-1 Selected Health Care Systems

M05_MARY9591_06_SE_C05.indd 130 06/09/14 6:10 PM

chaPter 5 cultural influences on Population health 131

System Description

Treatment: Traditional treatments in Chinese medicine include: Acupuncture: insertion of slender needles at specific points on the meridians to influence the flow of Qi within the body Qigong: meditative movements and breathing exercises to improve the flow of Qi Herbal preparations

Chiropractic Source: Roots in ancient Chinese and Greek writings; promoted in the United States with the establishment of a chiropractic professional organization by Daniel David Palmer in 1895 and the Palmer School of Chiropractic in 1897 Basic Concepts: Natural and conservative methods are best used to promote and restore health. The human body has a vast capacity to heal itself. Adjustment and manipulation of musculoskeletal articulations, particularly in the area of the spine, and adjacent tissues can be used to treat functional disorders. Cause of Disease: Disease is caused by misalignment of body parts. Diagnosis: Based on perceptions of misalignment, may include specific measures of alignment through physical examination or X-ray. Treatment: Treatment focuses on manipulation of body parts.

Homeopathy Source: Developed by a German allopathic physician, Samuel Hahnemann, who was disenchanted with 19th- century biomedicine Basic Concepts: One’s vital force can promote self-healing. Stimulation of vital force promotes the body’s healing response. Based on the law of similars—“like cures like”—and the law of infinitesimals—disease can be cured by use of very dilute doses of substances that are similar to the disease and would produce symptoms similar to those of the disease in a healthy person. Small doses of substances cure; larger doses damage the body’s ability to heal itself. The smaller the dose, the more effective in healing. Hering’s laws of cure: Healing occurs from head to foot. Healing occurs from internal to external. Healing progresses from more-vital to less-vital organs. Symptoms disappear in the reverse order of their appearance. Cause of Disease: Disease is caused by an imbalance or disruption in vital energy. Diagnosis: Diagnosis occurs by means of case taking or an interview to determine the client’s problem and all symptoms experienced, and involves categorizations of the client’s constitutional type. Treatment: Treatment is individualized and holistic, considering lifestyle as well as emotional state and other factors. Treatment involves prescription of remedies that are akin to the symptoms experienced, based on the Materia Medica, a compendium of remedies and their uses. Remedies may be derived from plant, mineral, or animal sources and are regulated by the FDA.

Native American Healing Source: North American tribes Basic Concepts: Health is a reflection of harmony between the individual and nature, supernatural beings, and other people. Body and spirit are one entity. Health and disease have both physical and spiritual aspects. Cause of Disease: Disease results from disharmony and may be caused by: Internal factors, such as negative thinking or disturbance in life energy External factors, such as: pathogenic forces (e.g., microorganisms, sorcery, or supernatural beings) environmental poisons (e.g., pollution, alcohol abuse, poor diet) traumatic physical, emotional, or spiritual events breach of taboo and inharmonious relationships with nature, other people, or spiritual beings Diagnosis: Diagnostic approaches vary from group to group and may include hand trembling, crystal gazing, dream interpretation, divination, questioning, and observation. Treatment: Treatment also varies among groups, but may include prayer, music and chanting, purification rituals and ceremonies, herbs, massage, counseling, and fasting. Family and community are frequently intimately involved in healing practices.

(Continued)

(Continued )

TABLE 5-1

M05_MARY9591_06_SE_C05.indd 131 06/09/14 6:10 PM

132 Unit 2 influences on Population health

System Description

Naturopathy Source: Initiated in the United States by Benjamin Lust, a proponent of hydrotherapy Basic Concepts: The body has the ability to heal itself. Natural substances have healing properties. Treatment should encompass the whole person. Prevention and health promotion are important to health. Cause of Disease: Disease results from alterations in the mechanisms by which the body heals itself. Diagnosis: Diagnosis is made by history and physical examination. Treatment: Treatments include a variety of therapies such as nutrition, botanicals, fasting, heat, cold, exercise, counseling, and lifestyle modification.

Shamanism Source: Siberia and Central and Southeast Asia. Variations also found among indigenous people worldwide. Basic Concepts: Shamanism focuses on harmony with nature, healing of self and community, daily spiritual practice, connection with sacred places. Health and illness result from the imbalance between the person and natural forces. Cause of Disease: Disease results from an imbalance between the individual and the spiritual world. Diagnosis: Diagnosis occurs by means of communication with the spirits responsible. Treatment: Ceremonies to honor natural spirits and promote harmony and balance

Traditional African Healing Source: African tribal, Native American, and White colonial practices Basic Concepts: Human beings are composed of body and spirit (which includes mind). The balance between hot and cold in the body is important for health. Cause of Disease: Disease may be caused by natural and supernatural causes or an imbalance between hot and cold. Treatment: Treatment varies with the identified cause of disease and may employ spiritual or magic practices, herbs and diet therapy, massage, and dermabrasive practices such as cupping, pinching, rubbing, and burning.

Data from: American Chiropractic Association (2014a, 2014b); Mhame, Busia, & Kasilo, 2010; National Center for Complementary and Alternative Medicine (2012a, 2012b, 2012c, 2012d, 2013a, 2013b, 2013c, 2013e). (See References in this chapter for full citations.)

(Continued)

There is also wide variation in the types of people who pro- vide health care in different cultural groups, from the family member or friend with expertise in dealing with illness to the specialist practitioner. Many people first seek advice on health from knowledgeable family members or friends before seeking more professional assistance. In the dominant U.S. culture, as well, people may rely on the wisdom and expertise of family members and friends for the care of minor illnesses or in mak- ing the decision to seek the assistance of a professional health care provider.

Professional assistance may be sought from a variety of dif- ferent practitioners, depending on one’s cultural background. There is also a growing tendency among the general public to seek health care from providers in non-biomedical health sys- tems. Many clients with back pain or headache, for example, are seeking pain relief through acupuncture and the use of chiropractic services. The National Health Interview Survey indicated that 38% of U.S. adults and 12% of children used some form of CAM (NCCAM, 2008). In 2007, national out-of- pocket expenditures for CAM were almost $34 billion. This fig- ure represents only 1.5% of total health care expenditures, but

more than 11% of out-of-pocket spending (NCCAM, 2013d). Some health insurance plans are beginning to cover some CAM practices such as chiropractic and acupuncture; however,

Members of many cultural groups seek the services of traditional practitioners. (Max Tactic/Fotolia)

TABLE 5-1

M05_MARY9591_06_SE_C05.indd 132 06/09/14 6:11 PM

chaPter 5 cultural influences on Population health 133

there are frequent restrictions on the type and extent of CAM covered, and deductibles and copayments may be higher than for conventional care (NCCAM, 2013d). Increases in insurance coverage for CAM are a function of consumer demand and the growing body of research indicating the effectiveness of some forms of CAM for a variety of health problems.

Some cultural groups include a wide array of health provid- ers, many of whom are highly specialized. Zuni (Native Ameri- can) healers, for example, are divided into several highly secret medicine societies, each of which specializes in the treatment of specific conditions. Specialization is also an emphasis in bio- medicine, and there is a variety of specialty areas of practice in medicine and in nursing. Population health nursing is one example of specialization in nursing. Among the Navajo, heal- ers may be divided into medicine men or women and diagnos- ticians. The function of the diagnostician is to determine the cause of illness through divination, whereas the medicine man or woman treats it (Spector, 2012). Singers are considered the most specialized practitioners among the Navajo and cure by means of specific songs and ceremonies (Purnell, 2012). Asian practitioners are often divided into the categories recognized in Chinese medicine, including acupuncturists and herbalists. Herbalists are also found among African American, Latino, and Appalachian cultural groups.

Religious healers, faith healers, or spiritualists are found among many cultural groups, including Asians, Latinos,

African Americans, and Appalachians. Religion as a source of healing is common, and prayer and other religious rituals may accompany more scientific forms of healing for many. The charismatic healing tradition of the Roman Catholic Church is another example of the use of religious practices in healing. Other cultural groups embrace the practice of psychic healers thought to possess healing energy that can be transmitted to others, usually by some form of touch. Belief in this transfer of energy underlies the practice of therapeutic touch as a nursing intervention.

Practitioners of healing magic may also be found in a num- ber of ethnic cultural groups. For example, espiritistas in the Latino alternative health tradition of spiritualism specialize in the treatment of illness caused by witchcraft (Purnell, 2012). Spiritual healers may also be seen among African American cultural groups, and the voodoo priest or priestess found among some African American groups is another example of magic used in healing (Spector, 2012).

Another group of health practitioners found in many cul- tures specializes in massage and is exemplified by the sabador in some Latino cultures. Massage and manipulation of body parts are also employed in chiropractic practice. Finally, many cultural groups include midwives as recognized health practi- tioners. In fact, midwifery as a specialized practice is a growing phenomenon in nursing that is gaining in popularity through- out the United States.

Evidence-Based Practice

CAM for HIv Symptom Relief The advent of highly active antiretroviral therapy (HAART) has resulted in the transformation of HIV/AIDS from an acute and frequently fatal communicable disease to a chronic disease with multiple symptoms and undesirable treatment effects. HAART can often result in total viral suppression with rigid adherence to the treatment regimen. Adherence, however, is compromised by the experience of unpalatable side effects. Many people experi- encing the chronic effects of both the disease and side effects of therapy have turned to a variety of complementary and alter- native methods of symptom control. For example, in one study, 38% of HIV infected persons used a CAM provider and 89% used a variety of micronutrients. In another study, nearly half of the patients seen in an HIV/AIDS treatment program reported using some form of CAM. For these reasons, it is important that the evidence base for CAM use in conjunction with HAART be examined.

A systematic review of 40 studies conducted from 2000 to 2009 examined the effectiveness of four categories of CAM and specific interventions related to each. The four categories of therapy included whole medicine systems (homeopathy, natu- ropathy, Ayurvedic medicine, and traditional Chinese medicine),

body–mind medicine (e.g., support groups, cognitive behavioral therapy, meditation, prayer, etc.), biologically based practices (e.g., herbs, dietary supplements, and specific foods), and energy therapies (e.g., therapeutic touch, qigong, reiki). Two prior sys- tematic reviews in 2002 and 2005 had found limited evidence to support CAM use, with some suggestion that stress management strategies might eventually be found to improve quality of life.

After the present review, Hoogbruin (2011) concluded that there is insufficient evidence that any particular complementary or alternative therapy was effective in managing HIV disease. Many CAM therapies interact with HAART or may lead to non- compliance with therapy in the belief that the disease is ad- equately controlled using CAM. For these reasons, population health nurses should educate the population of HIV-infected persons regarding the overall lack of evidence of effectiveness of CAM in addressing HIV symptoms and HAART side effects. Cli- ents in this population should be cautioned to discuss intended use of CAM with their conventional health care provider. Popula- tion health nurses should cultivate an awareness of the effective- ness of CAM for other health conditions in order to assist clients to make informed decisions about CAM use.

M05_MARY9591_06_SE_C05.indd 133 06/09/14 6:11 PM

134 Unit 2 influences on Population health

In assessing health system determinants for any cultural group, the population health nurse explores several areas re- lated to health care providers. Among these are the types of practitioners recognized by the group, the health-related ser- vices provided, and the methods employed. Who and where are the practitioners? Is there a recognized hierarchy among practitioners? Who uses what type of provider, and what is the prevailing attitude of community members toward different types of providers?

INTERACTIONS WITHIN AND AMONg HEALTH CARE SySTEMS. Another component of cultural assessment is the exploration of relationships and interactions between and among health care systems. Do members of an ethnic cultural group use the services of both biomedical and traditional health systems? If so, what is the effect of this dual usage? Another area for consideration lies in the attitudes of providers in one system toward providers in other systems. To what extent do providers in different systems interact with each other? What is the character of that interaction? For example, is it collaborative or adversarial?

Providers in one system may fail to see the value of practices of another system. This attitude is not restricted to biomedi- cal practitioners. For example, a few biomedical and alternative providers believe that having a disease such as measles provides more effective immunity than immunization. Similarly, bio- medical providers may perceive spiritual or magico-religious health practices employed in some traditional health systems as evidence of superstition.

Varying degrees of interaction occur between and among health care systems. In this discussion, we will focus primarily on interactions between the biomedical system and other sys- tems of health care. Some of the failure of interactions among systems is the result of repression of traditional systems of health care. For example, the practice of lay midwives attend- ing births was actively discouraged by the medical community in the United States, and many practiced their calling outside the law. On the other hand, interaction between systems may be encouraged. For example, CAM has been integrated into the national health systems of several countries. Referrals between health systems may be somewhat uneven, however, rather than equally reciprocal. In general, CAM practitioners may be more likely to make referrals to the biomedical system than vice versa.

Lack of interaction between and among health care systems may lead to a variety of problems for their users. As we saw ear- lier, for example, failure to tell providers of one system that one is using the services of another may contribute to health prob- lems such as drug–drug interactions. Many CAM users believe that biomedical physicians are prejudiced against herbals and other traditional practices or that they know little about them. In some instances, reliance on traditional health care practices may lead to delay in seeking care and more severe illness when biomedical care is sought.

People in ethnic cultural groups may encounter a variety of barriers to obtaining care in the biomedical system, resulting

in a preference for seeking care in traditional systems. Racial and cultural biases and inappropriate services, philosophi- cal differences, language barriers, and a lack of knowledge of available biomedical services are some of the reasons given for not seeking care in the biomedical system. In addition, some members of ethnic cultural groups report “language discrimination,” being treated unfairly because of their lan- guage or accent. As we will see in Chapter 20 , members of the GLBT culture may experience discrimination from bio- medical health care providers.

Some authors have noted that Eastern and Western systems of mental health care differ greatly due to their different philo- sophical traditions and conceptualizations of mental illness. Differences in interpersonal boundaries and language issues also complicate the use of conventional mental health services by members of some cultural groups. In addition, nonlinear thinking patterns typical of some cultural groups may be inter- preted by Western practitioners as confusion or resistance to treatment, and culturally unfamiliar behaviors may be viewed as pathological. Similarly, key concepts (e.g., death, rape, sui- cide) may have significantly different meanings in different cultural contexts, resulting in different emotional responses. All of these factors may lead to inappropriate diagnoses and treatment approaches in the Western mental health tradition.

Another health system determinant involves expectations of interactions between clients and health care providers. In many ethnic cultural groups, as well as in the dominant U.S. and biomedical cultures, the provider is seen as dominant and the client as subordinate. In some respects, this expectation is changing as many members of the dominant U.S. culture gain

global Perspectives

Although traditional Chinese medicine is gaining greater accep- tance and use in the United States, its use in China is declining. Some of the reasons for its decline are an increased emphasis on profit, decentralization, and movement to a fee-for-service and private insurance system for health care. In addition, there are a growing number of for-profit Western hospitals in China and greater emphasis on Western medicine in the education of younger providers. Another reason for the decline is the increas- ingly busy lifestyle of modern Chinese, who no longer have the time for frequent provider visits or preparation of herbal teas and other remedies. These pressures to move to a Westernized ap- proach to health care are viewed by some as a threat to the cul- tural significance of traditional Chinese medicine, a reduction in the availability of low-cost services, and loss of a valuable source of care for major segments of the population (Burke, Wong, & Clayson, 2003). How might the principles of integrative health care discussed in this chapter help to prevent this loss?

Decline of Traditional Medicine Use in China

M05_MARY9591_06_SE_C05.indd 134 06/09/14 6:11 PM

chaPter 5 cultural influences on Population health 135

knowledge of health-related matters from the Internet and are exposed to marketing initiatives by health-related vendors such as pharmaceutical companies.

Members of some groups expect providers to spend time in casual conversation or even to share meals before addressing intimate health issues. In the biomedical culture, however, the focus is on obtaining health-related information rather than on observing social amenities. Similarly, health care providers are taught to withhold personal information, which may make it difficult for clients from other cultural groups to develop a trusting relationship. Differences in relationships between pro- vider and client may lead members of some cultural groups to prefer traditional healers to professional providers. Some of the reasons for this preference may be perceptions of low risk in the interaction, an emphasis on high-touch interpersonal re- lationships, and a perception that traditional healers stimulate one’s innate healing mechanisms rather than using chemicals and other approaches that may seem unnatural to the client (Jackson, 2010). Tips for a focused assessment of health system determinants of health in cultural groups are presented above.

As we have seen, cultural assessment includes explora- tion of factors in each of the six categories of determinants of

health. A comprehensive tool for cultural assessment based on the  determinants of health can be found on the student resources site.

Planning Culturally Congruent Care and Delivery Systems Providers in all health systems should engage in culturally con- gruent care. Doing so requires that individual providers and health delivery systems emphasize cultural congruence with the populations served. The need for culturally appropriate care and care systems lies in the increasing diversity of popu- lations throughout the world, the increasing provision of care in the home setting where cultural factors are more influential, and the increasing disparities in health status among many eth- nic cultural minorities (OMH, 2013a). Benefits of culturally competent care include more appropriate and accurate diag- noses of health problems and better compliance with treatment recommendations, reduced delay in care seeking and use of services, enhanced client/provider communication, and greater compatibility of biomedical and traditional health care systems.

FOCUSED ASSESSMENT Health System Determinants in Cultural Assessment

Health Care Providers and Systems

• From whom do members of the cultural group seek advice on health promotion and illness prevention?

• From whom do members of the cultural group first seek assistance with health care problems?

• For what types of health issues is assistance sought by members of the cultural group?

• Do members of the cultural group seek assistance from different types of providers for different problems? If so, whom do they seek for what kinds of problems? What is the rationale for the types of providers selected?

• Who are the recognized providers of health care within the cultural group? What types of care do they provide? What is the extent of their use by members of the group?

• Do members of the cultural group voice a preference for providers with certain characteristics (e.g., nurse practitioners over physicians, providers of a specific gender, herbalists over biomedical providers)? If so, on what beliefs and attitudes are these preferences based?

• Are there barriers to the use of specific types of health care providers? If so, what are they?

• If members of the cultural group use multiple providers, are the providers aware of this? If not, why?

Perceptions of Health and Illness and Disease Causation

• How do members of the cultural group define health and illness? What do they perceive as the cause(s) of disease?

• How does the cultural group classify disease?

Health Practices

• What practices do members of the cultural group typically employ to promote health and prevent illness?

• What home remedies, if any, do members of cultural groups employ to treat health problems? For what problems are they used? How are they used?

• What over-the-counter remedies are used by the cultural group? For what and how are they used?

• What provider-prescribed medications and treatments are used by the cultural group? By whom are they prescribed? If therapies are prescribed by multiple providers, are all providers aware of this?

• What are the client’s/cultural group’s preferences with respect to the type of treatment modalities prescribed (e.g., massage, medications in liquid or tablet form)?

• What measures are used by the cultural group to deal with the consequences of long-term health problems (e.g., pain relief, mobility limitation)?

• Are any of the health practices or therapies employed by the cultural group potentially harmful?

M05_MARY9591_06_SE_C05.indd 135 06/09/14 6:11 PM

136 Unit 2 influences on Population health

Cultural Competence A number of terms are used to describe nursing and health care that take into account elements of clients’ culture. These include cultural congruence, ethnic nursing care, culture care, and culturally congruent care. The term that will be used in this book is cultural competence or culturally and linguisti- cally appropriate care. Culturally congruent care has been defined as “actions and decisions that fit with people’s lifeways to support satisfying health care and promote well-being or dignified death” (McFarland, Mixer, Wehbe-Alamah, & Burk, 2012, p. 263). Campinha-Bacote’s (2009) definition of cultural competence was presented earlier in this chapter. Another widely accepted definition of cultural competence is that ad- vanced by the Office of Minority Health (2013b, para. 1), “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that en- ables effective work in cross-cultural situations.” Basically, culturally appropriate care is care that meets, or is congruent with, the expectations of the recipient whatever their cultural orientation.

Culturally appropriate care incorporates several compo- nents. These include cultural diversity, cultural awareness, cultural sensitivity, and cultural competence. Cultural diver- sity reflects the cultural differences that exist between health care professionals and a given population or cultural group (e.g., differences between “straight” health care providers and members of the GLBT population or between “able” provid- ers and disabled clients). Cultural awareness encompasses pro- viders’ recognition of the influence of culture on health and health-related behaviors. Cultural sensitivity involves assum- ing a learner role with respect to the cultures of the populations served, and being willing to recognize cultural factors that in- fluence our interactions with others. Cultural competence, on the other hand, is the ability to interact effectively with people from all backgrounds (Edmonton Seniors Council, n.d.).

Several models of cultural competence have been developed that delineate the critical elements of the concept. Two of these are Leininger’s (2006) theory of culture care diversity and uni- versality and Campinha-Bacote’s (2009) process of cultural competence in health care services model. Leininger’s theory addresses the similarities (universalities) and differences (di- versities) among cultures and incorporates three modes of nursing activity, preservation and maintenance, accommoda- tion/negotiation, and restructuring/repatterning (McFarland et al., 2012). In the preservation and maintenance mode, the population health nurse assists members of the cultural group to maintain and promote healthful beliefs and practices, often by incorporating them in the plan of care. In the accommoda- tion/negotiation mode, the nurse assists the cultural group to adapt care delivery services or negotiate for culturally congru- ent care. When cultural beliefs and practices may be harmful to health, the nurse assists group members to restructure or repattern lifeways to more healthful ones. Restructuring and repatterning may also lead to changes in health professional behaviors or health care systems (Hulme, 2010).

A significant amount of repatterning has already occurred among many biomedical providers, resulting in a willingness to employ CAM in their practices. Similarly, repatterning has taken place in the insurance world, leading to coverage for some complementary and alternative therapies. As more such therapies are integrated into the biomedical system, it is antici- pated that the system itself may be repatterned in ways that will change the overall delivery of care to a more humanistic, less mechanistic perspective.

Repatterning may also be warranted for members of ethnic cultural groups to be able to function effectively within the dom- inant culture. For example, there may be a need to explain host country laws regarding child care and neglect to immigrants whose cultural practice is to have older siblings care for younger children. The presence of lead and other toxic substances in some traditional remedies is another area in which repattern- ing may be required. For example, lead in Cambodian protec- tive amulets has been linked to lead poisoning in young children (Healthy Homes and Lead Poisoning Prevention Bureau, 2011).

Clients from ethnic cultural groups, particularly immi- grants, may need nursing assistance in dealing with intergen- erational conflicts arising from different levels of acculturation among family members. For example, traditional food prepa- ration may create difficulty, conflict, and guilt for younger women who do not have time to prepare traditional cultural dishes due to changes in their roles with the necessity to work outside the home to support their families. Culturally compe- tent population health nurses could engage in interventions that could assist families experiencing these and other stresses of relocation.

Leininger’s theory gives rise to the Sunrise model in which culture is situated within the group’s worldview and social and cultural dimensions of life. The model also includes guidance for cultural assessment addressing elements of technological factors; religious and philosophical factors; kinship and social factors; cultural values, beliefs, and lifeways; political and legal factors; economic factors; and educational factors as they influ- ence the health of the cultural group (McFarland et al., 2012).

Campinha-Bacote’s model of the process of cultural com- petence in the delivery of health care services encompasses components of cultural desire, cultural awareness, cultural knowledge, cultural skill, and cultural encounters. The cul- tural desire component reflects the population health nurse’s motivation to provide culturally congruent care. Cultural de- sire includes the concept of cultural humility, which involves “seeing the greatness in others and coming into the realization of the dignity and worth of others” (Campinha-Bacote, 2009, p. 49). Cultural awareness involves exploration of one’s own biases, stereotypes, prejudices, and assumptions about those who differ from oneself. The element of cultural knowledge includes seeking information about the health-related beliefs and practices of the cultural group, incidence and prevalence of specific conditions within the group, and knowledge of treatment efficacy (e.g., rates of drug metabolism, responses to treatment). Cultural skill is the ability to collect data in a

M05_MARY9591_06_SE_C05.indd 136 06/09/14 6:11 PM

chaPter 5 cultural influences on Population health 137

culturally sensitive way and to perform a culturally based phys- ical assessment attending to differences in normal and abnor- mal findings. Finally, the process involves deliberately seeking opportunities for interactions with members of another cul- tural group in order to learn (Campinha-Bacote, 2009).

CHARACTERISTICS OF CULTURAL COMPETENCE. Provision of culturally congruent care requires the development of cultural competence on the part of individual health care providers and health care organizations. Individual cultural competence encompasses several characteristics. First among these is an awareness of one’s own culturally determined per- spectives without letting them influence one’s interactions with others. Cultural competence is also characterized by knowledge and understanding of another culture and by acceptance of and respect for other cultures. The culturally competent health care provider does not assume that other cultures are similar to his or her own and is nonjudgmental in examining the be- liefs, values, attitudes, and practices of other cultural groups. In addition, the competent provider displays an openness to and comfort with encounters with persons from other cultural heritages. Finally, cultural competence is characterized by a conscious process of adaptation of care to the cultural context (Purnell, 2012).

At the health system level, culturally and linguistically ap- propriate health care programs also display certain character- istic traits. These include a broad definition of culture beyond considerations of race, language, ethnicity, and recognition of value in clients’ cultural heritage. Culturally competent systems are also characterized by a recognition of the complexities in- volved in language interpretation and an awareness of the need to consider linguistic variation within cultural groups (includ- ing professional cultures), cultural variation within language groups (e.g., among the multiple cultural groups that speak Spanish), and variation in literacy levels among members of a particular cultural group. Culturally competent systems of care facilitate learning between providers and communities and involve communities in defining and addressing their health care needs. They also foster interagency collaboration and take steps to institutionalize cultural competency within the system. Characteristics of cultural competence at the individual pro- vider and health system levels are summarized in Table 5-2•.

These characteristics are exemplified in adherence to the “National Standards for Culturally and Linguistically Appropri- ate Services (CLAS) in Health and Health Care” developed by the OMH (2013a). These standards are discussed in more de- tail below.

CHALLENgES IN DEvELOPINg CULTURAL COMPETENCE. A number of challenges have been identified that may impede the development of cultural competence in individual provid- ers or in health care systems. The first challenge is the recog- nition of clinical differences among cultural groups. Providers may be “culturally blind” and fail to recognize the differences among cultures (including biomedical culture) and the influ- ence of culture on health and health care. Communication among cultural groups may also be a challenge in developing cultural competence, even among those that share a common language. The challenge in that case arises from differences in the way words are used, their particular meanings, and the interpretation of paralanguage and nonverbal aspects of com- munication. A third challenge is developing a sense of ethics and recognizing when it is appropriate to incorporate elements of culture in the plan of care and when those elements of cul- ture may be harmful and should be eliminated or modified. Developing trust between members of a cultural group and those of the biomedical culture may be another challenge in de- veloping cultural competence. As we will see in Chapter 20 , many members of the gay, lesbian, bisexual, and transgender cultures have reason to distrust health care providers. Distrust of biomedical providers is also a relatively common occurrence among members of some other cultural groups.

Cultural competence may also be impeded by stereotypes held by providers. Development of culture-specific knowledge has both benefits and disadvantages. On the plus side, knowl- edge of other cultures leads to recognition of cultural differ- ences, opens the mind to alternative viewpoints, and serves as a starting point for cultural assessment of individual clients or subgroups within the population. However, such knowl- edge may give providers a false sense of security in working with members of other cultures and may lead to stereotyping as discussed earlier. Stereotyping is a useful cognitive strategy for organizing information about the complex world in which we live, and is not necessarily associated with negative attitudes

TABLE 5-2 Individual and System-Level Characteristics of Cultural Competence

Individual Characteristics System Characteristics

• Awareness of personal perspectives • Knowledge and understanding of other cultures • Not assuming similarity to one’s own culture • Nonjudgmental view of other cultures • Openness to and comfort with cultural encounters • Conscious adaptation of care to the cultural context

• Broad definition of culture • Value attributed to cultural beliefs • Recognition of complexity in language interpretation • Facilitation of learning between providers and cultural communities • Involvement of cultural communities in defining and addressing health needs • Interagency collaboration • Institutionalization of cultural competence

M05_MARY9591_06_SE_C05.indd 137 06/09/14 6:11 PM

138 Unit 2 influences on Population health

toward members of other cultural groups. It is when providers fail to assess individuals or segments of a population group to see how closely they conform to beliefs and behaviors typical of the cultural group that stereotyping interferes with culturally competent care.

Other barriers to the provision of culturally competent care include viewing cultures as “them,” not “me,” without recogniz- ing the influence of culture on one’s own life; confusing race, cul- ture, and ethnicity; and misdiagnosing ethnic-specific medical concerns due to lack of knowledge or communication difficul- ties. Cultural mismatches may also impede culturally competent care. Ideally, both an ethnic match and a language match exist between the provider and the client. An ethnic match occurs when both the client and the provider have the same ethnic iden- tity. Given the dearth of biomedical providers from many ethnic cultural minority groups, ethnic matches are often difficult to obtain. In a language match, the client’s native language is one in which the provider is fluent. Ethnic and language matches seem to be particularly important in the area of mental health.

DESIgNINg CULTURALLy AND LINgUISTICALLy APPROPRIATE HEALTH CARE DELIvERy SySTEMS. Organizations, like individuals and other groups, have their own distinct culture. Organizational culture is the shared as- sumptions, beliefs, and values that result in shared behavioral norms and expectations for members of the organization. The organizational cultures of health care agencies and systems may make it more or less difficult for providers to engage in cultur- ally congruent care.

In addition to providing culturally and linguistically ap- propriate care for individual clients, families, and population groups, population health nurses can contribute to the devel- opment of culturally appropriate health care delivery systems. In 2000, the Office of Minority Health developed the National Standards for Culturally and Linguistically Appropriate Ser- vices, better known as the CLAS standards, to guide health care organizations in providing culturally competent care. Those standards were revised and enhanced in 2013 (OMH, 2013a), and are summarized in Table 5-3•.

TABLE 5-3 National Standards for Culturally and Linguistically Appropriate Services (CLAS)

Focus Related Standards

Principal Standard • Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Governance, leadership, workforce

• Advance and sustain organizational leadership that promotes CLAS and health equity through policy, practices, and allocated resources.

• Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.

• Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

Communication and language assistance

• Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.

• Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.

• Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.

• Provide easy to understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

Engagement, continuous improvement, and accountability

• Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations.

• Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and quality improvement activities.

• Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.

• Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.

• Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.

• Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.

• Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

Source: Office of Minority Health. (2013a). National standards for culturally and linguistically appropriate services (CLAS) in health and health care: A blueprint for advancing and sustaining CLAS policy and practice. Retrieved from https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf

M05_MARY9591_06_SE_C05.indd 138 06/09/14 6:11 PM

chaPter 5 cultural influences on Population health 139

Movement toward cultural proficiency and provision of culturally and linguistically appropriate care requires that a health system provide care with an understanding of and re- spect for culture and its influences on health and that the care provided incorporates community participation in its plan- ning and delivery. In addition, it requires staff who respect the cultures of others and who reflect and respond to the values and demographics of the population served. Finally, move- ment toward cultural proficiency and competent care requires policies that assure a consistent response to cultural differ- ences in the population served and continual improvement and accountability (OMH, 2013a). For further information about the CLAS standards, see the External Resources section of the student resources site.

The incorporation of CAM into biomedical practice through “integrative medicine” is another means providing culturally and linguistically appropriate health care services. Integrative medicine is defined by the American Association of Integrative Medicine (AAIM, 2011) as “health care that views the patient as the most important member of the medical team and applies all safe and effective therapies without subservience to any one school of medical thought.” The intent of integrative medicine is to deal with symptoms of illness as well as causes, whether those causes are mental, physical, or spiritual or a combination of these, through the best possible application of conventional and traditional therapies.

The World Health Organization’s (WHO) Traditional Medicines Strategy 2002–2005 identified four areas for action to promote the integration of CAM into biomedicine. Although

these strategies were developed several years ago, they continue to be relevant to population health nursing practice. The action areas identified included strategies to address needs related to policy; safety, efficacy, and quality; access; and rational use (WHO, 2002). Table 5-4• highlights each strategy and the related actions needed for effective integration of CAM into biomedical practice.

A 2005 report by the ”Institute of Medicine, 2005” suggested a systematic process for evaluating the appropriateness of in- corporating CAM into biomedical health systems. The process should begin with a determination of the persons responsible for gathering information about various forms of CAM and for making incorporation decisions. Both the informal and formal mandates affecting the system should be examined, as should the system’s mission and values and their congruence with various forms of CAM. In addition, an assessment of the internal and external environments as they affect incorporation of CAM in the institution should also be conducted. For example, are quali- fied practitioners of desired CAM available to the system? What forms of CAM are covered by insurance plans among the sys- tem’s clientele? All of this information can lead to an informed decision on whether or not to incorporate CAM in the setting.

Education regarding appropriate and inappropriate use of CAM is another way in which population health nurses may assist with repatterning for members of ethnic cultural groups as well as members of the dominant culture. WHO (2004) identified several considerations in educating the public re- garding safe and effective use of CAM that are still appropri- ate for population health nursing care. Categories of education

TABLE 5-4 WHO-Defined Areas for Action in Integrating CAM in Biomedical Practice

Area for Action Expected Outcomes

Policy Increased government support for and policies related to CAM Integration of relevant CAM into national health care systems Preservation of indigenous knowledge of CAM

Safety, efficacy, quality Increased knowledge of CAM through exchange of accurate information Review of research on use of CAM Selective support for clinical research on CAM Regulation of herbal medicines Safety monitoring of herbals, other CAM products, and practices Development of guidelines for evaluating the safety, efficacy, and quality of CAM Development of criteria for evidence-based data related to CAM

Access Development of criteria and indicators to measure cost-effectiveness of and access to CAM Official recognition of CAM providers Increased provision of CAM through national health systems Increased number of national organizations of CAM providers Development of guidelines for good agricultural practice related to medicinal plants

Rational use Training in CAM therapies for allopathic providers Training in basic primary care practice for CAM practitioners Provision of reliable consumer information on proper use of CAM Improved communication between CAM providers and conventional health care professionals

Source: World Health Organization. (2002). WHO traditional medicine strategy: 2002–2005. Retrieved from http://apps.who.int/medicinedocs/en/d/Js2297e/8.1. html#Js2297e.8.1

M05_MARY9591_06_SE_C05.indd 139 06/09/14 6:11 PM

140 Unit 2 influences on Population health

needed include general considerations, such as the need to be informed consumers and for both CAM and biomedical pro- viders to be conversant with CAM; knowledge of how to find reliable information; information about specific therapies; information regarding providers; and information about the costs of and insurance coverage for CAM. Specific areas of public education related to CAM are delineated in the client education box at right.

Population health nurses can be involved in the devel- opment of culturally and linguistically appropriate health care services in a number of ways. If they are employed in a particular organization that needs to adopt more cultur- ally appropriate approaches to health care, they can assess current practices and the barriers to culturally and linguisti- cally appropriate care that they represent. They can also be involved in the development of policies and procedures that promote cultural competence in the organization. In addi- tion, population health nurses can help the agency conduct an assessment of the cultural groups served and assist in the development of agency–community partnerships to better meet the needs of the population. If the nurse is not an em- ployee of an agency that needs to improve the cultural con- gruence of its services, he or she can bring to the attention of agency administrators the concerns of members of local cultural groups regarding the services provided. Community assessment and policy development may also be areas of in- volvement for nonemployee population health nurses. The process used in the development of culturally and linguisti- cally appropriate health care systems is essentially the same process used to develop any kind of health care program dis- cussed in Chapter 15 .

Evaluating Cultural Competence Evaluation of care provided to clients from another cultural group should focus on both the outcomes of care and the deliv- ery processes employed. In terms of outcomes, nurses should examine indicators of health status for individual clients and for subcultural groups. For example, has the nurse been able to improve the client’s nutritional status without changing his or her cultural dietary pattern? Has the frequency of success- ful pregnancy outcomes been increased for members of a given cultural group? Have inappropriate biomedical practices been modified to promote better care?

Health care delivery systems should also be examined in terms of their cultural congruence. The assessment profile discussed earlier provides direction for assessing the cultural congruence of care provided by health care delivery systems. At the population level, the extent to which disparities in health among culturally diverse populations have been decreased is

another way of evaluating the cultural congruence of the na- tional health care system. A particular health system could look also at the extent of disparities among its clientele as one mea- sure of its cultural competence.

CLIENT EDUCATION

General Considerations

• Use of CAM by informed consumers, knowledgeable about appropriate uses and safety considerations

• Extent of provider knowledge regarding CAM including knowledge of CAM use by particular clients

Finding and Identifying Reliable Information Regarding CAM

• Credibility and objectivity of information sources • Purpose of the information source (e.g., if product

sales are the primary purpose, information may be slanted)

• Relevance and accuracy of information presented • Frequency with which information is updated

Information Regarding Specific Therapies

• Claims and evidence supporting them • Product quality information regarding active ingredients,

recognition of quality standards, storage information, expiration date, quality control of raw materials

• Precautions for use • Adverse events/potential toxicity • Interactions and contraindications • Information regarding dose, time, frequency, duration,

method of administration, preparation instructions • Safety for use with children, pregnant women, the

elderly

Information Regarding CAM Practitioners

• Qualifications for practice, education, and experience related to the therapy

• Certification, if relevant • Surveillance and monitoring

Cost/Insurance Coverage

• Typical costs of CAM • What forms of CAM are covered under insurance

Source: World Health Organization. (2004). Guidelines on developing consumer information on proper use of traditional, complementary and alternative medicine. Geneva, Switzerland: Author.

Safe Use of Complementary and Alternative Medicine

M05_MARY9591_06_SE_C05.indd 140 06/09/14 6:11 PM

chaPter 5 cultural influences on Population health 141

Many groups display unique cultural beliefs, values, and behav- ior, including the dominant U.S. and biomedical cultures as well as other groups such as ethnic cultural groups and members of the GLBT and disabled populations. Culture influences health in a variety of ways, both direct and indirect. Culture affects definitions of health and illness within a population group and influences how health and illness are viewed, as well as the value of health to members of the population. Culture also influences how population groups seek to promote health and prevent and deal with health problems.

Cultural assessment can be directed by the six categories of determinants of health included in the population health nurs- ing model. Culturally congruent care may include preserving elements of a cultural heritage, negotiation and accommoda- tion of clients’ cultures or that of the biomedical community, or repatterning to eliminate cultural practices that are harmful to health. Culturally congruent health care occurs at the individ- ual client/family level and in the design of health care systems to provide care that is congruent with the values and expectations of the client population.

CHAPTER RECAP

Apple Valley is a rural agricultural community approximately 100 miles from the U.S.–Mexico border. Because of the mild climate, there are crops to be tended and harvested much of the year, and many Latino migrant workers are involved in this work. Although there is work for a significant portion of the year, many of the laborers have extended families still in Mexico. They frequently work for several months, then return to Mexico to share their earnings and visit family members. When they return to the United States, they often come as nuclear family groups, and both parents work in the fields. Children may or may not attend school while in Apple Valley.

There are high infant and maternal mortality rates among this group as the women do not usually receive care during their pregnancies. In part, this is because of the high cost of care, but it also results from lack of facility with English and inability to take time from work to receive care. Although most of the workers are legal immigrants, they are not eligible for financial

assistance or care at the local health department prenatal clinic. Complicated deliveries often occur in the local hospital, how- ever, and contribute to the burden of “uncompensated care” since the migrant families are usually unable to pay the hospital bills. According to some of the workers, there is a Latino woman living year round in Apple Valley who serves as a midwife for some of the women. 1. What cultural factors are operating in this situation? What

other circumstances, not necessarily cultural in origin, com- plicate the situation?

2. What interventions by the population health nurse could help reduce the infant and maternal mortality rates?

3. Who else should be involved in efforts to resolve the prob- lem? Why?

4. How could the population health nurse motivate involve- ment by other segments of the population?

Culture and CareCASE STUDy

Abdel-Khalek, A. M. (2009). Religiosity, subjective well-being, and depression in Saudi children and adolescents. Religion, & Culture, 12, 803–815. doi:10.1080/13674670903006755

Acculturation. (n.d.). In Dictionary of cross-cultural terminology/intercultural terminology. Retrieved from http://www.dot-connect.com/Dictionary_of_ Cross-Cultural_terminology_Inter_cultural_terminology.html

American Association of Integrative Medicine. (2011). About integrative medicine. Retrieved from http://www.aaimedicine.com/about/

American Association of Naturopathic Medicine. (2011). What is naturopathic medicine? Retrieved from http://www.naturopathic.org/content. asp?contentid=59

American Chiropractic Association. (2014a). History of chiropractic c are . R e t r i e v e d f r o m ht t p : / / w w w. a c at o d ay. o r g / l e v e l 3 _ c s s .cfm?T1ID=13&T2ID=61&T3ID=149

American Chiropractic Association. (2014b). What is chiropractic? Retrieved from http://www.acatoday.org/level2_css.cfm?T1ID=13&T2ID=61

REFERENCES

M05_MARY9591_06_SE_C05.indd 141 06/09/14 6:11 PM

142 Unit 2 influences on Population health

Baron-Epel, O., Friedman, N., & Lernau, O. (2009). Fatalism and mammography in a multicultural population. Oncology Nursing Forum, 36, 353–361.

Burke, A., Wong, Y., & Clayson, Z. (2003). Traditional medicine in China today: Implications for indigenous health systems in a modern world. American Journal of Public Health, 93, 1082–1083.

Campinha-Bacote, J. (2009). A culturally competent model of care for African Americans. Urologic Nursing, 29(1), 49–54.

Center for Health and Healing. (n.d.). Native American medicine. Retrieved from http://www.healthandhealingny.org/tradition_healing/native.html

Centers for Disease Control and Prevention. (2011). National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. Retrieved from http://www.cdc.gov/diabetes/ pubs/estimates11.htm#4

Ciftci, A., Jones, N., & Corrigan, P. W. (2013). Mental health stigma in the Muslim community. Journal of Muslim Mental Health, 7, 17–32. permalink: http://hdl.handle.net/2027/spo.10381607.0007.102

Clark, M. J., & Natipagon-Shah, B. (2008). Thai American women’s perceptions regarding mammography participation. Public Health Nursing, 25, 212–220.

Crowley-Matoka, M., Saha, S., Dobscha, S. K., & Burgess, D. J. (2009). Problems of quality and equity in pain management: Exploring the role of biomedical culture. Pain Management, 10, 1312–1324.

Dance of the Deer Foundation Center for Shamanic Studies. (2014). What is shamanism?. Retrieved from http://www.shamanism.com/ what-is-shamanism/

Dugdale, D. C., & Mason, J. R. (2010). Glucose-6-phosphate dehydrogenase deficiency. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/ article/000528.htm

Edmonton Seniors Coordinating Council. (n.d.). Glossary of cross cultural terms. Retrieved from http://www.seniorscouncil.net/uploads/files/Issues/ Mobilizing_Action_Report/Glossary%20of%20Cross%20Cultural%20 Terms.pdf

Fatalism. (n.d.). In Merriam-Webster’s online dictionary (11th ed.). Retrieved from www.merriam-webster.com/dictionary/fatalism

Green, B. L. (2010). Culture is treatment: Considering pedagogy in the care of aboriginal people. Journal of Psychosocial Nursing, 48(7), 27–34. doi:10.3928/02793695-20100504-04

Greenwood, S. (2009). The anthropology of magic. New York, NY: Berg. Gupta, V. B. (2010). Impact of culture on healthcare seeking behavior of Asian

Indians. Journal of Cultural Diversity, 17, 13–19. Health culture. (n.d.). Free online dictionary. Retrieved from http://medical-

dictionary.thefreedictionary.com/health+culture Healthy Homes and Lead Poisoning Prevention Bureau. (2011). Lead poisoning

of a child associated with use of a Cambodian amulet—New York City, 2009. Morbidity and Mortality Weekly Report, 60, 69–71.

Hoogbruin, A. (2011). Complementary and alternative therapy (CAT) use and highly active retroviral therapy (HAART): Current evidence in the literature, 2000–2009. Journal of Clinical Nursing, 20, 925–939.

Hulme, P. A. (2010). Cultural considerations in evidence-based practice. Journal of Transcultural Nursing, 21, 271–280.

Inglehart, R., & Welzel, C. (n.d.). The WVS cultural map of the world. Retrieved from http://www.worldvaluessurvey.org/wvs/articles/folder_published/ article_base_54

Inglehart, R., & Welzel, C. (2010). Changing mass priorities: The link between modernization and democracy. Perspectives on Politics, 8, 551–567. doi:10.1017/S1537592710001258

Institute of Medicine. (2005). Complementary and alternative medicine in the United States. Washington, DC: Author.

Isaac, D. (2013). Culture-bound syndromes in mental health: A discussion paper. Journal of Psychiatric and Mental Health Nursing, 20, 355–361. doi: 10.1111/jpm.12016

Jackson, C. (2010, May–June). Evidence-based practice: Pushback from a holistic perspective. Holistic Nursing Practice, pp. 120–124.

Juang, L. P., & Alvarez, A. A. (2010). Discrimination and adjustment among Chinese American adolescents: Family conflict and family cohesion as vulnerability and protective factors. American Journal of Public Health, 100, 2403–2408. doi:10.2105/AJPH.2009.185959

Katme, A. M. (2009). Foodandfaith fact files – Islam. Retrieved from permalink: http://www.faithandfood.com/Islam.php

Keeping kosher: Jewish dietary laws. (n.d.). Retrieved from http://www .religionfacts.com/judaism/practices/kosher.htm

Leininger, M. M. (2006). Culture care diversity and universality theory and evolution of the ethnonursing method. In M. M. Leininger & M. R. McFarland (Eds.), Culture care diversity and universality: A worldwide theory of nursing (2nd ed., pp. 1–41). Sudbury, MA: Jones and Bartlett.

Magda, R. (2010). Lifting the language barrier. Advance for Nurses, 7(8), 8–9. McFarland, M. R., Mixer S. J., Webhe-Alamah, H., & Burk, R. (2012).

Ethnonursing: A qualitative research method for studying culturally competent care across disciplines. International Journal of Qualitative Methods, 11, 259–279.

McLaurin, J. A. (2002). Assimilation, acculturation, and alternative medicines. MCN Streamline: The Migrant Health News Source, 8(6), 1–3.

Mhame, P. P., Busia, K., & Kasilo, M. J. (2010). Clinical practices of African traditional medicine. Retrieved from https://www.aho.afro.who.int/en/ahm/ issue/13/reports/clinical-practices-african-traditional-medicine

National Alliance on Mental Illness. (2013). What is anorexia nervosa? Retrieved from http://www.nami.org/Template.cfm?Section=By_Illness&template=/ ContentManagement/ContentDisplay.cfm&ContentID=7409

National Cancer Institute. (2012). Spiritual assessment. Retrieved from http:// www.cancer.gov/cancertopics/pdq/supportivecare/spirituality/Patient/ page3

National Center for Complementary and Alternative Medicine. (2008). The use of complementary and alternative medicine in the United States. Retrieved from http://nccam.nih.gov/news/camstats/2007/camsurvey_fs1.htm

National Center for Complementary and Alternative Medicine. (2012a). Acupuncture: An introduction. Retrieved from http://nccam.nih.gov/health/ acupuncture/introduction.htm

National Center for Complementary and Alternative Medicine. (2012b). CAM basics: What is complementary and alternative medicine? Retrieved from http://nccam.nih.gov/sites/nccam.nih.gov/files/D347_05-25-2012.pdf

National Center for Complementary and Alternative Medicine. (2012c). Naturopathy: An introduction. Retrieved from http://nccam.nih.gov/health/ naturopathy/naturopathyintro.htm

National Center for Complementary and Alternative Medicine. (2012d). Terms related to complementary and alternative medicine. Retrieved from http:// nccam.nih.gov/health/providers/camterms.htm

National Center for Complementary and Alternative Medicine. (2013a). Ayurvedic medicine: An introduction. Retrieved from http://nccam.nih.gov/ health/ayurveda/introduction.htm

National Center for Complementary and Alternative Medicine. (2013b). Complementary, alternative, or integrative health: What’s in a name?. Retrieved from http://nccam.nih.gov/health/whatiscam

National Center for Complementary and Alternative Medicine. (2013c). Homeopathy: An introduction. Retrieved from http://nccam.nih.gov/health/ homeopathy

National Center for Complementary and Alternative Medicine. (2013d). Paying for complementary health approaches. Retrieved from http://nccam.nih.gov/ health/financial/

National Center for Complementary and Alternative Medicine. (2013e). Traditional Chinese medicine: An introduction. Retrieved from http:// nccam.nih.gov/health/whatiscam/chinesemed.htm

M05_MARY9591_06_SE_C05.indd 142 06/09/14 6:11 PM

chaPter 5 cultural influences on Population health 143

National Center for Education Statistics. (2012). PIAAC 2012 results. Retrieved from http://nces.ed.gov/surveys/piaac/results/summary.aspx

Natural Medicines Comprehensive Database. (2012). Pennyroyal. Retrieved from http://www.nlm.nih.gov/medlineplus/druginfo/natural/480.html

Office of Minority Health. (2013a). National standards for culturally and linguistically appropriate services (CLAS) in health and health care: A blueprint for advancing and sustaining CLAS policy and practice. Retrieved from https://www.thinkculturalhealth.hhs.gov/pdfs/ EnhancedCLASStandardsBlueprint.pdf

Office of Minority Health. (2013b). What is cultural competency? Retrieved from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=11

Okulicz-Kozaryn, A. (2010). Religiosity and life satisfaction across nat ions . Mental Health , Rel ig ion , & Culture , 13 , 155–169 . doi:10.1080/13674670903273801

Partnership for the Public’s Health. (n.d.). Tips and tools: Working effectively across languages. Oakland, CA: Author.

Pascoe, E. A., & Smart, R. L. (2009). Perceived discrimination and health: A meta-analytic review. Psychological Bulletin, 135, 531–554. doi: 10.1037/ a0016059

Pflaum, J. S. (1996). Helper woman: A biography of Elinor Delight Gregg (Unpublished doctoral dissertation). University of San Diego, San Diego, CA.

Purnell, L. D. (2012). Transcultural health care: A culturally competent approach (4th ed.). Philadelphia, PA: F. A. Davis.

Rabinowitz, Y. G., Mausbach, B. T., Atkinson, P. J., & Gallagher-Thompson, D. (2009). The relationship between religiosity and health behaviors in female care givers of older adults with dementia. Aging & Mental Health, 13, 788–798. doi:10.1080/13607860903046446

Sanseeha, L., Chontawan, R., Sethabouppha, H., Disayavanish, C., & Turale, S. (2009). Illness perspectives of Thais diagnosed with schizophrenia. Nursing and Health Sciences, 11, 306–311. doi:10.1111/j.1442-2018.2009.00474.x

Singh Balhara, Y. P. (2011). Culture-bound syndrome: Has it found its right niche? Indian Journal of Psychological Medicine, 33, 210–215. doi: 10.4103/0253-7176.92055

Sorkin, D. H., Ngo-Metzger, Q., & De Alba, I. (2010). Racial and ethnic discrimination in health care: Impact on perceived quality of care. Journal of General Internal Medicine, 25, 390–396. doi: 10.1007/s11606-010-1257-5

Spector, R. E. (2012). Cultural diversity in health and illness (8th ed.). Upper Saddle River, NJ: Prentice Hall.

Spencer, M., S., Chen, J., Gee, G. C., Fabian, C. G., & Takeuchi, D. T. (2010). Discrimination and mental health—Related services use in a national study of Asian Americans. American Journal of Public Health, 100, 2397–2402. doi:10.2105/AJPH.2009.176321

Tang, G., Lanza, O., Rodriguez, F. M., & Chang, A. (2011). The Kaiser Permante Clinician Cultural and Linguistic Assessment Initiative: Research and development in patient-provider language concordance. American Journal of Public Health, 101, 205–208. doi:10.2105/AJPH.2009.177055

Ulmer, C., McFadden, B., & Nerenz, D. R. (Eds.). (2009). Race, ethnicity, and language data: Standardization for healthcare quality improvement. Retrieved from http://www.nap.edu/catalog/12696.html

U.S. Census Bureau. (2013a). Statistical abstract of the United State 2012s: Components of population change. Retrieved from https://www.census.gov/ compendia/statab/2012/tables/12s0005.pdf

U.S. Census Bureau. (2013b). Statistical abstract of the United States, 2012: Foreign- born population—selected characteristic by region of origin: 2010. Retrieved from https://www.census.gov/compendia/statab/2012/tables/12s0041.pdf

U.S. Census Bureau. (2013c). Statistical abstract of the United States, 2012: Native and foreign-born population by selected characteristics: 2010. Retrieved from https://www.census.gov/compendia/statab/2012/tables/12s0040.pdf

U.S. Census Bureau. (2013d). 2011 Statistical abstract of the United States, 2012: Languages spoken at home. Retrieved from https://www.census.gov /compendia/statab/2012/tables/12s0053.pdf

U.S. Census Bureau. (2013e). Statistical abstract of the United States, 2012: Population: Elderly, Selected characteristics of racial groups and Hispanic or Latino population, 2009. Retrieved from https://www.census.gov/compendia /statab/2012/tables/12s0036.pdf

U.S. Census Bureau. (2013f). Statistical Abstract of the United States, 2012: Resident population by sex, race, and Hispanic origin status: 2000 to 2009. Retrieved from https://www.census.gov/compendia/statab/2012/tables/12s0006.pdf

U.S. Census Bureau. (2013g). Statistical Abstract of the United States, 2012: Resident population projections by race, and Hispanic origin status, and age: 2010 and 2015. Retrieved from https://www.census.gov/compendia/ statab/2012/tables/12s0012.pdf

U.S. Census Bureau, American Fact Finder. (2012). Languages spoken at home? Retrieved from http://factfinder2.census.gov/faces/tableservices/jsf/pages /productview.xhtml?pid=ACS_12_1YR_S1601&prodType=table

U.S. Department of Health and Human Services. (2013). Health communication and health information technology . Retrieved from http://www .healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=18

van Betten, P. T., & Moriarty, M. (2004). Nursing illuminations: A book of days. St Louis, MO: Mosby.

Wehbe-Alamah, H. (2008). Bridging generic and professional care practices for Muslim patients through use of Leininger’s culture care model. Contemporary Nurse, 28, 83–97.

World Health Organization. (2002). WHO traditional medicine strategy: 2002-2005. Retrieved from http://apps.who.int/medicinedocs/en/d /Js2297e/8.1.html#Js2297e.8.1

World Health Organization. (2004). Guidelines on developing consumer information on proper use of traditional, complementary and alternative medicine. Geneva, Switzerland: Author.

World Health Organization. (2009). Health Promotion Track 2: Health literacy and health behavior. 7th global conference on health promotion. Retrieved from http://www.who.int/healthpromotion/conferences/7gchp/track2/en/ index.html

Yang, H., Tranulis, C., & Freudenreich, O. (2009). Keeping culture-bound syndromes in cultural context: The case of koro. International Journal of Culture and Mental Health, 2, 86–91. doi:10.1080/03637750902792964

Yeung, A., Shyu, I., Fisher, L., Wu, S., Yang, H., & Fava, M. (2010). Culturally sensitive collaborative treatment for depressed Chinese Americans in primary care. American Journal of Public Health, 100, 2397–2402. doi:10.2105/AJPH. 2009.184911

M05_MARY9591_06_SE_C05.indd 143 06/09/14 6:11 PM

chaPter

6 Economic Influences on Population Health Learning Outcomes

After reading this chapter, you should be able to:

1. Analyze the interrelationships among economic conditions, health care services, and health status.

2. Discuss factors contributing to escalating health care costs.

3. Discuss the effects of economic factors on the provision of public health services.

4. Analyze the effects of selected health care reimbursement mechanisms.

5. Distinguish among selected approaches to financing health care services.

Key Terms

assignment

block grant

capitation

charity care

consumer price index (CPI)

copayment

cost shifting

deductible

devolution

economics

health disparity

limiting charge

managed care organization (MCO)

medigap plans

pay-for-performance reimbursement

per capita expenditures

per diem payment

premiums

prospective reimbursement

reimbursement

Resource-Based Relative Value Scale (RBRVS)

retrospective reimbursement

uncompensated care

M06_MARY9591_06_SE_C06.indd 144 06/09/14 6:38 PM

Establishing a “Shoestring” Clinic

Economic issues related to access to health care are a continuing problem in American Society and were part of the impetus for such developments as the Henry Street Settlement. In much of the na- tion, these issues have continued to undermine the health of the population, and various strategies have been undertaken to address them.

Upper East Tennessee is on the edge of the Appalachian region and shares a number of features of that region, including lack of access to health care for a significant portion of the population. Awareness of this need prompted population health nursing students and faculty to create a weekly “clinic” to meet the health care needs of low-income residents of a federal housing project. The clinic was first held in a recreation room at the housing project, but this proved untenable because the landlord was not willing to permit regular use of the room. The clinic was moved to rooms pro- vided by a nearby church, and members of the congregation became part of its clientele. Clinic services included health histories and physical examinations, blood pressure monitoring, health education, and referral for needed health care services.

During the academic year, the clinic was staffed 1 day a week by population health nursing faculty and students. Faculty members continued to staff the clinic during breaks and over the summer to assure continuity of services. Students were involved in planning the services and de- veloping a record system, forms, and referral contacts in the larger community. In addition to the weekly clinic, students and faculty made home visits to clients needing additional follow-up. Local physicians were contacted to inform them of the availability of the clinic for low-income clients who needed monitoring or health education. Several physicians took advantage of the services to request follow-up for their clients regarding issues of medication compliance or health education.

Although the clinic was initiated in the 1980s, long before the days of Health Insurance Porta- bility and Accountability Act (HIPAA), strict measures were taken to promote client confidentiality. Client records (and equipment) were not left at the clinic site, but were locked in the trunk of one faculty member’s car and transported to the site each week. Over the course of several years, sev- eral hundred clients were seen and multiple referrals were initiated to obtain low cost services for clients in need of them.

A d

vo ca

cy T

h en

Promoting a Living Wage

A community needs assessment conducted by a collaborative of community agencies and residents and coordinated by a population health nurse indicated that low salaries were a significant influence on the health status of the community. After additional data gathering, the members of the collaborative initiated a campaign to promote a living wage for as large a segment of the population as possible. As a result of their efforts, a living wage ordinance was passed by the city. The ordinance required payment of a living wage, approximately three times the minimum wage level in the state, to all city employees. In addition, all businesses that contracted with the city were required to guarantee the same living wage to their employees before submitting bids for contract services. Although the ordinance did not cover the entire population, it provided an adequate income for a large proportion of the city’s residents.

A d

vo ca

cy N

ow

145

M06_MARY9591_06_SE_C06.indd 145 06/09/14 6:38 PM

146 Unit 2 influences on Population health

Economics can be defined as the way in which a society distributes its resources to address human wants and needs. Scarcity results when there are in-sufficient resources to satisfy the wants and desires of the population, and economics determines how those scarce resources will be distributed among the population. Currently, the federal government and the states are experiencing an eco- nomic crisis that affects the health of the population as well as the health care services that are provided. This crisis is the result of several factors, including recent tax cuts, poor eco- nomic performance, and increased expenditures in areas such as defense and national security. In 2010, for example, federal spending related to national defense was more than twice the funds spent on all nondefense activities (U.S. Census Bureau, 2013). These factors are unlikely to change in the near future for a number of reasons. Congress is unlikely to reduce federal spending and likely to extend tax cuts under pressure from many constituencies. These factors will maintain expenditures while reducing the revenues that could fund them. Although tax cuts and low interest rates will stimulate the economy in the short run, they are likely to cause a long-term imbalance, lead- ing to increasing deficits, lower rates of national savings, higher interest rates, and a slowed economy as well as reductions in government-supported services. All of these factors will lead to a greater scarcity of health resources and more severe effects on the health of the population.

When we consider the economic context of health, we often think of the effects of poverty on health status or the increasing cost of health care. However, there are many different aspects to the economic context in which population health nursing takes place. The two major considerations in this area are the interrelationships between economics and health and the financing of health care services. Each of these aspects will be discussed here.

Economics and Health—The Interrelationships Three fundamental economic principles must be considered in examining the effects of economic conditions on health and health care services. The first principle is that resources are always more limited than what is needed for desired levels of consumption. Second, resources have alternative uses. Third, different people will have differing ideas as to what those uses should be. Based on these principles, the basic question related to health care economics is how limited resources should be used. What types of health services should consume the re- sources available?

The interrelationships among economic factors and health status are many and varied. In this chapter, we will discuss three specific relationships: (a) the relationship between health and societal productivity and stability, (b) health care spending and rising costs, and (c) the effects of socioeconomic factors on health status.

Societal Productivity and Stability As we noted earlier, we often think of the effects of economic factors on health status. What we tend to forget, however, is that health also affects a nation’s economic welfare. A healthy population is more productive than an unhealthy one and is better able to learn and to use education effectively to increase society’s overall productivity. When people are unable to work due to health deficiencies, society loses their productive ca- pability. In addition, the productive capacity of other family members may also be lost. For example, diseases leading to dis- ability result in lost productivity for those affected and for fam- ily members who must leave work to care for them.

Poverty and ill health lead to lower income and slowed eco- nomic growth as well as social instability and conflict. Con- versely, nations with strong economies are better able to afford health care and other determinants of health.

Health care programs may also have a more direct effect on the economy than that seen in increased capacity for production. For example, state Medicaid programs generate revenue for states beyond the costs of the programs. This revenue comes from a number of sources, including federal block grants that would otherwise not come to the states, new business, and new jobs. A block grant is a lump sum made available to the states by the federal government to be used as each state sees fit within certain broadly defined parameters. Similarly, health care services in general generate revenues that support the overall economy.

Health Care Spending The amount of money spent on health care services in the United States has been increasing at an alarming rate for the last several years. For example, national personal health care expenditures increased from $27.3 billion in 1960 to nearly $2.5 trillion in 2009 (U.S. Census Bureau, 2013). Health spend- ing is expected to continue to grow by an average rate of 6.2% per year from 2015 through 2022 (Centers for Medicare and Medicaid Services [CMS], 2014b).

Overall, health care spending has risen from 5% of the gross domestic product (GDP) in 1960 to 17.2% in 2012 (CMS, 2014d), and is expected to rise to 19.9% of the GDP by 2022. U.S. per capita expenditures for health care in 2012 were $8,195 (CMS, 2014c). Per capita expenditures reflect the average amount spent on health care per person per year. Health care expenditures have increased consistently from 1 year to the next. From 1990 to 2009, per capita health care expenditures more than doubled (U.S. Census Bureau, 2013). Figure 6-1• presents a breakdown of different types of health care expen- ditures as well as the sources of funding for health care, which will be discussed in more detail later.

Factors that have contributed to increasing health care spending include an aging population, greater use of technol- ogy, an emphasis on costly specialty care, costs of care for the uninsured, and the labor-intensive nature of health care deliv- ery (Sultz & Young, 2010). An aging population contributes

M06_MARY9591_06_SE_C06.indd 146 06/09/14 6:38 PM

chaPter 6 economic influences on Population health 147

to greater demand for and use of services, particularly as the prevalence of chronic diseases with high costs for disease man- agement increases in older age groups. The size of the older population relative to other age groups in the United States has increased consistently over the last several decades. In 1990, for example, people over the age of 65 years comprised only 29.6% of the U.S. population; by 2010 the proportion of the popula- tion over 65 years of age had increased to 38.6% of the popula- tion (U.S. Census Bureau, 2013). People over age 65 consume a large portion of the health care services provided each year.

Greater use of technology, particularly in response to fears of malpractice, and greater use of specialty care have also con- tributed to an increase in health care spending. Nearly two thirds of U.S. physicians are specialists, who tend to command higher reimbursement than generalists and employ more ex- pensive technology. In addition, specialists have been associ- ated with more inappropriate use of costly therapies. Greater use of technology also creates a demand for a better prepared health care workforce at all levels, thereby increasing the costs of its use (Sultz & Young, 2010).

Health care spending differs for different elements of the health care system. For example, as indicated in Figure 6-1, an estimated 28% of health care dollars was spent on hospital care, 43% on physician and clinical services (physicians, nurse prac- titioners, and others), 5% on dental care, 7% on nursing home care, 4% on home health care, and 13% on prescription drug costs (CMS, 2013c). Health care delivery is a labor-intensive segment of the economy, requiring 24-hour-a-day and 7-day- a-week coverage in some settings.

Costs of uncompensated care for the uninsured and in- creasing prescription drug prices are two other factors

implicated in rising health care costs. Uncompensated care is that proportion of care for which the provider receives no reimbursement and includes both charity care and bad debt (American Hospital Association [AHA], 2014). A large seg- ment of the population is uninsured or underinsured, result- ing in large amounts of uncompensated care provided by health care institutions and providers. Approximately three fourths of uncompensated care is provided by federal, state, and local government agencies (Clemans-Cope, Garrett, & Buettgens, 2010).

Before the enactment of the Patient Protection and Afford- able Care Act, uncompensated care amounted to about $61 bil- lion per year, but this is expected to drop to $25 billion as the provisions of the Act are implemented (Clemans-Cope et al., 2010). AHA data indicate that uncompensated hospital care in the United States amounted to $45.9 billion in 2012 or 6.1% of U.S. hospitals’ total expenses (AHA, 2014).

Uncompensated care leads to a phenomenon known as cost shifting, the passing on of the cost of uncompensated care to those who do pay for care, either those who pay out-of-pocket or those covered by health insurance. Cost shifting leads in turn to higher insurance premiums and higher overall costs for health care.

U.S. drug prices have risen considerably more than the consumer price index. The consumer price index (CPI) is “a measure of the average change over time in the prices paid by urban consumers for a market basket of consumer goods and services” (U.S. Bureau of Labor Statistics, 2013a, para. 1). In 2009, U.S. prescription drug costs amounted to $249.9 bil- lion, and prescription drug spending increased by nearly 9% from 2008 to 2009 alone (U.S. Census Bureau, 2013). In 2011,

FIguRe 6-1 Distribution of Health Care Funding Sources and National expenditures, 2012 Source: Centers for Medicare and Medicaid Services. (2013c). Medicare and Medicaid research review/ 2013 statistical supplement. Retrieved from http://www.cms.gov/ Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareMedicaidStatSupp/Downloads/2013_Section1.pdf

Personal health care expenditures, 2012 Expenditures: $2.3 trillion

Source of funds

Medicaid (16%)

Out-of- pocket (14%)

Private insurance

(34%) Medicare

(23%)

Dental (5%)

Hospital (28%)

Physician and clinical services

(43%)

Home health (4%)

Type of expenditures

Other health insurance (4%)

Other third-party (9%)

Prescription drugs (13%)

Nursing care facilities (7%)

M06_MARY9591_06_SE_C06.indd 147 06/09/14 6:38 PM

148 Unit 2 influences on Population health

the average retail price for each drug prescribed for people over 65 years of age was $28 (Kaiser Family Foundation, 2011).

Many authors have suggested allowing U.S. citizens to pur- chase less expensive prescription drugs from international markets or discounted drugs from U.S. manufacturers. The Veterans Administration (VA) and other federal agencies, for example, have very successfully negotiated for drug discounts with U.S. pharmaceutical companies.

A large proportion of Americans are without any assistance in paying for prescription medications. With increasing costs, many employers are reducing or eliminating prescription cover- age from health care plans or requiring higher copayments by beneficiaries. As a result, many people fail to take medications as directed due to the costs. Those most seriously affected by rising prescription drug costs have been the elderly who live on fixed incomes that do not increase with rising inflation rates. Some effort has been made to improve prescription drug access for Medicare beneficiaries through the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. This legislation initiated Medicare Prescription Drug Coverage to assist older Americans with drug costs. This program will be discussed in more detail in the section related to the Medicare program.

Socioeconomic Factors and Health Status Socioeconomic status affects health directly, in terms of ac- cess to health care, as well as indirectly, through factors such as social and educational opportunities, knowledge of health promotion and prevention measures, and shaping health be- haviors. Despite the relatively high standard of living in the

United States, the point has been made that “there are consid- erable pockets of the population for whom access to care and the effects on health status are much more similar to those of poorer and less successful Third World countries than they are to the rest of the industrial world” (Vladek, 2003, p. 16). This statement was supported by the findings of Crossing the Quality Chasm, an Institute of Medicine report published in 2001, and continues to be supported by current data.

Socioeconomic factors have a variety of effects on the health status of the population. Two major factors that will be discussed here are poverty and lack of health insurance. Questions for assessing the economic status of a population are provided in the focused assessment on page 149. A more in-depth assessment tool is available on the student resources site.

POvErTy. Poverty affects one’s ability to gain access to the necessities of life that support health and wellness, including food, shelter, and access to health care services. Poverty is measured in terms of one’s income relative to the current federal or state income guidelines. The poverty level is defined in terms of both household income and size. In 2013, for example, the poverty level for a family of five was an annual income less than $25,570 in all states except Alaska and Hawaii, which had slightly higher income levels defining poverty (CMS, 2012a).

In 2011, 46.2 million people in the United States were liv- ing in poverty. This figure represents 15% of the U.S. popula- tion. The median household income declined by 8.1% between 2007 and 2011, with steeper declines for Blacks and non-His- panic Whites (DeNavas-Walt, Proctor, Smith, 2012). In large part, these declines are due to the overall economic downturn

Evidence-Based Practice

Health and Neighborhood Socioeconomic Status Numerous recent research studies have demonstrated links be- tween the socioeconomic status of one’s neighborhood and a vari- ety of adverse health events. These associations have been found independent of one’s own socioeconomic status in the United States as well as other countries such as Japan (Murakami, Sasaki, Takahashi, & Uenishi, 2010), Germany (Dittmann & Goebel, 2010), and Israel (Gerber, Myers, Goldbourt, Benyamini, & Drory, 2011). For example, neighborhood socioeconomic sta- tus has been linked to psychosocial functioning and frailty in older adults (Everson-Rose et al., 2011; Lang et al., 2009) and overall health status among persons with diabetes (Gary-Webb et al., 2011). Neighborhood socioeconomic status has also been linked to rates of fatal coronary heart disease (Foraker et al., 2011) and hospitalizations for injuries (Zarzaur, Croce, Fabian, Fischer, & Magnotti, 2010).

In addition, neighborhood socioeconomic levels have been as- sociated with health-related behaviors. For example, youth from lower socioeconomic status neighborhoods were found to be

less involved in physical activity than those from more affluent neighborhoods (Boone-Heinonen et al., 2011). Similar findings were noted with respect to physical activity following myocardial infarction (Gerber et al., 2011). Neighborhood socioeconomic status has even been linked to screen-time in preschool children (Carson, Spense, Cutumisu, & Cargill, 2010), fruit and vegetable consumption among older women (Nicklett et al., 2010), and overall life satisfaction (Dittmann & Goebel, 2010).

Population health nurses may be able to help individual clients and families deal with economic issues, but they cannot address the issue of low neighborhood socioeconomic status by themselves. As we saw in the Advocacy Now feature at the beginning of this chapter, however, they can advocate for a living wage, more effective economic assistance programs, and better overall economic status for members of the population in conjunction with other groups and organizations. What might you do to promote improvements in socioeconomic status for low- income neighborhoods in your community?

M06_MARY9591_06_SE_C06.indd 148 06/09/14 6:38 PM

chaPter 6 economic influences on Population health 149

FOCuSEd ASSESSmENT Assessing the Economic Status of a Population

• What proportion of the population receives employment- based health insurance benefits? Why do others not receive benefits (e.g., part-time employment, cannot afford premiums, etc.)?

• How are most health care services for the population funded?

• What revenue sources fund public health services for the population? Are these revenues adequate to provide needed services?

• What is the average income of the group?

• What proportion of the group has incomes at or below poverty level?

• What subpopulations are included in the low-income group?

• What proportion of low-income families receives some form of public assistance? Are all those eligible for assistance receiving it? If not, why not?

• What is the level of unemployment in the population? For those who are employed, what are the typical salaries?

beginning in 2007. Poverty rates differ considerably among ra- cial and ethnic groups with the highest rates among U.S. Blacks (25.8% in 2009) followed by Hispanics (25.3%), and Whites and Asians (12.2% and 12.5%, respectively) (U.S. Census Bureau, 2013). Children constitute a significant proportion of those liv- ing in poverty, and in 2011, 21.9% of U.S. children under 18 years of age were living in poverty (DeNavas-Walt et al., 2012).

Poverty contributes to a variety of disparities related to health among segments of the population. A health disparity is defined by Healthy People 2020 as:

a particular type of health difference that is closely linked with social or economic disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gen- der, mental health, cognitive, sensory, or physical disability, sexual orientation or gender identity, geographic location, or other characteristics historically linked to discrimination or exclusion. (U.S. Department of Health and Human Services [USDHHS], 2010, para.6)

Disparities occur with respect to morbidity and mortality as well as access to preventive health services. Poverty leads to malnutrition, poor housing, lack of health care, and lack of adequate child care, all of which have negative health implica- tions. In addition, poverty is associated with low literacy levels, which limit earning power and access to health care.

LACK OF HEALTH INSurANCE. The second major way in which economic factors affect health is through diminished access to needed health care services. Diminished access occurs as a result of the mixed effects of poverty and lack of health care insurance. In fact, 38% of the uninsured are people with incomes below poverty level. During 2011, 48 million non- elderly people in the United States were uninsured. This is a decrease of 1.3 million from 2010 (Kaiser Commission on Medicaid and the Uninsured, 2012a). Lack of insurance is not confined to those living in actual poverty. In 2009, for example,

32% of people with incomes 200% to 300% above the federal poverty level were uninsured, and more than one fifth of those 300% to 400% above poverty were without health insurance. People who remain uninsured for a year or more are seven times more likely to forgo needed health care due to costs, and even being without coverage for 1 to 3 months results in a fourfold likelihood of forgoing or delaying care (Fox & Richards, 2010). The likelihood of going without needed care is twice as high for uninsured persons with disabilities as it is for those without a disability (National Center for Health Statistics [NCHS], 2010). Data from 2002 to 2004 suggested that 21% of the 92 million adults with chronic conditions were uninsured for at least 1 month, and 23% of those with both chronic conditions and disabilities were uninsured at some point. Lack of insurance among these groups led to greater problems accessing needed care, fewer ambulatory care visits, less prescription drug use, and higher out-of-pocket expenses than for their insured counterparts (Gulley, Rasch, & Chan, 2011).

Research has shown that low-income neighborhoods affect the health of even those of moderate income who live in them.

M06_MARY9591_06_SE_C06.indd 149 06/09/14 6:38 PM

150 Unit 2 influences on Population health

Lack of health insurance is most common among young to middle-aged adults. More than 83% of those uninsured for the entire year in 2009 were 18 to 64 years of age, compared to 14.8% of children under age 18 and only 1.3% of persons over 65 years of age (U.S. Census Bureau, 2013). In large part, these coverage differences are due to the availability of Medicare for the elderly and the Medicaid and Children’s Health Insurance Programs (CHIP) for children. Each of these programs will be discussed in more detail later in this chapter.

Differences in health insurance coverage are also noted by race and ethnicity, with members of ethnic minority groups less likely to be covered. For example, in 2009, only 16% of the White U.S. population was uninsured compared to 32% of Hispanic, 21% of Black, and 17% of Asian residents (U.S. Census Bureau, 2013).

There are a number of reasons for lack of health insurance in such a large portion of the population. Slightly more than half (55.8%) of people under 65 years of age who had health insurance in 2009 received it as an employment-based ben- efit (DeNavas-Walt et al., 2012). Those without insurance may be unemployed or work in jobs that do not provide insur- ance coverage. Others may lose coverage due to job loss; loss of eligibility for Medicaid or State Children’s Health Insurance Programs (SCHIP); or loss of coverage through a spouse due to death, separation, or divorce (Kaiser Commission on Med- icaid and the Uninsured, 2012a, 2012b). Even those eligible for employment-based health insurance may not be covered due to inability to pay the beneficiary portion of premiums or compet- ing priorities for limited incomes. For example, the average fam- ily cost for employment-related health insurance was $15,745 in 2012, comprising about 28% of total premium costs, beyond the ability of many families to afford. From 2002 to 2012, the over- all cost of premiums increased by 97% and workers’ share of premiums increased by the same amount while wages increased by only 33% on average. In the 2009 National Health Interview Survey, 48% of those who were uninsured indicated that it was because of cost. Another 28% reported they had lost or changed jobs and so lost coverage, and 12% said their employers did not provide health insurance benefits or they were refused coverage by an insurance company (NCHS, 2011).

Lack of health insurance is associated with a variety of health effects. For example, the uninsured are less likely than those with insurance to receive cancer screening and other pre- ventive services and are often less healthy in general than their insured counterparts. They are also less likely to comply with medication regimens for chronic diseases due to costs and may experience greater mortality.

Having health insurance is associated with better health status, a regular source of care, and more appropriate use of health care services. In addition, people with insurance are more likely to receive health-promotive and illness-preventive services (Kaiser Commission on Medicaid and the Uninsured, 2012a). For example, in 2012, uninsured adults were five times more likely than insured adults not to have a regular source of care. Similarly, the uninsured were more than six times more

likely to go without needed care due to cost and nearly five times more likely not to get a prescription filled than those with insurance (Kaiser Commission on Medicaid and the Un- insured, 2012a).

According to a critical Institute of Medicine report (IOM, 2003), lack of health insurance has implications for society as well as for the individuals involved. For example, lack of insur- ance leads to premature death and loss of social productivity. In addition, the uncompensated care related to high numbers of uninsured individuals in the population may lead to health system closure and loss of providers, resulting in decreased community health care capacity. Because health problems have been allowed to escalate due to the inability to afford care, the ultimate societal costs for treatment are much higher than they would be if treatment was initiated earlier.

Lack of health insurance and its implications for access to needed health care services was recognized in the develop- ment of the national health objectives. Access to health care services is the first topical area addressed in Healthy People 2020. According to the U.S. Department of Health and Human Services (USDHHS, 2013b), lack of access to health care leads to both personal and societal consequences that include unmet health needs, delay in receiving needed care, inability to obtain preventive services, and increased hospitalizations that might have been prevented. Healthy People 2020 objectives related to access to care are presented on page 151. Many of the objectives are developmental in nature, indicating that there is no baseline data for the current status of a particular objective. During the course of implementation of the objectives, baseline data will be obtained and appropriate targets set for achievement by 2020.

Health Care reimbursement Systems When people receive health care, those who provide care need to be paid for their services. Payment for health services or re- imbursement, involves two aspects, the way in which payments are made and the source of the funds for payment. In this sec- tion, we will discuss the approaches to paying for services, or reimbursement systems. Reimbursement is compensation, usually through a public or commercial insurance plan, for health services provided. Payment approaches to be addressed include retrospective and prospective reimbursement, capita- tion, and a new approach termed pay-for-performance.

Retrospective Reimbursement Retrospective reimbursement is payment for services ren- dered based on the cost of those services; cost is determined after the fact. Forms of retrospective reimbursement include fee-for-service payment and discounted fee-for-service pay- ment as well as per diem payment. In a fee-for-service system, providers are paid for each service rendered after that service has been provided. Fee-for-service payment is based on the unit of service, such as a single visit to a provider or a single

M06_MARY9591_06_SE_C06.indd 150 06/09/14 6:38 PM

chaPter 6 economic influences on Population health 151

Healthy People 2020

Objectives for Access to Health Services

OBjeCtIVe

BaSelINe (yeaR)

taRget

CuRReNt Data (yeaR)

Data SOuRCe

AHS-1.1: Increase the proportion of persons with health insurance

83.2% (2008) 100% 82.8% (2011)

National Health Interview Survey (NHIS), CDC, NCHS

AHS-1.3: Increase the proportion of persons with prescription drug coverage

Developmental Developmental NDA National Health Interview Survey (NHIS), CDC/NCHS

AHS-2: Increase the proportion of insured persons with coverage for clinical preventive services

Developmental Developmental NDA Children’s Health Insurance Program (CHIP), CMS, AGing Integrated Database (AGID), AoA, CMS claims data, Medicare Current Beneficiary Survey (MCBS), CMS

AHS-3: Increase the proportion of people with a usual primary care provider

76.3% (2007)

83.9% 76.8% (2010)

Medical Expenditure Panel Survey (MEPS), AHRQ

AHS-4: Increase the number of practicing primary care providers

Developmental Developmental NDA

AHS-5.1: Increase the proportion of persons of all ages who have a specific source of ongoing care

86.4% (2008)

95% 86.8% (2011)

National Health Interview Survey (NHIS), CDC, NCHS

AHS-6.2: Reduce the proportion of individuals who are unable to obtain or delay in obtaining necessary medical care

7% (2007)

4.2% 4.6% (2010)

Medical Expenditure Panel Survey (MEPS), AHRQ

AHS-6.3: Reduce the proportion of people who are unable to obtain or delay in obtaining necessary dental care

5.5% (2007)

5% 5.8% (2010)

Medical Expenditure Panel Survey (MEPS), AHRQ

AHS-6.4: Reduce the proportion of people who are unable to obtain or delay in ob- taining necessary prescription medicines

3.1% (2007)

2.8% 3.3% (2010)

Medical Expenditure Panel Survey (MEPS), AHRQ

AHS-7: Increase the proportion of persons who receive appropriate evidence-based clinical preventive services

Developmental Developmental NDA Medical Expenditure Panel Survey (MEPS), AHRQ

AHS-8: Increase the proportion of persons who have access to rapidly responding prehospital emergency medical services

Developmental Developmental NDA National EMS Information System (NEMSIS)

AHS-9: Reduce the proportion of hospital emergency department visits in which the wait time to see an emergency department clinician exceeds the recommended time

Developmental Developmental NDA National Hospital Ambulatory Medical Care Survey (NHAMCS), CDC, NCHS

NDA= No data available Source: U.S. Department of Health and Human Services. (2013a). Access to health services: Objectives. Retrieved from http://www.healthypeople.gov/2020/ topicsobjectives2020/objectiveslist.aspx?topicId=1

M06_MARY9591_06_SE_C06.indd 151 06/09/14 6:38 PM

152 Unit 2 influences on Population health

procedure. Discounted fee-for-service mechanisms are used when third parties (e.g., an insurance company or health care plan) negotiates with providers who agree to charge less than their usual fee in return for being designated a “preferred provider” to whom patients are routinely referred.

Per diem payment is a reimbursement arrangement in which a health care facility is paid retrospectively, at a flat rate per day, for the number of days a client was hospitalized or received care. Per diem reimbursement is usually used for institutional providers such as hospitals, skilled nursing facili- ties, and long-term-care facilities.

Retrospective reimbursement has the disadvantage of en- couraging health care providers to give services that may not be necessary, merely because they are reimbursable. A provider who can be reimbursed for each office visit may be tempted to see a client three times when two visits would suffice. Or tests and treatments may be given that are not strictly necessary. For example, a surgeon might suggest a hysterectomy to a woman when other, less expensive measures would be equally effective.

Prospective Reimbursement In 1983, prompted by rising costs, the federal government in- stituted prospective reimbursement for services provided un- der Medicare. Prospective reimbursement is payment at a predetermined, fixed rate for a specific health care program or set of services (CMS, 2013f). Prospective payment rates are based on the extent of resources typically used in providing a given type of service. Prospective payment minimizes the im- petus for providers to render unneeded services because they are paid on a per incident basis rather than on the basis of the number of services provided. Because prospective payment is based on the average amount of service required for a particu- lar condition, health care providers actually lose money if they provide unneeded services.

Forms of prospective payment include diagnosis-related groups (DRGs), the Resource-Based Relative Value Scale (RBRVS), and capitation. Both DRG and RBRVS systems are based on payment for each episode of illness.

Prospective payment for services provided under the Medicare program is based on clients’ diagnoses, with set fees for care of clients who fall into specific diagnosis-related groups. As we saw in Chapter 2 , DRGs are categories of cli- ent diagnoses for which typical costs of care have been cal- culated, based on the cost of specific services required. In the DRG system, health care organizations, such as hospitals and skilled nursing facilities, are paid a set fee based on a client’s diagnosis and the typical costs of care for someone with that diagnosis.

A similar prospective payment system, the Resource-Based Relative Value Scale (RBRVS), was initiated in 1992 for physi- cian services provided to Medicare clients. In this system, the typical costs of a given health service have been calculated based on the prevailing cost for that service in a particular locale. Physicians providing a given service are paid a flat fee based on

the estimated cost of the service. Costs are based on the cod- ing categories of the Current Procedural Terminology Manual (CPT) developed by the American Medical Association (AMA) and used for Medicare billing purposes. The Healthcare Com- mon Procedure Coding System (HCPCS), also based on the AMA’s CPT codes, is used in the National Correct Coding Ini- tiative for providers billing Medicaid (CMS, 2014a). Variations of the RBRVS are also used by commercial insurance organiza- tions to reimburse health care providers.

Capitation Capitation is a particular type of prospective reimbursement in which the provider or health care system is paid a set prede- termined fee for a defined set of health services for each client enrolled in a particular health plan (Goldsteen & Goldsteen, 2012). In a capitated system, a third-party payer, such as an in- surance company or health plan, pays providers on the basis of the number of persons enrolled in the plan who select the par- ticular provider. Capitation has the advantages of certainty for the payer in terms of the cost of services and for the provider in a guaranteed patient population. However, the provider must provide all needed services under a fixed budget and may lose money if clients’ service needs exceed the amount of pay- ment. Capitation is a prominent feature of many managed care plans, which will be discussed in the section on commercial insurance.

Pay-for-Performance Pay-for-performance reimbursement is a relatively new ap- proach to paying for health care services in which providers and health care institutions receive bonus payments for achieving specific quality outcomes. For example, providers whose immu- nization rates reach certain targets may be given additional in- come by insurance providers. Pay-for-performance may occur in the form of additional payments for meeting global threshold targets for an entire client population or using a piece-rate per- formance reimbursement approach in which the provider is re- warded for each client that meets designated benchmarks. This system has the advantage of rewarding high performing pro- viders and organizations, but may not promote improvement in low performers. In addition, it may encourage providers and health care delivery systems to avoid high-risk clients for whom it is more difficult to achieve the targeted outcomes. Pay-for- performance has been shown, however, to improve immuniza- tion rates in systems in which it has been implemented (Chien, Li, & Rosenthal, 2010).

A reverse approach to pay-for-performance has been initi- ated by Medicare with its “never events.” In 2002, the National Quality Forum (NQF) developed a list of serious reportable events (SREs) that are serious errors and events that include both “errors caused by care management (rather than the un- derlying disease) and errors that occur from failure to follow standard care or institutional practices and policies” (NQF, 2006, p. 1).The list includes 28 events in six categories: surgical

M06_MARY9591_06_SE_C06.indd 152 06/09/14 6:38 PM

chaPter 6 economic influences on Population health 153

events, product or devices events, patient protection events, care management events, environmental events, and criminal events. These SREs or “hospital-acquired conditions” (HACs) are basically preventable with quality care and should “never occur.” Based on the concept of SREs, Medicare developed a list of hospital-acquired conditions incorporating mul- tiple diagnostic codes, for which health care institutions will not be reimbursed for care (although care to address adverse patient effects must be provided). An initial list of eight non- reimbursable conditions was instituted in 2008, but has since been expanded (CMS, 2012b; Healy & Cromwell, 2012). The Affordable Care Act required that similar provisions for non- reimbursement of these events be incorporated into the Medicaid reimbursement system (Medicaid.gov, n.d.c). These events have significant financial implications in that health care organizations are not reimbursed for care provided for these preventable conditions. Institution of non-reimbursement for such events, however, has led to a decline in the rates of several HACs including falls and trauma, catheter-associated urinary tract infections, and deep vein thrombosis/pulmonary embolism (Healy & Cromwell, 2012).

Health Care Funding Sources The second aspect of payment for health care services involves the source of funds for payment. Sources of health care funding include personal payment, commercial insurance, government-funded programs, and charity.

Personal Payment Perhaps the easiest to understand and least often used ap- proach to financing health care is personal payment. In a per- sonal payment system, when you see a provider for care, you pay him or her directly out of your pocket. Personal payment tends to be used by the very wealthy, by the uninsured (if they can afford any payment at all), or for certain specific goods and services that are not covered under an insurance plan. For ex- ample, if you do not have vision coverage in your health insur- ance plan, you would personally pay for your eye examination, new glasses, and so on. The entire risk for the costs of health care rests on the recipient of care.

Personal payment for health care services and products comprises one part of out-of-pocket expenses incurred by people who receive health care services. Insurance premi- ums, deductibles, and copayments are the other components of out-of-pocket funding. Premiums are the periodic, usu- ally monthly, amounts paid for health insurance benefits. A deductible is the amount of money that you must pay out- of-pocket before an insurance plan begins to pay for any care. A copayment or coinsurance payment is a fixed amount or percentage of costs that a client pays for each visit or service provided (Goldstein & Goldstein, 2012). Copayment is over and above the amount that is covered by one’s health insur- ance. In 2012, out-of-pocket payments accounted for 14% of U.S. health care expenditures, compared to nearly 34% from

private insurance and 45% from public sources (CMS, 2013c). Out- of-pocket expenses can be fairly significant, with more than 8% of people with health care expenses paying more than $2,000 out-of-pocket in 2006 (NCHS, 2013).

Personal payment is also the funding approach used in flat- rate medical clinics that are becoming more common in the United States. Flat-rate clinics charge clients a fixed or flat rate, typically on a monthly (e.g., $100 a month) or per-visit basis (e.g., a flat rate of $30 for each visit) for routine health care. Many of the recipients of care at flat-rate clinics have health insurance coverage for hospitalization, but use the clinics to address routine illness needs (McDonald, 2012). In flat-rate clinics, the risk for the cost of care is borne by the clinic.

Commercial Insurance Commercial insurance may involve either traditional fee- for-service retrospective reimbursement or a managed care approach to health care services. In traditional indemnity in- surance plans, the client or his or her employer pays for in- surance coverage. When services are provided, the insurance plan “indemnifies” the client, compensating him or her for the expenses incurred in obtaining services. Sometimes the client pays for services and is reimbursed for the payment; more of- ten, however, insurance companies pay providers directly. Pay- ment is made retrospectively after services are provided and is based on whatever fee the provider charges.

Managed care has no single definition but refers to a set of principles that govern provider–payer–recipient relationships or “a system of health care delivery that influences or controls utilization of services and costs of services by providing both the financing of care and the health services for covered individuals” (Goldsteen & Goldsteen, 2012, p. 290). In managed care, the payer and provider functions of health care are combined in the same organization. This is in contrast to more traditional indemnity insurance, in which the insurance company pays for care but does not actually provide the care given. A managed care organization (MCO) is a system of health care delivery that attempts to control costs while being accountable for the health outcomes of a group of enrolled individuals (Goldsteen & Goldsteen, 2012). MCOs are characterized by integration of funding and delivery systems and a comprehen- sive array of services. In 2010, 99% of the U.S. population who received health insurance through an employer were enrolled in some form of managed care plan (Claxton et al., 2010), and managed care plans covered more than 135 million people (Managed Care On-line, 2011).

Despite a wide and growing variety, managed care plans usu- ally have two elements in common. First, they generally require some form of authorization for services, particularly specialty services, and second, they usually include some restriction on choice of providers. The types and forms of MCOs create a veritable alphabet soup and include open- and closed-panel health maintenance organizations (HMOs), preferred pro- vider organizations (PPOs), point of service (POS) plans, and others. Managed care organizations are usually characterized

M06_MARY9591_06_SE_C06.indd 153 06/09/14 6:38 PM

154 Unit 2 influences on Population health

by a specific enrolled population, a designated set of covered services (usually including a variety of health-promotive and illness-preventive services), and a fixed subscription or enroll- ment premium that covers all designated services. Table 6-1• summarizes key features of some of the more common forms of MCOs.

Commercial insurance may be purchased individually by private individuals or through employment-based group health plans. Both forms of commercial insurance will be dis- cussed briefly.

INdIvIduAL INSurANCE. Individual health insurance is purchased by an individual directly from an insurance company. It tends to be expensive because the individual does not have the bargaining power of a large entity such as a corporation that can guarantee the insurance company a number of subscribers. Individual policies also tend to have limited coverage, again because of the expense. Some people may not be eligible for such policies because of existing health conditions that make

them a poor economic risk for the insurance company. Under the Consolidated Omnibus Reconciliation Act (COBRA), individuals who have been insured under an employment- based group plan may continue individual coverage at the group premium rate for 18 months after termination of employment. This legal provision is available whether or not there is a preexisting medical condition, but the individual is responsible for the entire cost of the premium, which makes it unaffordable for many people following a job loss (U.S. Department of Labor, n.d.).

EmPLOymENT-BASEd GrOuP HEALTH PLANS. By far the greatest number of people with commercial insurance obtains it by way of employment. Because of the number of people they insure, employers are able to obtain insurance for whole groups of employees at discounted rates not available to individual purchasers. Employment-based insurance is popular because it is purchased with pretax dollars. Employee health benefits are a pretax deduction for the employer and are not

TABLE 6-1 Key Features of Common Forms of managed Care Organizations

Type of mCO Key Features

All MCOs Provide comprehensive health care to an enrolled group for a specified fee (premium). Emphasize health promotion and illness prevention as means of minimizing costs. Attempt to minimize costs by providing care in the least expensive environment with the least expensive provider.

Health maintenance organization (HMO) Depends on subtype (see below). Members are generally restricted to services from providers within the plan. Services provided outside the plan are not covered and the member is liable for the full cost of outside services. Primary care providers (PCPs) function as “gatekeepers” preventing members from seeking specialty care without authorization.

Open-panel HMO HMO contracts with groups of providers who may see clients from other MCOs as well as fee-for-service clients. • Direct contract—HMO contracts directly with independent physicians for service for its members • Individual Practice Association (IPA)—HMO contracts with groups of physicians

Closed-panel HMO Providers see only members of the particular HMO, usually in facilities provided by the HMO. • Group model—HMO contracts with a group of providers and hospitals separately to provide services

exclusively for HMO members (also known as an exclusive provider organization, EPO) • Staff model—HMO employs providers on a salaried basis

Network model HMO HMO contracts with several large multispecialty groups of providers that operate independently of each other. Mixed model HMO Same HMO incorporates two or more of the above types of arrangements. So a given HMO might have

separate closed-panel and open-panel segments that usually operate independently of each other. Individual Practice Association (IPA) Group of independent providers (usually physicians) forms an association to contract with managed care

organizations to provide services to MCO enrollees. Preferred provider organizations (PPOs) MCO includes a group of independent “preferred providers” (hospitals, physicians, and other providers)

that provide services at a discounted rate to MCO members. If members choose to obtain services outside the plan, they are covered at a reduced rate, and the member must pay the difference (usually 20% of costs).

Point of service (POS) plans Plan members choose a participating PCP who serves as a gatekeeper for specialty care. Specialty care requires a referral, but the member may choose to see a specialist outside the plan and pay a higher deductible, copayment, or both. Differentials may be as high as 20% to 40% of the cost of services.

Integrated delivery systems (IDSs) Coordinated network of health care organizations that provide a continuum of services to a defined population. Characterized by a defined population, a defined set of services, clinical and administrative integration of services and information systems, a capitated payment system, and pooled revenues from several sources. Emphasizes centralized planning and management and a shared mission and vision. Includes hospital beds and at least one long-term-care service. May include contracts with several HMOs for the provision of services.

Other weird arrangements (OWAs) Because of the proliferation and combination of features of many different models of MCOs, there are other types of plans that defy description. These models are collectively referred to as OWAs.

M06_MARY9591_06_SE_C06.indd 154 06/09/14 6:38 PM

chaPter 6 economic influences on Population health 155

currently considered taxable income for employees. In 2011, 56% of the U.S. population under 65 years of age obtained health insurance through an employer (NCHS, 2013), and 67% of the total U.S. population were enrolled in some sort of group health insurance plan (U.S. Census Bureau, 2013).

As we saw earlier, however, significant segments of the pop- ulation are not eligible for employment-based health insurance. In 2013, only 72% of civilian workers in the United States had access to employment-based health benefits, and only 56% ac- tually participated in benefits plans. Participation rates were even lower for low-income workers, with only 42% of those with wages in the lowest 25% participating (U.S. Bureau of Labor Statistics, 2013b). Access to health insurance benefits is somewhat dependent on the size of the employer’s workforce with 86% of companies with more than 100 employees provid- ing access to health benefits compared to only 57% of those with fewer than 100 workers (U.S. Bureau of Labor Statistics, 2013b). Retirees may also lack access to continued employer-sponsored health insurance benefits. In 2010, for example, less than 18% of workers were employed by companies that provided health benefits to early retirees who were not yet eligible for Medicare. Those organizations that do offer retiree health insurance cov- erage are changing to less expensive benefits packages, increas- ing premiums, or reducing eligibility (Fronstin & Adams, 2012).

In addition, the cost of group health plan premiums, while not as expensive as individual insurance coverage, has contin- ued to escalate, with annual increases in insurance premiums consistently outstripping wage increases and overall inflation rates. From 2003 to 2013, the average annual health insurance premium increased by 80%, and the contribution required of the average employee increased by 89% (Kaiser Family Foun- dation and Health Research & Educational Trust, 2013). In 2013, the average monthly premium for employment-based family insurance was $901 for all U.S. civilian workers, with ap- proximately 31% of the cost of premiums contributed by the employee (U.S. Bureau of Labor Statistics, 2013b).

Employers are faced with one of several unpalatable options due to rising premium costs: (a) pay the increased premiums, thereby reducing their profit margins, (b) reduce the level of benefits covered, (c) pass a larger share of health insurance costs on to employees (e.g., a greater percentage of premiums and larger deductibles and copayments), or (d) discontinue coverage altogether (Kaiser Family Foundation and Health Research & Educational Trust, 2013). For example, in 2009, a single-person employment-based insurance policy required an average deductible of $917, and the average deductible for family coverage was $1,761. Similarly, nearly 73% of employer- sponsored health plans required a copayment for each doctor visit, with an overall average copayment of $21.53. In addition, covered employees were required to pay 18.6% of the cost of care as a coinsurance payment (Davis, 2011).

Increases in the cost of health insurance have led to a pro- liferation of types of employment-based coverage in an effort to reduce costs to employers, including defined benefits plans, defined contribution plans, fixed contribution plans, and

consumer-driven plans. In defined benefits plans, employers select a predetermined set of benefits that are covered by the plan. Differing sets of benefits may be available under different plans or from different companies. For example, benefits may or may not cover reproductive services such as contraception. Similarly, dental insurance plans may or may not cover any amount for orthodontics. Employees of large companies may have a choice among several different defined benefits plans.

In a defined contribution plan, the employer provides a set amount of money to each employee, which the employee can use to purchase whatever type of insurance plan is desired. Defined contribution plans have more advantages for employ- ers than employees. Employers’ health insurance costs remain constant, but employees may find that the amount provided does not go far to cover the costs of a desirable health insur- ance plan. In a fixed contribution plan, the employer chooses a specific benefits package and provides a fixed amount toward the premiums for that package, with the expectation that the employee will pay the difference in the cost of the plan.

A fourth approach is a consumer-driven plan, in which the employer usually provides a defined catastrophic coverage for serious illness or injury as well as a flexible health care spending account. The employee can then use the amount in the health spending account to pay directly for any other health care ex- penses incurred. Health spending accounts are similar to the health savings accounts allowed by the Internal Revenue Service. A health savings account is money contributed by the employee through payroll deduction prior to taxes that is available for cer- tain health care expenses not covered by insurance plans. The health spending account included in a consumer-driven health plan differs in that the contribution is made by the employer rather than the employee. In many such plans, monies left in a health spending account can be carried over in subsequent years; in others, whatever money is not spent in a given year is forfeited.

Consumer-driven plans have the advantage of covering cat- astrophic events, the most expensive area of health care, with flexibility for addressing other health care needs. They have the disadvantage of controlling only the small portion of health care expenditures outside of catastrophic coverage. In addi- tion, there is concern that ill-informed consumers may make poor health choices that later lead to the need for more costly services. Attempts to prevent this from occurring include the incorporation of online access to health-related information and nurse counseling and coaching. There is also the possibil- ity that if many people who receive employment-based health care coverage opt for consumer-driven plans, it will reduce the number of people with traditional commercial insurance, driv- ing prices beyond the capacity of many to afford.

The options available to most employees whose employers provide health insurance benefits include some form of man- aged care plan. Most employers who provide access to health in- surance (84%) offer only one option, with larger employers more likely to offer more than one plan option. Among all U.S. civil- ian firms, 24% offered access to HMOs, 53% to PPOs, and 25% to POSs. Only 2% offered employees the option of conventional

M06_MARY9591_06_SE_C06.indd 155 06/09/14 6:38 PM

156 Unit 2 influences on Population health

fee-for-service insurance. A growing percentage of busi- nesses (15% in 2010) offered eligible employees the choice of high- deductible health plans with a savings option (HDHP/ SOs). These plans are similar to consumer-driven plans dis- cussed earlier and are characterized by a high annual deduct- ible amount (averaging $1,700 to $2,000) to be paid by the employee before the insurance plan provides any coverage coupled with a Health Savings Account or Health Reimburse- ment Arrangement. In the health savings account, the em- ployee makes nontaxable contributions to the account to be used for health-related expenses. In a health reimbursement ar- rangement, the contribution is made by the employer (Claxton et al., 2010). HDHP/SOs generally have lower premium costs than other group plans (Kaiser Family Foundation and Health Research & Educational Trust, 2013). Figure 6-2 • depicts the process of health care funding through employment-based managed care participation.

Self-funded insurance is another option selected by some businesses to minimize insurance costs. Self-funded insurance and self-insurance are more radical approaches taken by some large employers and unions. In a self-funded insurance plan, an employer collects pooled premiums from its employees and

uses funds that would have paid insurance company premiums to pay for the costs of care provided to employees and their de- pendents. Self-insured programs are similar, but the employing organization hires a third party (often a commercial insurance company) to administer the program and process claims. Some physician networks assist companies in developing self-funded insurance plans and may negotiate to provide services under the plan. Plans may also include PPO and POS managed care options (PhysiciansCare Health Plans, n.d.b). Self-funded insurance is one component of the “other third-party” source of health care funding depicted in Figure 6-1.

Self-funded plans have a number of advantages for employ- ers allowed under the Employee Retirement Income Security Act (ERISA). They avoid the third party that increases pre- mium costs. In addition, costs are based on the level of pooled risk of the company’s employees, not all participants in an insurance program. Since employees of many companies are relatively young and healthy, this decreases costs. Self-fund- ing avoids the premium tax collected by state governments as a percentage of commercial insurance premiums, and self- funded programs are exempt from state insurance regulations. Although they are regulated by the U.S. Department of Labor, they do not have to meet the minimum benefits requirements of commercial plans and can provide a health benefits package tailored to the needs of the company’s employees (Physicians- Care Health Plans, n.d.a).

In self-funded plans, the risk for excessive health care costs is borne by the employer or union. However, these organiza- tions often get around this disadvantage by purchasing cor- porate insurance protecting them against catastrophic losses (PhysiciansCare Health Plans, n.d.b).

HEALTH INSurANCE ExCHANGES. Under the Patient Protection and Affordable Care Act [HP 3590], enacted in 2010, each state is required to establish some form of health insurance exchange by 2014. The exchanges are designed to permit individuals and small businesses to shop for affordable health insurance coverage. States have some options in the development of the exchanges. The state may create its own exchange or separate exchanges for individuals and small businesses or let the federal government administer a state exchange. States may also choose to cooperate with other states to create regional exchanges (Alliance for Health Reform, 2010a).

State insurance exchanges will offer a variety of plans pro- viding federally designated tiers of coverage. These tiers are as follows:

• Bronze tier: Covers 60% of costs for all services included in the plan (exclusive of premiums)

• Silver tier: Covers 70% of costs for all services included in the plan

• Gold tier: Covers 80% of costs for all services included in the plan

• Platinum tier: Covers 90% of costs for all services included in the plan (Healthcare.gov, n.d.a).

FIguRe 6-2 Health Care Funding through employment-based Managed Care Plan enrollment

Services

Copay

Provider

Employees

PremiumEmployer

Additional premiums

Capitation

MCO

M06_MARY9591_06_SE_C06.indd 156 06/09/14 6:38 PM

chaPter 6 economic influences on Population health 157

The exchanges will have the advantage of buying power due to the number of people involved, so coverage will be less expensive than is currently the case for individuals and com- panies with small numbers of employees. State exchanges may be administered by state government agencies or by nonprofit groups (Alliance for Health Reform, 2010b) and will be avail- able only to citizens and legal residents of the United States. They will not be available to anyone who is incarcerated, so it will not assist state and local law enforcement agencies to reduce the costs of health care to prisoners (Kaiser Family Foundation, 2013). They may, however, be available to per- sons awaiting trial. Whether or not coverage will terminate if conviction occurs or will merely be suspended is yet to be determined. The requirements to be met by state insurance exchanges are highlighted at right. Data from one of the larg- est existing state risk pools cover too few of the uninsured to resolve the overall problem of access to care, and concerns exist over how those enrolled will be integrated into the reformed health care system. As of September 2010, 27 states and the District of Columbia had chosen to administer their own risk pools, and the other 23 states had opted for a federally adminis- tered plan (Blewett, Spencer, & Burke, 2011).

Government-Funded Care Federal, state, and local governments are another significant source of health care funding in the United States. In govern- ment-funded health programs, the risk for the costs of care is borne by the government, and ultimately by taxpayers. In 2012, 43% of the insured population in the United States was covered by government health insurance (U.S. Census Bureau, 2013), and government funding sources paid for 45% of personal health care expenditures in the United States. (CMS, 2014d). These funds primarily fall into the Medicare and Medicaid sources of funding depicted in Figure 6-1. The remainder of federal government programs (e.g., Department of Veterans Affairs, Department of Defense, and so on) fall into the “other third-party” category in the figure.

Federal, state, and local governments have a variety of pro- grams that finance health care. The two major federal gov- ernment programs are Medicare and Medicaid. Medicare is designed to provide care for the elderly and certain individuals who are disabled. The Medicaid program is jointly financed by federal and state funds and was developed to address the health care needs of the poor. Other federal health care programs in- clude the Department of Veterans Affairs, military programs including Department of Defense facilities and the TRICARE program, the Federal Employee Health Benefits Program ( FEHBP), the Indian Health Service, and the National Health Service Corps.

The Department of Veterans Affairs and the Indian Health Service provide services for selected population groups, military

Health care reform. (Nebari/Fotolia)

Requirements for State Insurance Exchanges

• Provide easy web-based access to information on plan options, benefits, and costs in a standard format.

• Operate a toll-free hotline to provide information to consumers.

• Assist in screening and enrolling eligible persons in existing public insurance programs.

• Use a standardized enrollment form for all plans and programs.

• Use consumer navigators to help consumers or employers make health insurance decisions.

• Inform consumers of satisfaction and quality ratings of insurance plans available through the exchange.

• Offer plans that:

• Cover the basic federal benefits package and any additional benefits mandated by the state.

• Include caps on out-of-pocket spending for plan enrollees.

• Offer only designated tiers of coverage and offer at least one silver and one gold level plan.

• Have an adequate number of health care providers in the plan.

• Meet specified marketing standards. • Meet relevant quality, quality improvement, and

accreditation standards. • Meet transparency standards, including disclosure of

claims denials. • Make prior justification for premium increases.

• Solicit consumer and public input.

• Publish financial information and be audited by the Department of Health and Human Services.

• Be self-financing through premiums and other state resources by January 2015.

Data from: Families USA. (2010). Implementing health insurance exchanges: A guide to state activities and choices. Retrieved from http://familiesusa.org/ sites/default/files/product_documents/Guide-to-Exchanges.pdf

Highlights

M06_MARY9591_06_SE_C06.indd 157 06/09/14 6:38 PM

158 Unit 2 influences on Population health

veterans and Native Americans, respectively. Both Department of Defense and TRICARE programs provide services to active- duty members of the military, retirees, and their dependents. Department of Defense facilities are managed and staffed by the military. TRICARE, on the other hand, is a program by which members of the military, retirees, and their dependents receive care in the civilian sector with funding provided by the federal government. TRICARE is also available to members of the National Guard and Reserves and their families. TRICARE functions much like traditional commercial health insurance or managed care plans and provides several options includ- ing dental and pharmacy coverage options. A similar type of program, FEHBP, serves employees of federal agencies outside of the military. In this program, the federal government func- tions primarily as an employer purchasing employment-based health insurance for employees, just as in the private sector (U.S. Office of Personnel Management, n.d.). The National Health Service Corps is designed to provide health care ser- vices in underserved areas of the country. Like Medicaid, the SCHIP is funded by the federal government but administered by the states. The SCHIP program was initiated to provide care for poor children who did not meet eligibility requirements for Medicaid (Medicaid.gov, n.d.a). Medicare, Medicaid, and SCHIP are discussed in more detail below. Local jurisdictions, such as counties, often have programs that fund health services for indigent persons who are not eligible for Medicaid.

mEdICArE. Medicare is part of the social insurance program arising from provisions of the Social Security Act. Under Medicare, people over 65 years of age who are eligible

for Social Security benefits receive partial coverage of health services. Certain other individuals, such as the disabled and those with end-stage renal disease who require renal dialysis or transplant, are eligible for Medicare coverage before age 65 (CMS, 2013d; Social Security Administration, 2010). In 2011, Medicare provided coverage for approximately 48.6 million people, including 39 million over 65 years of age and 8.3 million non-elderly people with permanent disabilities. Federal expenditures for Medicare in 2011 amounted to nearly $514.3 million and the federal allocation for 2012 was over $545 million (CMS, 2011).

At its inception in 1965, Medicare was intended to pro- tect the elderly against expensive hospitalizations. The op- tional Medicare Part B was added to cover physician expenses. Medicare Part C, previously called Medicare + Choice and now Medicare Advantage, was instituted in 1997 to provide beneficiaries with a choice of options among traditional fee- for-service practices and managed care plans (Social Security Administration, 2010). Medicare Part D, Medicare Prescrip- tion Drug Coverage, was initiated under the Medicare Pre- scription Drug, Improvement, and Modernization Act of 2003 and was fully implemented in 2006. Each of the components of Medicare will be discussed briefly. Elements of each compo- nent are summarized in Table 6-2•.

Medicare Part A covers medically necessary hospitalization, care in a skilled nursing facility (SNF), some home health care, hospice services, and blood administered in an inpatient setting. Part A coverage is available to all participants in the Social Secu- rity program and is provided without additional premiums to those who are eligible for Social Security or railroad retirement

TABLE 6-2 Components of medicare

medicare Component Services Premiums (2014) deductible (2014) Copayment

Part A • Hospitalization • Skilled nursing facility • Home health • Hospice • Blood (given in an

inpatient setting)

• None for 99% of Medicare beneficiaries

• $426/month for those who are otherwise ineligible

$1,216/benefit period Hospitalization • None for first 60 days • $304/day for days 61–90 • $608/day for days 91+

Part B • Physician services • Outpatient services • Some home health care • Durable medical

equipment • Screening/preventive

services

$104.90/month (2014) $147/year for approved services

• 20% of cost for most services

Medicare Advantage Plans • Replaces Medicare A & B for enrollees

• May include additional services

Based on plan Based on plan Based on plan

Medicare Part D Prescription drug services Based on plan Maximum/year deter- mined by CMS

• 25% of drug costs from $250 to $2,850

• 47.5% of the cost of brand name drugs and a variable amount for generic drugs (2014)

M06_MARY9591_06_SE_C06.indd 158 06/09/14 6:38 PM

chaPter 6 economic influences on Population health 159

benefits, a dependent parent of an eligible dead child, those meeting disability eligibility criteria, and spouses of those who paid Medicare taxes through their employment, and those with kidney failure (Social Security Administration, 2010). Fund- ing for Medicare Part A is derived from nonvoluntary Social Security payroll taxes on one’s income with a matching pay- ment from the employer. Elderly people who do not meet the eligibility criteria may enroll in Medicare Part A with payment of a monthly premium, and state assistance with premiums is available for low-income elderly (CMS, 2013d, 2013e; Cuban- ski et al., 2010).

Part A benefits begin after the beneficiary has incurred the specified annual deductible amount ($1,216 in 2014) (CMS, 2013b). Benefits are paid within a benefit period. A benefit pe- riod begins with admission to a hospital or SNF and ends when no further hospital or SNF care has been received for 60 con- secutive days. One may have several benefit periods within a given year and must pay the deductible for each benefit period. Within each benefit period, Medicare pays all covered costs for the first 60 days. For hospitalizations longer than 60 days, the beneficiary pays a copayment for each additional day ($304 a day for days 61 to 90 and $608 a day after 90 days in 2014) (CMS, 2013b).

Medicare Part B covers medically necessary provider ser- vices, outpatient care, some home health care, and other ser- vices that are not covered under Part A (CMS, 2012c). Part B also covers a variety of preventive services including colorectal, breast, cervical, and prostate cancer screening; osteoporosis screening; immunizations; and so on.

Part B coverage is optional and entails payment of an ad- ditional premium similar to that paid for private health insurance, but much less costly. Due to recent changes in regu- lations, premiums are now somewhat higher for recipients with higher incomes than for the general population (Social Security Administration, 2010). By law, the Medicare Part B premium must be sufficient to cover 25% of the program’s costs, so the premium increases each year as health care costs increase. For 2014, the monthly premium was $104.90; the same as for 2013 (CMS, 2013b). Part B premiums may be slightly higher for Medicare beneficiaries who did not enroll in Part B when they first became eligible. Beneficiaries with incomes less than 135% of the federal poverty level may receive assistance with their Part B premiums, and for some Medicare enrollees, the Medicaid program pays their Medicare Part B premiums.

Like Part A, there is a deductible amount that must be paid before Part B coverage begins ($147 in 2014), but unlike Part A, the Part B deductible is paid only once a year. In addition to the monthly premiums and annual deductible, beneficiaries pay a copayment for Medicare-approved services or supplies. Provi- sions of the Affordable Care Act eliminate cost-sharing (de- ductible and copayment) requirements for preventive services under Medicare.

If health service providers accept Medicare assignment, beneficiaries do not have any additional costs for Medicare- approved services. Assignment is an agreement whereby the Medicare beneficiary agrees to allow the service provider to

bill Medicare directly for services or goods (e.g., a walker or ventilator) provided. In return, the provider agrees to accept the Medicare reimbursement amount as full payment. If pro- viders do not accept assignment, the greatest amount that the beneficiary can be charged for a Medicare-approved service or product is 15% above the Medicare-approved amount for that service or product. This is called the limiting charge.

As noted earlier, Medicare Part C, or Medicare Advantage, was intended to permit Medicare enrollees to exercise the same options with respect to their health care as others in the U.S. population and to take the place of medigap plans or supplemental insurance to cover costs for services not pro- vided under Medicare. Specifically, the program allowed ben- eficiaries to apply their Medicare funding to enrollment in a Medicare-approved managed care plan. Medicare Advantage Plans may include health maintenance organizations, preferred provider organizations(PPOs), and Medicare private fee-for- service plans, depending on what is available in a given locale ( Medicare.gov, n.d.b). In 2010, 24.6% of Medicare Part A and 20.4% of Part B disbursements were made to managed care or- ganizations (CMS, 2011).

Medicare HMOs and PPOs are similar to those discussed in the section on employment-based group health plans. Medicare special needs plans provide coverage to select groups of people, such as nursing home residents, those who are eligible for both Medicare and Medicaid, and those with certain chronic or dis- abling conditions. Medicare private fee-for- service plans allow recipients to choose any provider that accepts the plan, and the plan determines what the recipients’ share of the cost will be. Some Medicare Advantage Plans also include prescription drug coverage and services not included under the Original Medicare Plan (Parts A & B). Like Medicare Part B, there is usually an additional premium for a Medicare Advantage plan that is paid by the enrollee.

In 2006, the major provisions of the Medicare Prescrip- tion Drug, Improvement, and Modernization Act of 2003 were implemented as Medicare Part D, Medicare Prescription Drug Plans. This drug subsidization program is available to all Part A, B, and C recipients and requires beneficiaries to enroll in one of many Medicare Prescription Plans offered by private insurance companies. Although described as a “vol- untary” plan, Medicare beneficiaries who choose not to enroll in a prescription plan will be required to pay increased pre- miums of 1% for every month that they delay coverage, un- less their drug coverage during that time was as good as Part D coverage (Social Security Administration, 2010). For some Medicare recipients, prescription drug coverage may be pro- vided under Medicare Advantage plans rather than specific Part D plans (Medicare.gov, n.d.a). Prescription drug cover- age plans vary in terms of costs, drugs covered, and pharma- cies participating. Medicare beneficiaries with incomes below 135% of poverty level can get assistance with Part D premi- ums, and those between 135% and 150% of poverty level can receive partial assistance (CMS, 2013a). In 2010, more than 28 million Medicare beneficiaries were enrolled in Part D prescription plans (CMS, 2011).

M06_MARY9591_06_SE_C06.indd 159 06/09/14 6:38 PM

160 Unit 2 influences on Population health

Plan beneficiaries pay a deductible amount prior to cover- age. The deductible varies from plan to plan, but cannot ex- ceed the amount specified by CMS for a given year. After the deductible is paid, the beneficiary pays a copayment (typi- cally 25% of the cost) for each prescription until costs reach a specified amount ($2,850 in 2014). Once total drug costs have reached that amount, the beneficiary pays 47.5% of brand name drug costs and a specified amount for generic drugs that will decrease to 25% by 2010 until total drug expendi- tures for the year reach another set amount, at which point the beneficiary resumes paying a small copayment for each prescription. Drug costs in the specified window are referred to as the “ doughnut hole,” or gap in prescription drug care cov- erage under Medicare (Medicare.gov, n.d.a). The Affordable Care Act provided a $250 rebate for Medicare beneficiaries in the doughnut hole during 2010 and will eventually close the coverage gap completely (Alliance for Health Reform, 2010b).

Although the Medicare program has provided significant assistance to the elderly population with respect to hospital- ization and, to a lesser extent, provider services, it does not provide adequate coverage in a number of areas. For example, mental health services are only partially covered, and long-term custodial health care is not addressed at all by the program. As we saw earlier, prescription drug coverage may be inadequate even with Medicare Part D. Medicare has begun to provide for some preventive services such as influenza and pneumonia im- munization and mammography, but these are generally con- sidered insufficient to meet the health promotion needs of the elderly population.

mEdICAId. The Medicaid program was established in 1965 to provide health care services to a large segment of the population who could not otherwise afford care. Its original purpose was to integrate the indigent into mainstream health care services. Medicaid and the Children’s Health Insurance Program (CHIP) provide services for more than 60 million people in the United States, including 31 million children, 11 million non-elderly low-income parents, caretakers, pregnant women, and other adults, and 8.8 million people with disabilities. Medicaid also funds care for 4.6 million low-income seniors who need assistance with Part B Medicare premiums and prescription drug coverage and 3.7 million people with disabilities who also receive Medicare assistance (Medicaid.gov, n.d.b, 2014). Based on the most recent CMS Data Compendium, federal Medicaid expenditures for 2010 were $383.4 million, with a 2012 allocation of more than $997 million (CMS, 2011). Despite the availability of Medicaid coverage, however, many children remain uninsured. Given the economic downturn since 2007, however, the number of uninsured U.S. children would have been far higher without the Medicaid program (Kaiser Commission on Medicaid and the Uninsured, 2012a).

Medicaid is a means-tested program, which means that eligibility for services is based on one’s income (Goldsteen & Goldsteen, 2012). Under the program, the federal government provides block grants to the states that are combined with

matching state funds. Matching rates depend on the per capita income of the state, with lower-income states receiving more federal money for every state dollar expended.

The Medicaid program is administered by the states, but state programs must provide a minimum set of federally defined benefits. Beyond that, states are free to determine the level of service provided as well as eligibility require- ments for the program, and both benefits and requirements may differ drastically from state to state. States may choose to expand eligibility for Medicaid to cover people with in- comes too high to meet regular eligibility requirements, but with extensive medical expenses. Eligibility expansions may also encompass other groups of people such as institution- alized low-income persons, low-income women diagnosed with breast or cervical cancer through Centers for Disease Control and Prevention (CDC) screening programs, and others (Medicaid.gov, 2014).

In the past, Medicaid covered most prescription drug costs for enrollees. Now prescription drug costs for “dual eligibles,” persons eligible for both Medicare and Medicaid, will be cov- ered under a Medicare Prescription Drug Plan. Medicaid will cover the costs of Medicare Prescription Drug Plan premiums, but it is anticipated that the change will increase copayments for prescription drugs from those previously paid under the Medicaid program.

Because both Medicare and Medicaid are programs that arise out of federal legislation, they are often confusing. Table 6-3 • provides characteristic features that may help differentiate the two programs.

STATE CHILdrEN’S HEALTH INSurANCE PrOGrAm (SCHIP). The State Children’s Health Insurance Program was authorized by Congress in 1997 to address the health insurance needs of low-income children and pregnant women who do not meet the income eligibility requirements for Medicaid. The enacting legislation gave states the option of either expanding existing Medicaid programs or creating separate SCHIP

TABLE 6-3 differentiating Features of medicare and medicaid

Feature medicare medicaid

Funding source Social Security contributions

General tax revenues (federal and state)

Program administration

Federal State

Beneficiaries Elderly and disabled persons

Medically indigent

Benefits Standardized for each component Hospitalization, primary care (under Part B only), prescription drugs, selected preventive ser- vices, no dental services

Vary from state to state Primary care, preventive services, prescription drug coverage, hospi- talization, may include dental services

M06_MARY9591_06_SE_C06.indd 160 06/09/14 6:38 PM

chaPter 6 economic influences on Population health 161

programs to include uninsured children who were eligible for Medicaid but unenrolled, or with family incomes too high for Medicaid eligibility but too low to afford commercial insurance coverage (Medicaid.gov, 2014). Most SCHIP programs provide services to children in families with incomes at or below 200% of the federal poverty level, but eligibility thresholds may be higher or lower in some states. The SCHIP program gave the states extraordinary latitude in determining how to deal with the problem of uninsured children and is an example of a phenomenon called devolution, or the transfer of responsibility for an area from federal to state governments or other jurisdictions (Devolution, 2011).

In 2010, 7.7 million children were enrolled under a SCHIP (CHIP Statistical Enrollment Data System, 2011). Under the provisions of the 2009 reauthorization bill, coverage was ex- panded to 11 million to provide coverage for nearly half of the uninsured children in the United States (Alliance for Health Reform, 2010c). Total federal funding for 2010 for the CHIP program was $11.4 billion and the 2012 federal funding alloca- tion was $13.4 billion (CMS, 2011).

Like Medicaid, SCHIP is state administered but funded jointly by federal and state governments. The federal govern- ment pays an average of 72% of the costs of SCHIP in a given state. SCHIP, in conjunction with Medicaid, was responsible for decreasing the number of uninsured children by 2.7 mil- lion in spite of increasing child poverty and family loss of employment-based insurance. Both SCHIP and Medicaid have been shown to be effective in meeting the care needs of those insured. In addition, expansion of both SCHIP and Medicaid programs have been credited with decreases in child mortality as a result of external causes (e.g., accidental injury) (Howell, Decker, Hogan, Yemane, & Foster, 2010). For further information about Medicare, Medicaid, and SCHIP, see the External Resources section of the student re- sources site.

Charity Care Charity care is the “other private” source of health care fund- ing depicted in Figure 6-1. Charity care is defined as care that is provided free of charge to individuals who meet established financial criteria and that was never expected to generate rev- enue. There is no reliable estimate of the amount of charity care provided in the United States, because the costs for charity care are accounted for in different ways in health care organizations’ accounting systems. IRS data indicated that the percentage of charity care by U.S. hospitals in 2009 ranged from 7.3% for small hospitals to 9.8% for large hospitals (Dunn & Becker, 2013).

Private charitable giving for all purposes (not just health) amounted to $298.4 billion in 2010. Approximately 8.3% of charitable contributions are made to health care organizations; another 32% is given to religious organizations, and approxi- mately 12% is contributed to human services agencies, both of which provide some health-related services. In addition, nearly 27% of the U.S. population provided voluntary services, amounting to 15.2 billion hours in 2011 (Blackwood, Roeger, &

Pettijohn, 2012). Charitable giving tends to decrease during hard economic times and frequently does not keep pace with inflation and the cost of providing charity care. In addition, many nonprofit organizations are faced with growing demands for assistance during economic downturns stretching their re- sources even further.

Charity care may be provided by individual health care or- ganizations or funded by a wide variety of voluntary organi- zations and philanthropic foundations. For example, the Gates Foundation has funded a massive international immunization campaign. Other organizations and foundations fund similar health care programs as well as providing services or funding services for individual needy clients and families. The National Center for Charitable Statistics (n.d.) lists three types of non- profit organizations that may provide health-related services: 501c3 organizations that include health care and community service agencies, 501c3 private foundations that most often provide funding grants to other nonprofit agencies, and other tax-exempt groups, such as unions, veterans groups, and social and recreational clubs. Voluntary health organizations will be discussed in more detail in Chapter 7 .

Both the Better Business Bureau (BBB, 2003) Wise Giving Alliance and the Federal Trade Commission (FTC) (2012) pro- vide tips on selecting reputable charities to which one might wish to give donations. In addition, the BBB has promulgated standards for charity accountability against which a potential donor can judge a charity’s worthiness. The Alliance also pub- lishes reports about major charity organizations that are avail- able to the general public on its website.

Health Insurance and reform In March of 2010, President Barack Obama signed the Patient Protection and Affordable Care Act instituting a variety of re- forms to health insurance and programs to improve the health of the U.S. population. Some of the effects of the law have been presented earlier, but we will discuss others here. Gen- eral categories of provisions within the law address mandatory coverage, employer requirements, expansion of public pro- grams, premium and cost-sharing subsidies, tax changes, and the health insurance exchanges discussed earlier. Other areas addressed in the bill include creation of an essential benefits package, changes to private insurance, the role of the states in implementing the law, cost containment, quality improvement, prevention and wellness services, long-term care, and other in- vestments (Kaiser Family Foundation, 2013).

Under the law, individual U.S. citizens and legal residents will be required to have health insurance coverage that meets minimum requirements or pay a tax penalty, which may be a flat fee or a percentage of family income. Similarly, employers with 50 or more employees will be required to provide health insurance coverage for their employees or pay a fee of $2,000 per full-time employee. Some individuals and employers may be eligible for subsidies or tax credits to offset the costs of in- surance premiums. In addition, some individuals may qualify

M06_MARY9591_06_SE_C06.indd 161 06/09/14 6:38 PM

162 Unit 2 influences on Population health

for cost-sharing subsidies to assist with deductibles and copay- ments. Employers may also receive reimbursement for health claims of retirees not yet eligible for Medicare to offset the costs of allowing retirees to participate in employment-based group plans (Kaiser Family Foundation, 2013).

The law also provides for expansion of Medicaid eligibil- ity to all non-Medicare eligible individuals with incomes up to 133% of the federal poverty level and maintains state require- ments for SCHIP programs. After 2015, states will receive an increase in their federal CHIP matching rates (Kaiser Family Foundation, 2013).

Some changes in tax provisions include removal of unpre- scribed over-the-counter drugs from eligible expenses that can be reimbursed from health savings accounts and limiting contributions to flexible spending accounts to $2,500 per year (adjusted for cost of living increases). The law also changes the threshold for including unreimbursed health expenses as itemized deductions in computing income taxes, imposes new annual fees for pharmaceutical manufacturers, and initiates an- nual fees for the insurance sector (with lower fees for nonprofit insurers). The law also provides for the creation of an essential health insurance benefits package that provides a comprehen- sive set of services, covers 60% of the cost of services, and limits cost-sharing requirements. The Act, however, specifically pro- hibits the inclusion of abortion services in the essential benefits package (Kaiser Family Foundation, 2013).

Some of the most far-reaching provisions of the Affordable Care Act involve changes to private insurance. These include increasing the age for dependent children’s coverage to 26 years, prohibiting lifetime limits on coverage and withdrawal of coverage except in the case of client fraud, and requiring jus- tification of premium increases. Additional provisions require all new plans to conform to one of the tiers of coverage dis- cussed earlier, limit deductibles and waiting times for cover- age and provide for the creation of an Internet website to assist individuals to explore insurance options, and the develop- ment of standards for providing benefits information (Kaiser Family Foundation, 2013). The legislation also prohibits denial of coverage due to the presence of a preexisting condition and requires that 85% of insurance premiums from large employers

and 80% from small employers be spent on health care services rather than administrative costs (U.S. Department of Health and Human Services [USDHHS], n.d.a).

Cost-containment provisions in the law include adop- tion of a single set of rules for eligibility verification and filing claims as well as a variety of cost-containment strategies for Medicare and Medicaid. Research funding is included for qual- ity improvement pilot projects. Another system improvement strategy is an increase in Medicaid payments to providers to conform to Medicare rates (Kaiser Family Foundation, 2013).

This far-reaching piece of legislation might go some way to providing coverage to the millions of uninsured residents of the United States and would also result in needed insurance reform. Unfortunately, however, provisions of the law are already being challenged. Recently, a federal judge ruled the mandate for indi- vidual health insurance coverage to be unconstitutional because it exceeds the federal government’s authority to regulate interstate commerce. In doing so, however, the judge refrained from issu- ing an injunction to stop implementation of the mandate pend- ing appeal of his ruling (Lowes, 2010). In addition, powerful lobbies and members of the Republican party have already vowed to move toward repeal of the law. Population health nurses and other concerned citizens need to be actively involved in efforts to sway legislators to prevent this from happening. Thus far, most legal challenges to the law have not been successful.

One of the arguments against the legislation is the cost of its implementation. According to the Congressional Budget Office (CBO, 2010b), as much as $50 billion may be involved in imple- mentation. Much of this funding is not included in the law it- self, but would require additional congressional appropriations for functions added to existing federal agencies and grants and other program funding required under the legislation. There would also be costs associated with Internal Revenue Service ac- tivities in verifying premium and cost-sharing credits included in income tax deductions and the increased eligibility under Medicare, Medicaid, and CHIP programs. On the other hand, it is also estimated that the direct spending and revenue effects at the federal level would result in a reduction of federal deficits of $118 billion from 2010 to 2019. During that time, federal finan- cial commitment for health care would be expected to increase by about $210, but this increase would be offset by provisions of the law that would generate revenue and decrease the costs of providing health care through greater efficiency. Costs for state and local governments related to health care funding are ex- pected to increase substantially, but overall the implementation of the law would reduce the number of uninsured non-elderly people in the United States by more than half (CBO, 2010a).

Health Care reform and Population Health The Patient Protection and Affordable Care Act also includes a variety of provisions that will influence the health of the over- all population beyond the effects of providing access to care

Global Perspectives

Select three other countries and explore how health care services are funded in those countries. How does health care funding differ from that in the United States? What are the advantages and disadvantages of these other approaches to funding health care delivery? What effects do they have on population health status? What effects, if any, do they have on the role of the population health nurse?

Health Care Funding in Other Countries

M06_MARY9591_06_SE_C06.indd 162 06/09/14 6:38 PM

chaPter 6 economic influences on Population health 163

through health insurance. Significant attention is given in the law to coverage of preventive health services and elimination of cost-sharing requirements for health promotion and illness prevention services (Kaiser Family Foundation, 2013). Some of the specific preventive services for adults, women, and children addressed in the law include screenings (e.g., for abdominal aortic aneurysm, alcohol misuse, blood pressure, depression, and mammography, among others), immunizations for adults and children, tobacco counseling and cessation assistance, and other counseling services (e.g., diet, sexually transmitted in- fection prevention) (USDHHS, n.d.b). Specific provisions in- clude restriction of federal coverage to preventive services with significant levels of evidence of their effectiveness, removal of barriers to preventive services under Medicare and Medicaid (particularly for adults), initiation of annual wellness visits and personalized prevention plans for Medicare beneficiaries, and incentives to states to initiate activities among Medicaid re- cipients to change lifestyle behaviors to prevent chronic illness (Trust for America’s Health, n.d.).

HR 3590 also created the National Prevention, Health Promotion and Public Health Council to coordinate federal efforts related to prevention, wellness and health promotion,

and public and integrative health systems. The council is also charged with creating a national strategy with goals and objec- tives to improve health through federally supported prevention and promotion programs. In addition, the legislation estab- lished a Prevention and Public Health Fund to support preven- tion and public health initiatives, including research, screening, and intervention activities (Trust for America’s Health, n.d.).

HR 3590 also directs the Secretary of Health and Human Services to support planning and implementation of a public– private partnership and media campaign to promote public awareness and education related to health promotion and pre- vention. Other provisions support school-based health centers and community transformation grants for community initia- tives to prevent chronic disease and sequellae, address health disparities, and develop a stronger evidence base for preven- tive activities; and grants to develop and evaluate promotion and prevention programs for Medicare beneficiaries (Trust for America’s Health, n.d.). Population health nurses can ac- quaint communities with the opportunities for funding of health promotion and prevention programs and assist them in writing grant proposals and implementing and evaluating such programs.

Economic conditions have both direct and indirect effects on the population’s health. Direct effects stem from funding allo- cated to health care services. Indirect effects reflect the ability of members of the population to obtain the resources needed for good health (e.g., appropriate housing, good nutrition) as well as their ability to afford health care services.

The cost of providing health care services in the United States has increased dramatically in the last few decades without an appreciable increase in the population’s health status. Some of the factors involved in this increase include an aging popu- lation, greater use of technology, emphasis on costly specialty care, costs of care for the uninsured, and the labor-intensive nature of health care delivery. Failure to engage in health pro- motion and illness prevention activities has also increased the costs of health care when problems occur.

Funding for health care services in the United States derives from several sources. These include personal payment, commer- cial health insurance, government services and government- funded insurance programs, and charity care. Approaches to reimbursement for health care services include retrospective payment, prospective payment, and pay-for-performance. Pop- ulation health nurses need to be conversant with health services funding mechanisms to assist clients to obtain needed services. They can also campaign for allocation of sufficient funding for health care, particularly to cover the uninsured elements of the population, and develop and test cost-effective interventions to meet population health needs.

CHAPTEr rECAP

You have been appointed to the mayor’s task force on health care in the midsize community in which you work as a population health nurse. The assessment of population

health and economic status conducted by the task force in- dicates that most of the population’s health care needs are adequately met at all levels of health care. The exception to

CASE STudy Financing Care for the underserved

M06_MARY9591_06_SE_C06.indd 163 06/09/14 6:38 PM

164 Unit 2 influences on Population health

this, however, is the population of the migrant farm camp at the edge of town.

This group consists primarily of male Mexican workers who have entered the United States on legal work visas. Very few of the workers have brought their families with them. Most of this population receives no health care except for treatment in the emergency room of the community hospital. Usually, this care is provided for work-related injuries or serious illness. Members of this group receive no health promotion or preventive care and do not seek care for minor illnesses because of their inability to pay.

Because most of these people are in the United States legally, they would be eligible for county medical assistance (CMA); however, very few have applied for this program because of lan- guage barriers, lack of transportation to the social services of- fice, and inability to afford to take the time off work to submit an application. Even if they did receive assistance, they would be unlikely to find a regular health care provider who has a contract with the county to provide services under CMA reim- bursement. Only one community clinic and one independent nurse practitioner, in addition to the community hospital, have county contracts. Local physicians receive adequate income

from private paying clients and those with private health insur- ance. Because of the extended time between provision of ser- vices and receipt of reimbursement, these physicians no longer accept county assistance clients.

The rest of the population is well off when compared with average state and national incomes. With the exception of the migrant workers, most residents are employed by three large in- dustries and receive salaries that are quite adequate to meet the cost of living. Because of the industry present in the community, the local tax base is more than adequate. The community does not budget any public funds for health care as the majority of the population is adequately served by private providers. There is no local health department, but the county offers public health services in a town 50 miles away. 1. What factors are influencing the health status of the migrant

group? 2. How would you finance health care for this population group? 3. Would fee-for-service care or managed care arrangements

be more appropriate for providing care to the migrant population? Why?

Alliance for Health Reform. (2010a). Designing a marketplace that works: Steps to affordable coverage. Retrieved November 10, 2010, from http://www. allhealth.org/briefing_detail.asp?bi=197

Alliance for Health Reform. (2010b). The future of children’s health coverage. Retrieved November 10, 2010, from http://www.allhealth.org/publications /Child_health_insurance/The_Future_of_Childrens_Health_Coverage_98 .pdf

Alliance for Health Reform. (2010c). Implementing health reform: federal rules and state roles. Retrieved November 10, 2010, from http://www.allhealth. org/publications/State_health_issues/Implementing_Health_Reform_-_ Federal_Rules_and_State_Roles_100.pdf

American Hospital Association. (2014). Uncompensated hospital care cost fact sheet. Retrieved from http://www.aha.org/content/14/14uncompensatedcare .pdf

Better Business Bureau. (2003). Standards for charity accountability. Retrieved November 10, 2010, from http://www.bbb.org/us/Charity-Standards

Blackwood, A., Roeger, K. L., & Pettijohn, S. L. (2012) The nonprofit sector in brief. Retrieved from http://www.urban.org/UploadedPDF/412674- The- Nonprofit-Sector-in-Brief.pdf

Blewett, L. A., Spencer, D., & Burke, C. E. (2011). State high-risk pools: An update on the Minnesota Comprehensive Health Association. american Journal of Public Health, 101, 231–237. doi:10.2105/AJPH.2009.185975

Boone-Heinonen, J., Diex Roux, A. V., Kiefe, C. I., Lewis, C. E., Guilkey, D. K., & Gordon-Larsen, P. (2011). Neighborhood socioeconomic status predictors of physical activity through young to middle adulthood: The CARDIA study. Social Science & Medicine, 72, 641–649. doi:10.1016 /josocscimed.2010.12.013

Carson, V., Spence, J. C., Cutumisu, N., & Cargill, L. (2010). Association between neighborhood socioeconomic status and screen time among

pre-school children: A cross-sectional study. BMJ Public Health, 10. Retrieved from http://www.biomedcentral.com/1471-2458/10/367.

Centers for Medicare and Medicaid Services. (2011). Data compendium. Retrieved from http://www.cms.gov/Research-Statistics-Data-and- Systems/Statistics-Trends-and-Reports/DataCompendium/2011_Data_ Compendium.html

Centers for Medicare and Medicaid Services. (2012a). 2013 poverty guidelines. Retrieved from http://www.medicaid.gov/Medicaid-CHIP-Program- Information/By-Topics/Eligibility/Downloads/2013- Federal-Poverty-level- charts.pdf

Centers for Medicare and Medicaid Services. (2012b). Hospital-acquired conditions (HaCs) in acute inpatient prospective payment system (IPPS) hospitals . Retrieved from http://www.cms.gov/Medicare/ Medicare-Fee-for- Service-Payment/HospitalAcqCond/Downloads/ HACFactsheet.pdf

Centers for Medicare and Medicaid Services. (2012c). Medicare part B. Retrieved from http://www.cms.gov/Medicare/Medicare-General- Information/MedicareGenInfo/Part-B.html

Centers for Medicare and Medicaid Services. (2013a). Bridging the coverage gap. Retrieved from http://www.cms.gov/Medicare/Prescription-Drug- Coverage/PrescriptionDrugCovGenIn/bridgingthegap.html

Centers for Medicare and Medicaid Services. (2013b). CMS announces major savings for Medicare beneficiaries. Retrieved from http://www.cms.gov /Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases- Items/2013-10-28.html

Centers for Medicare and Medicaid Services. (2013c). Medicare and Medicaid research review/ 2013 statistical supplement. Retrieved from http://www .cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and- Reports/MedicareMedicaidStatSupp/Downloads/2013_Section1.pdf

rEFErENCES

M06_MARY9591_06_SE_C06.indd 164 06/09/14 6:38 PM

chaPter 6 economic influences on Population health 165

Centers for Medicare and Medicaid Services. (2013d). Medicare part a. Retrieved from http://www.cms.gov/Medicare/Medicare-General- Information/MedicareGenInfo/Part-A.html

Centers for Medicare and Medicaid Services. (2013e). Medicare Program - General Information. Retrieved from http://www.cms.gov/Medicare /Medicare-General-Information/MedicareGenInfo/index.html?redirect= /MedicareGenInfo

Centers for Medicare & Medicaid Services. (2013f ). Prospective payment systems—General information. Retrieved from http://www.cms.gov/ Medicare /Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/index .html?redirect=/ProspMedicareFeeSvcPmtGen

Centers for Medicare and Medicaid Services. (2014a). National Correct Coding Initiative edits. Retrieved from http://www.cms.gov/Medicare/Coding /NationalCorrectCodInitEd/index.html

Centers for Medicare and Medicaid Services. (2014b). National health expenditure projections 2012–2022. Retrieved from http://www.cms.gov/ Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ NationalHealthExpendData/Downloads/Proj2012.pdf

Centers for Medicare and Medicaid Services. (2014c). National health expenditures 2012 highlights. Retrieved from https://www.cms.gov/ Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ NationalHealthExpendData/Downloads/highlights.pdf

Chien, A. T., Li, Z., & Rosenthal, M. B. (2010). Improving timely childhood immunizations through pay for performance in medicaid-managed care. Health Services Research, 45, 1934–1945. doi:10.1111/j.1475-6773.2010.01168.x

CHIP Statistical Enrollment Data System. (2011). CHIP ever enrolled in year. Retrieved from http://www.medicaid.gov/Medicaid-CHIP-Program- Information/By-Topics/Childrens-Health-Insurance-Program-CHIP/ Downloads/CHIPEverEnrolledYearGraph.pdf

Claxton, G., DiJulio, B., Finder, B., Lundy, J., McHugh, M., Osel-Anto, A., …, Gabel, J. (2010). Employee health benefits: 2010 annual survey. Retrieved January 5, 2011, from http://ehbs.kff.org/pdf/2010/8085.pdf

Clemans-Cope, L., Garrett, B., & Buettgens, M. (2010). Health care spending under reform: Less uncompensated care and lower costs to small employers. Retrieved November 15, 2010, from http://www.urban.org/ uploadedpdf/412016_health_care_spending.pdf

Congressional Budget Office. (2010a). HR 3590, patient protection and affordable Care act: Cost estimate for the bill as passed on December 24, 2009. Retrieved from http://www.cbo.gov/ftpdocs/113xx/doc11307/Reid_ Letter_HR3590.pdf

Congressional Budget Office. (2010b). Potential effects of the patient protection and affordable Care act on discretionary spending. Retrieved from http:// www.cbo.gov/ftpdocs/113xx/doc11307/Specified_Authorizations_HR3590. pdf

Cubanski, J., Huang, J., Damico, A., Jacobson, G., & Neuman, T. (2010). Medicare chartbook (4th ed.). Menlo Park, CA: Henry J. Kaiser Family Foundation.

Davis, K. E. (2011). Co-pays, deductibles, and coinsurance percentages for employer-sponsored health insurance in the private sector, by industry classification, 2009. Retrieved from http://meps.ahrq.gov/mepsweb/data_ files/publications/st323/stat323.pdf

DeNavas-Walt, C., Proctor, B. D., & Smith, J. C. (2012). Income, poverty, and health insurance coverage in the United States: 2011. Retrieved November 15, 2010, from http://www.census.gov/prod/2012pubs/p60-243.pdf

Devolution. (2011). Encyclopædia Britannica. Retrieved from http://www. britannica.com/EBchecked/topic/155042/devolution

Dittmann, J., & Goebel, J. (2010). Your house, your car, your education: The socioeconomic situation of the neighborhood and its impact on life satisfaction in Germany. Social Indicators Research, 96, 497–513. doi:10.1007/s11205-009-9489-7

Dunn, L., & Becker, S. (2013). 50 things to know about the hospital industry. Retrieved from http://www.beckershospitalreview.com/hospital- management-administration/50-things-to-know-about-the-hospital- industry.html

Everson-Rose, S. A., Sharupski, K. A., Barnes, L. L., Beck, T., Evans, D. A., & Mendes de Leon, C. F. (2011). Neighborhood socioeconomic conditions are associated with psychosocial functioning in older people. Health & Place, 17, 793–800. doi:10.1016/j.healthplace.2011.02.007

Families USA. (2010). Implementing health insurance exchanges: a guide to state activities and choices. Retrieved from http://familiesusa.org/sites/default/ files/product_documents/Guide-to-Exchanges.pdf

Federal Trade Commission. (2012). Before giving to charity. Retrieved from http://www.consumer.ftc.gov/articles/0074-giving-charity

Foraker, R. E., Rose, K. M., Kucharska-Newton, A. M., Ni, H., Suchindran, C. M., & Whitsel, E. A. (2011). Variation in rates of fatal coronary heart disease by neighborhood socioeconomic status: The atherosclerosis risk in communities surveillance. annals of Epidemiology, 21, 580–588.

Fox, J. B., & Richards, C. L. (2010). Vital signs: Health insurance coverage and health care utilization—United States, 2006–2009 and January–March 2010. Morbidity and Mortality Weekly Report, 59, 1448–1454.

Fronstin, P., & Adams, N. (2012). Employment-based retiree health benefits: Trends in access and coverage, 1997–2010. Retrieved from http://www.ebri .org/pdf/briefspdf/EBRI_IB_10-2012_No377_RetHlth.pdf

Gary-Webb, T. L., Baptiste-Roberts, K., Pham, L., Wesche-Thobaben, J., Patricio, J., Pi-Sunyer, F. X., …, Look AHEAD Research Group. (2011). Neighborhood socioeconomic status, depression, and health status in the Look AHEAD (Action for Health in Diabetes) study. BMJ Public Health, 11, 349. Retrieved from http://www.biomedcentral.com/1471-2458/11/349

Gerber, Y., Myers, V., Goldbourt, U., Benyamini, Y., & Drory, Y. (2011). Neighborhood socioeconomic status and leisure time physical activity after myocardial infarction: A longitudinal study. american Journal of Preventive Medicine, 3, 266–273. doi:10.1016/j.amepre.2011.05.016

Goldsteen, R. L., & Goldsteen, K. (2012). Introduction to the U.S. health care system (7th ed.). New York, NY: Springer.

Gulley, S. P., Rasch, E. K., & Chan, L. (2011). Ongoing coverage for ongoing care: Access, utilization, and out-of-pocket spending among uninsured working-aged adults with chronic health needs. american Journal of Public Health, 101, 368–375. doi:10.2105/AJPH.2010.191569

Healthcare.gov. (n.d.a). Health plan categories. Retrieved from https://www. healthcare.gov/glossary/health-plan-categories/

Healy D., & Cromwell, J. (2012). Hospital-acquired conditions - Present on admission: Examination of spillover events and unintended consequences. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/HospitalAcqCond/Downloads/HAC-SpilloverEffects.pdf

Howell, E., Decker, S., Hogan, S., Yemane, A., & Foster, J. (2010). Declining child mortality and continuing racial disparities in the era of Medicaid and SCHIP insurance coverage expansions.american Journal of Public Health, 100, 2500–2506.`doi:10.2105/AJPH.2009.184622

Institute of Medicine. (2001). Crossing the quality chasm. Washington, DC: National Academies Press.

Institute of Medicine. (2003). Hidden costs, value lost: Uninsurance in america. Washington, DC: National Academies Press.

Kaiser Commission on Medicaid and the Uninsured. (2012a). five facts about the uninsured. Retrieved November 15, 2010, from http:// kaiserfamilyfoundation.files.wordpress.com/2013/01/7806-05.pdf

Kaiser Commission on Medicaid and the Uninsured. (2012b). The uninsured and the difference health insurance makes. from http://www.kff.org/ uninsured/upload/1420-12.pdf

M06_MARY9591_06_SE_C06.indd 165 06/09/14 6:38 PM

166 Unit 2 influences on Population health

Kaiser Family Foundation. (2011). Retail prescription drugs filled at pharmacies (annual per capita by age). Retrieved from http://kff.org/other/ state-indicator/retail-rx-drugs-by-age/

Kaiser Family Foundation. (2013). Summary of new health reform law. Retrieved from http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021. pdf

Kaiser Family Foundation and Health Research & Educational Trust. (2013). Employer health benefits: 2013 summary of findings. Retrieved from http://kaiserfamilyfoundation.files.wordpress.com/2013/08/8466- employer-health-benefits-2013_summary-of-findings2.pdf

Lang, I., Hubbard, R. E., Andrew, M. K., Llewellyn, D. J., Melzer, D., & Rockwood, K. (2009). Neighborhood deprivation, individual socioeconomic status, and frailty in older adults. Journal of the american Geriatrics Society, 57, 1776–1780. doi:10.1111/j.1532-5415.2009.02480.x

Lowes, R. (2010). Individual mandate in health care reform law ruled unconstitutional by federal judge. Retrieved from www.medscape.com/ viewarticle/734110?src=nl_newsalert

Managed Care On-line. (2011). Managed care fact sheets: National statistics. Retrieved January 5, 2011, from http://www.mcareol.com/factshts/factnati. htm

McDonald, R. (2012). for uninsured in Ore.: a f lat rate for health care . Retrieved from http://www.npr.org/2012/06/11/154738940 /for-uninsured-in-ore-a-flat-fee-for-health-care

Medicaid.gov. (n.d.a). Children’s Health Insurance Program. Retrieved from http://www.medicaid.gov/CHIP/CHIP-Program-Information.html

Medicaid.gov. (n.d.b). Medicaid by population. Retrieved from http://www .medicaid.gov/Medicaid-CHIP-Program-Information/By-Population /By-Population.html

Medicaid.gov. (n.d.c). Provider preventable conditions. Retrieved from http:// www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics /Financing-and-Reimbursement/Provider-Preventable-Conditions.html

Medicaid.gov. (2014). Eligibility. Retrieved from http://www.medicaid.gov/ Medicaid-CHIP-Program-Information/By-Topics/Eligibility/Eligibility.html

Medicare.gov. (n.d.a). Costs for Medicare drug coverage. Retrieved from https:// www.medicare.gov/part-d/costs/part-d-costs.html

Medicare.gov. (n.d.b). Medicare advantage plans. Retrieved from https://www .healthcare.gov/glossary/health-plan-categories/

Medicare.gov. (n.d.c). Medicare special needs plans. Retrieved from http://www .medicare.gov/sign-up-change-plans/medicare-health-plans/medicare- advantage-plans/special-needs-plans.html

Murakami, K., Sasaki, S., Takahashi, Y., & Uenishi, K. (2010). Neighborhood socioeconomic status in relation to dietary intake and insulin resistance syndrome in female Japanese dietetic students. Nutrition, 26, 508–414. doi:10.1016/j.nut.2009.08.025

National Center for Charitable Statistics. (20n.d.). Key data concepts. Retrieved November 15, 2010, from http://nccs.urban.org/database/concepts.cfm

National Center for Health Statistics. (2010). Delayed or forgone medical care because of cost concerns among adults aged 18–64 years, Y disability and health insurance coverage status—National Health Interview Survey, United States, 2009. Morbidity and Mortality Weekly Report, 59, 1456.

National Center for Health Statistics. (2011). Reasons for no health insurance coverage among uninsured persons aged <65 years—National Health Interview Survey (NHIS), United States, 2009. Morbidity and Mortality Weekly Report, 60, 19.

National Center for Health Statistics. (2013). Health, United States, 2013: With Special feature on Emergency Care. Retrieved from www.cdc.gov/nchs /data/hus/hus12.pdf

National Quality Forum. (2006). Serious reportable events (SREs): Transparency, accountability critical to reducing medical errors and harm. Retrieved from http://www.qualityforum.org/projects/sre2006.aspx

Nicklett, E. J., Szanton, S., Sun, K., Ferrucci, L., Fried, L. P., Guralnik, J. M., & Semba, R. D. (2010). Neighborhood socioeconomic status is associated with serum carotenoid concentrations in older, community-dwelling women. Journal of Nutrition, 141, 284–289. doi:10.3945/jn.110.129684

Office of the Assistant Secretary of Defense. (n.d.). TRICaRE overview. Retrieved from http://ra.defense.gov/benefits/tricare/overview.html

Physicians Care Health Plans. (n.d.a). advantages of self-funding. Retrieved January 6, 2011, from http://www.physicianscare.com/content/public/ default.aspx?d=327

Physicians Care Health Plans. (n.d.b). Is self-funding or fully insured right for your company? Retrieved January 6, 2011, from http://www.physicianscare. com/content/public/default.aspx?d=330

Social Security Administration. (2010). Medicare. Retrieved August 7, 2010, from http://www.socialsecurity.gov/pubs/10043.html

Sultz, H. A., & Young, K. M. (2010). Health care USa: Understanding its organization and delivery (7th ed.). Sudbury, MA: Jones and Bartlett.

Trust for America’s Health. (n.d). Patient protection and affordable care act (HR 3590): Selected prevention, public health & workforce provisions. Retrieved from http://healthyamericans.org/assets/files/Summary.pdf

U.S. Bureau of Labor Statistics. (2013a). Consumer price index: frequently asked questions (faQs). Retrieved from http://www.bls.gov/cpi/cpifaq .htm#Question_1

U.S. Bureau of Labor Statistics. (2013b). National Compensation Survey: Employee benefits in the United States, March 2013. Retrieved from http:// www.bls.gov/ncs/ebs/benefits/

U.S. Census Bureau. (2013). Statistical abstract of the United States, 2012. Retrieved from http://www.census.gov/compendia/statab/

U.S. Department of Health and Human Services. (n.d.a). about the law. Retrieved from http://www.hhs.gov/healthcare/rights/index.html

U.S. Department of Health and Human Services. (n.d.b). Prevention and wellness. Retrieved from http://www.hhs.gov/healthcare/prevention/index .html

U.S. Department of Health and Human Services. (2010). Disparities. Retrieved from http://www.healthypeople.gov/2020/about/DisparitiesAbout.aspx

U.S. Department of Health and Human Services. (2013a). access to health services: Objectives. Retrieved from http://www.healthypeople.gov/2020 /topicsobjectives2020/objectiveslist.aspx?opicId=1

U.S. Department of Health and Human Services. (2013b). access to health services: Overview. Retrieved from http://www.healthypeople.gov/2020 /topicsobjectives2020/overview.aspx?opicid=1

U.S. Department of Labor. (n.d.). Health plans and benefits: Continuation of health coverage – COBRa. Retrieved from http://www.dol.gov/dol/topic /health-plans/cobra.htm

U.S. Office of Personnel Management. (n.d.). federal Employees Health Benefits Program. Retrieved from http://www.opm.gov/healthcare-insurance /healthcare/

Vladek, B. (2003). Universal health insurance in the United States: Reflections on the past, the present, and the future. american Journal of Public Health, 93, 16–19.

Zarzaur, B. L., Croce, M. A., Fabian, T. C., Fischer, P., & Magnotti, L. J. (2010). Population-based analysis of neighborhood socioeconomic status and injury admission rates and in-hospital mortality. Journal of the american College of Surgeons, 211, 216–223. doi:10.1016/j. jamcollsurg.2010.03.036

M06_MARY9591_06_SE_C06.indd 166 06/09/14 6:38 PM

chaPter

complementary/alternative health care subsystem

health care system

local public health system

official health agencies

pass-through funds

personal health care sector

popular health care subsystem

population health care sector

public health practice

public health system

scientific health care subsystem

state public health system

voluntary health agencies

Key Terms

Learning Outcomes

After reading this chapter, you should be able to:

1. Describe the components of the U.S. health care system.

2. Describe the organizational structure of the U.S. health care delivery system.

3. Compare and contrast official and voluntary health agencies.

4. Describe at least five functions performed by voluntary health agencies.

5. Discuss the involvement of local, state, and national governments in health care in the United States.

6. Compare selected features of national health care systems.

Health System Influences on Population Health7

M07_MARY9591_06_SE_C07.indd 167 06/09/14 6:38 PM

168

Nursing and Health System Reform

On February 22, 2010, a letter was sent to President Barack Obama and leaders in the U.S. Senate and House of Representatives presenting the nursing profession’s perspectives on the proposed health care reform legislation, which eventually became the Patient Protection and Affordable Care Act. The letter was drafted by a coalition of 47 national nursing organizations called the Nursing Community and addressed multiple provisions of the proposed bill. Specifically, the letter sup- ported provisions to expand the nursing workforce, nurse-managed health clinics, and primary care, prevention, health promotion, and emergency services. In addition, support was voiced for provisions to improve patient outcomes and reduce hospitalizations while reducing the costs of care, improving care coordination, increasing nursing home visitation programs, and incorporat- ing best practices and evidence-based care into health care delivery systems, as well as provisions related to reimbursement for advanced practice nursing services.

The letter also addressed provisions of the bill requiring modification. These included inclusion of nurse midwives and nurse anesthetists in pay-for-performance plans along with nurse practitio- ners and clinical nurse specialists, equal representation from health disciplines on the National

A d

vo ca

cy N

ow

Lemuel Shattuck and Public Health Organization

Although not a health professional, Lemuel Shattuck was known as a public health advocate. Fol- lowing his career as an educator and merchant at age 46, he devoted the remainder of his life to improving public health. Shattuck was convinced of the need for the accurate collections of vital statistics as a means of monitoring the health of the public and was instrumental in the passage of the Massachusetts Registration Act (Koslow, 2011). In addition, Shattuck recommended a decen- nial federal census (Lemuel Shattuck Biography (1739–1859), 2011).

Shattuck conducted a census of the city of Boston in 1845 and was shocked by the mortality figures collected, particularly with respect to maternal and infant mortality (Lemuel Shattuck (1793– 1789): Prophet of American Public Health, 1959). As a member of the Massachusetts legislature, he instigated the appointment of a state commission chaired by himself to investigate the sanitary conditions of the state. The commission’s report, published in 1850, made broad recommendations for measures to improve the public’s health. The members of the committee drafted sweeping legisla- tion that addressed such issues as creation of state and local boards of health, sanitary laws, health promotion and illness prevention, immunization, sanitation and nuisance control, school health, food and medication safety, and communicable disease control. At the end of the report, the commission provided a series of reasons for approving the recommended plan of action as follows:

•  Because it is a practical measure •  Because it is a useful measure •  Because it is an economical measure •  Because it is a philanthropic and charitable measure •  Because it is a moral measure •  Because the progress of the age demands it •  Because it involves an important duty (Shattuck, 1850) Although the commission’s legislative proposal was not passed, the vision for the organization

of public health care services outlined in the report served as the foundation for the later develop- ment of boards of health in Massachusetts and throughout the country (London School of Hygiene and Tropical Medicine, 2010).

A d

vo ca

cy T

h en

M07_MARY9591_06_SE_C07.indd 168 06/09/14 6:38 PM

169

Health Care Workforce Commission, and inclusion of nurse-sensitive quality and performance indi- cators in evaluation research.

Throughout the letter, the writers highlighted facts and figures that supported their positions. Given nursing’s often-divisive approach to change, the ability to develop a common voice with respect to health care reform legislation was a major accomplishment and one that advocated for both the status of the profession and the needs of the American public.

Population health nursing occurs in the context of a health care delivery system that creates constraints and provides opportunities for practice. For ex-ample, the lack of emphasis on health promotion in the health care delivery system increases the need for health promotion efforts by population health nurses but simultane- ously limits funds available for health promotion activities. In order to function effectively within the system and to achieve improvements in the public’s health, population health nurses must understand how the health care delivery system is orga- nized, how it works, and how it influences population health nursing practice and the public’s health status.

Exploring the organization of health care delivery systems can help us to understand how these systems developed, how they work, and how and why they sometimes fail to work. Moreover, we can identify factors that positively or negatively influence population health nursing practice. Finally, we can identify areas where change is needed in the health care deliv- ery system to best fulfill our goal as population health nurses, namely, the promotion of the public’s health. We will look first at the U.S. health care system and then make some com- parisons with the systems of other developed and developing nations.

The U.S. Health Care System Sometimes referred to as a “nonsystem,” the health care deliv- ery system in the United States is a mixture of multiple sources of care at multiple levels. Each source and level is affected by a variety of external forces.

Forces Influencing the Health Care System Health system observers have identified several forces that in- fluence the organization and effectiveness of the U.S. health care system. Some of these factors include changing popula- tion demographics, growing numbers of uninsured residents, increasing demands for accountability, technological advances and innovation, professional labor issues, economic global- ization, changes in delivery systems, and information man- agement issues (Sultz & Young, 2014). The population in the United States, as in every other nation, is growing older, and older people tend to be the greatest users of health care services due to the prevalence of chronic disease in this population. In

addition, the U.S. population is changing in terms of the ethnic groups represented; necessitating changes in health care deliv- ery systems to accommodate clients from multiple cultures.

At the same time, there is a growing number of uninsured and underinsured individuals in the population, particularly among members of ethnic and cultural minority groups. In Chapters 6 and 21 , we have and will examine some of the factors leading to this growth, but the very existence of a large population of uninsured individuals results in unmet needs in the health care system as it currently exists. From 1994 to 2007, the number of uninsured people in the United States increased from 15.8% of the non-elderly population to 17.1%, and an es- timated 45 million people had no health insurance coverage in 2008 (Cover the Uninsured, 2009). The Affordable Care Act passed in 2010 was designed to provide insurance coverage for non-elderly persons with incomes below 133% of the federal poverty level (Kaiser Family Foundation, 2010); the legislation appears to have had a positive effect on the number of unin- sured. For example, the percentage of people without health insurance had declined to 15.4% by 2012 (U.S. Census Bureau, 2013). Projections indicate that by 2019 the Act will result in decreases in the rate of uninsured persons to less than 14% in all but one state, with a large number of states’ rates reduced below 8% (Commonwealth Fund, 2011).

Lack of health insurance is equivalent to lack of access to health care services for many people. In addition to the loss of health of individuals, lack of access to care poses significant costs to society. These costs lie in the loss of productive citi- zens through early death and disability as well as higher health care costs due to increasingly serious diseases that could have been treated at lower cost early in their course. Access to health care through affordable health insurance is perhaps the most important focus for advocacy to promote population health in the United States.

Another influence on health care systems is increasing public demand for accountability for both the quality of care provided and the use of resources to provide that care. Initia- tives to assure standards of quality and limit the escalating costs of health care services have profoundly affected how health care is delivered. These and other economic influences on the health care system are addressed in more detail in Chapter 6 . Tech- nological advances significantly influence the cost of health care and greatly affect health care delivery systems. Furthermore, the

M07_MARY9591_06_SE_C07.indd 169 06/09/14 6:38 PM

170 Unit 2 influences on Population health

widespread availability of high-tech information sources, such as the Internet, allows the U.S. public to be better informed of technological advances in care and encourages them to demand costly, high-tech services.

The primary professional labor issue facing health care de- livery systems is the shortage of health care personnel, particu- larly nurses. With many other occupational choices available to potential recruits, health care systems have had to make many changes to attract young people to health care occupations and to specific practice locales (e.g., rural or inner-city areas). A sec- ond issue related to the professional workforce is the increasing need for advanced education for effective practice. The cost of educating providers and the need to provide the technol- ogy required to support the level of practice for which they are educated further increase the cost of health care services. In ad- dition, health care systems are facing a need to change the ways they do business in order to attract providers (e.g., more flex- ible schedules, opportunities for job sharing, etc.).

Chapter 8 will address the effects of globalization on health and health care delivery. As we will see, the effects of globaliza- tion on health and health care delivery are both positive and negative. Changes in the organization of health care delivery systems also affect the operation and overall effectiveness of the U.S. health care system. For example, mergers of several in- stitutions into large, for-profit organizations and competition among systems have a definite impact on health care delivery. Finally, changes in information management systems have led to changes in the completeness, accuracy, and transferability of in- formation within and among health care organizations (Sultz & Young, 2014). For the most part this influence has been posi- tive, leading to faster access to client care information, but it also raises issues of privacy and confidentiality.

All of these forces, as well as others that will be addressed elsewhere in this book (e.g., political activity and threats of ter- rorism), have contributed to the U.S. health care system as it presently exists and as it continues to evolve. Exploration of the health care system within the context of these forces can help us develop strategies to guide that evolution to greater effectiveness.

Components of the U.S. Health Care System The World Health Organization (WHO, 2014) has defined a health care system as the network of personnel, agencies and organizations, and resources designed to promote, maintain, and restore the health of the population. No two health systems are alike, but many national health care systems share a num- ber of commonalities. The major exception to this perception of commonality is the United States, which is the only developed nation in the world without a comprehensive approach to fund- ing or providing health care services (Goldsteen & Goldsteen, 2012). Health care delivery in the United States has been de- scribed as an “unsystematic system” (Budrys, 2012) because of its multicentric and uncoordinated nature. Despite the relative accuracy of this description, we can still examine U.S. health care delivery in terms of the structure depicted in Figure 7-1•.

The organizational structure for health care delivery in the United States consists of three major elements or subsystems, depicted in Figure 7-1. These subsystems include the popular health care subsystem, the complementary or alternative health care subsystem, and the scientific health care subsystem.

THe POPULAR HeALTH CARe SUbSySTem. Most health-related care is provided within the popular health care subsystem. The popular health care subsystem is the component of the health care system in which care is provided by oneself, family members, or friends, in short by people who are not considered health care providers. It is estimated that 70% to 90% of illness care is provided within this system. The popular subsystem includes health care that each of us provides for ourselves and our families. When you have a headache, for example, you may take an over-the-counter analgesic. If you are constipated, you may either increase the bulk, fiber, and fluid in your diet or take a laxative. If your child has a mild fever, you might give him or her an antipyretic. All of these self-care or family care practices constitute popular subsystem health care.

Although health care in this subsystem is provided by one- self or by family members, population health nurses have an educational role in the popular subsystem. As we shall see in Chapter 9 , one of the purposes of health education is to pre- pare clients to make informed self-care decisions. For example, a population health nurse might caution a client against overuse of laxatives and suggest dietary approaches to dealing with constipa- tion, or the nurse may inform parents about the hazards of giving aspirin to children and recommend a nonaspirin substitute.

THe COmPLemeNTARy/ALTeRNATIve HeALTH CARe SUbSySTem. When self-care fails or seems in appropriate, people often turn to other sources of health care. Some of these

Figure 7-1 Organizational Structure of the u.S. Health Care Delivery System

Alternative/ complementary

health care subsystem

Popular health care subsystem

Scienti c health care subsystem

M07_MARY9591_06_SE_C07.indd 170 06/09/14 6:38 PM

chaPter 7 health System influences on Population health 171

sources might be folk health practitioners. The complementary/ alternative health care subsystem consists of providers and practices outside the scientific health care subsystem that are specifically focused on promotion of health and prevention of and care for illness. The terms complementary and alternative are often used interchangeably when discussing this subsystem, but actually differ in terms of their relationship to the scientific subsystem. Complementary health care practices are those that are used in conjunction with scientific care to complement and enhance its effects. Alternative practices, on the other hand, are used in place of, or as alternatives to, scientific interventions. Any given health practice may be considered complementary or alternative depending on its use in relation to scientific subsystem practices.

Practitioners in this subsystem are individuals who are believed to have special health-related knowledge or training beyond that of the average member of the society. Examples of alternative/complementary health care providers are the curanderas found among Latinos in the northeastern and southwestern regions of the United States and the herbalists found in these and other areas. The role of the population health nurse in the complementary/alternative health care subsystem is to assess the influence of this subsystem on health and to incorporate traditional health practices into the plan of care as appropriate. On occasion, the nurse may also need to caution clients against specific alternative practices that may be harmful to health (e.g., the use of traditional remedies that contain lead or other contaminants) or educate clients regard- ing the interactions between alternative and scientific thera- pies. The complementary/alternative health care subsystem was discussed in Chapter 5 .

THe SCIeNTIfIC HeALTH CARe SUbSySTem. The professional or scientific health care subsystem is the system of care based on scientific research–derived evidence. Health care provided in the scientific subsystem is based on knowledge derived from the biological, physical, and behavioral sciences and includes the services of nurses, physicians, pharmacists, social workers, and other health care professionals.

The scientific health care subsystem consists of two sectors that differ primarily in their focus of care. These sectors are the personal health care sector and the public, or population, health care sector.

The personal health care sector. The personal health care sector is the segment of the scientific health care subsystem that provides health-related services to individual clients. The primary emphasis in this sector is cure of disease and restoration of health, although individuals may also receive some health- promotive and illness-preventive services.

There are five major components to this sector of the health care system: health care institutions, personnel, health commodities firms, education/research institutions, and financing systems (Goldsteen & Goldsteen, 2012). The insti- tutional component consists of health provider office settings,

clinics, hospitals, nursing homes, and other places where care is dispensed to individual clients. The personnel component is composed of the professionals who provide services. Health commodities firms include industries that manufacture or sup- ply the materials and equipment required to implement health care services. Some examples of commodities firms include pharmaceutical companies and manufacturers of durable med- ical equipment or health-related computer software.

Both educational and research institutions are components of the personal health sector in that they educate health profes- sionals to provide individual client care services and conduct research related to therapeutic interventions and delivery sys- tems. The final component of the sector comprises the systems that finance care, which include insurers, philanthropic institu- tions, and government agencies.

Any given element of the sector may embody several of these components. For example, a university hospital may provide ser- vices, educate providers, and conduct research. As we saw in Chapter 6 , some health care organizations, such as managed care organizations (MCOs), also incorporate the financing element.

The personal health care sector may be further divided into for-profit and not-for-profit segments. In the for-profit seg- ment, health care services are provided with the intention of deriving monetary gain. Within this segment are the “propri- etary” service providers, such as physicians and health care institutions designed to create revenue, and corporations that provide health care to employees (and occasionally their fam- ilies) in order to limit the drain of health insurance costs on company revenue (Goldsteen & Goldsteen, 2012). Population health nurses’ primary relationship with the personal health care sector is linking clients to sources of health care and ad- vocating for the availability of personal health care services needed by members of the population. A few population health nurses, who also function in advanced practice nursing roles (e.g., nurse practitioner, clinical nurse specialist, etc.) may also provide direct services in the personal health care sector.

The population health care sector. The population health care sector consists of both public and private organizations whose focus is the health of the total population. This sector is also referred to as the public health system, which has been defined as “All public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction. These systems are a network of entities with differing roles, relationships, and interactions that contribute to the health and well-being of the community or state” (National Public Health Performance Standards Program [NPHPSP], n.d., p. 32).

Public health practice is defined as “the art and science of preventing disease, promoting population health and extend- ing life through organized local and global efforts” (McMichael & Beaglehole, 2009, p. 2). General goals for public health prac- tice include improving population health, reducing health in- equalities within the population, and developing environments that support health (McMichael & Beaglehole, 2009).

M07_MARY9591_06_SE_C07.indd 171 06/09/14 6:38 PM

172 Unit 2 influences on Population health

In a classic report on “The Future of the Public’s Health in the 21st Century,” the Institute of Medicine (IOM) (2003) identified six areas of action and change that must be under- taken to assure effective population health in the United States:

• Adopting a population health approach that considers the multiple determinants of health;

• Strengthening the governmental and public health infrastruc- ture, which forms the backbone of the public health system;

• Building a new generation of intersectoral partnerships that also draw on the perspectives and resources of diverse com- munities and actively engage them in health action;

• Developing systems of accountability to assure the quality and availability of public health services;

• Making evidence the foundation of decision making and the measure of success; and

• Enhancing and facilitating communication within the pub- lic health system (e.g., among all levels of the governmental public health infrastructure and between public health pro- fessionals and community members). (p. 4)

One segment of the IOM that focuses specifically on pop- ulation health is the Board on Population Health and Public Health Practice. This 16-member board focuses on issues af- fecting the public’s health from general public health principles to addressing specific population health issues. Recent activities of the board have ranged from examination of issues related to specific communicable diseases, to integration of public health and primary care activities, to action related to chronic disease, health literacy, and tobacco cessation (IOM, 2011).

A particularly salient recent activity of the board has been the constitution of a committee to develop public health strategies to improve health. The committee examined population health strategies in the context of the provisions of the Affordable Care Act (ACA) discussed in Chapter 6 and in more detail later in this chapter. A report by the committee noted that ACA con- tains a number of provisions that support population health, including an emphasis on health promotion and illness preven- tion and the requirement for hospitals receiving federal funding to conduct periodic community needs assessments and to de- velop plans to address identified needs. The committee noted, however, that in order to achieve the “Triple Aim” identified by the Institute for Healthcare Improvement (2014) (improved population health, enhanced patient experience of care, and reduced or controlled costs), the health care system needs to “move from a culture of sickness to a culture of care and then to a culture of health” (Alper, 2013, p. 17). There is a need to create a market for health, rather than a market for disease or care, by creating a payment system that rewards improvements in health, rather than treatment of disease. Strategies identified to enhance population health included:

• Public health collaboration with multiple stakeholders in addressing health

• Use of financial incentives to align provider and hospital interests with a health focus

• Creation of information systems to assess and monitor pop- ulation health, including development of metrics to measure progress

• Integration of a health focus into all areas of care • Developing an agreed-upon vision, culture, and goals • Community engagement in priority setting and action • Effective training for health professionals to integrate and

advocate for a health focus in care • Development of certification and licensing that supports

new population health roles • Creation of learning and improving environments (Alper,

2013)

Population health nurses will be actively involved in initiat- ing and implementing all of these strategies.

Care provided in the population health care sector has tradi- tionally centered on promoting health and preventing disease, although some curative care does occur in this sector. Empha- sis is on designing health care programs that meet the needs of population groups.

Official public health agencies. Official health agencies are agencies of local, state, and national governments that are responsible for the health of the people in their jurisdictions. Official agencies are supported by tax revenues and other public funding. They are accountable to the citizens of their jurisdiction, usually through an elected or appointed governing body. Many of the activities conducted by official agencies are mandated by law. For example, local health departments are required by state law to report cases of certain diseases. We will discuss specific functions of official agencies at local, state, and national levels in more detail later in this chapter. Generally speaking, however, official public health agencies are responsible for providing the ten essential public health services discussed in Chapter 1 .

Voluntary health agencies. Voluntary health agencies are nonprofit organizations that provide adjuncts to services provided by government agencies. These may include institutional and personal services that address the needs of special groups, education for public health, or prevention, screening, health maintenance, rehabilitation, or terminal care services (Sultz & Young, 2014). Voluntary agencies may focus on a specific disease entity, an organ system, or a population group. Voluntary agencies are funded primarily by donations. They are accountable to their supporters, and their activities are determined by supporter interests rather than legal mandate. Their primary emphasis is on research, education, and policy development, although they may provide some direct health care services.

Voluntary agencies can be categorized on the basis of their source of funding. The first category consists of agencies sup- ported by citizen contributions, such as the American Cancer Society. The first agency of this type in the United States was the Antituberculosis Society founded in Philadelphia in 1892. The focus of this type of agency frequently changes as health needs change. For example, the Antituberculosis Society is known today as the American Lung Association, indicating

M07_MARY9591_06_SE_C07.indd 172 06/09/14 6:38 PM

chaPter 7 health System influences on Population health 173

its broader focus on a variety of respiratory conditions. The second category consists of foundations established by private philanthropic contributions. An example of this type of vol- untary organization would be the Kellogg Foundation, which provides funding for health care research. Today, more than 3,000 philanthropic foundations support health efforts. The third category of voluntary agency is funded by member dues. The American Public Health Association and the American Nurses Association are examples of this type of agency.

Integrating agencies, such as the United Way, coordinate the fund-raising activities of several voluntary agencies. A fifth type of voluntary agency includes religious organizations that derive their funds from contributions by members of a congregation. These groups often focus on local needs and are particularly effec- tive because of their ability to draw on volunteers. The final cat- egory of voluntary health agency is the commercial organization that engages in health care activities. For example, the American Dairy Association provides literature and visual aids for nutrition education. Similarly, health insurance companies often dissemi- nate literature on health promotion and illness prevention.

Voluntary agencies often explore areas that are poorly ad- dressed by the other components of the health care system. For example, research that culminated in the development of a vaccine for polio was the early focus of the March of Dimes. Now, polio immunization is largely a function of official agen- cies. Education of the public and health professionals regard- ing health-related issues is another major focus of voluntary agencies. For example, the American Cancer Society has spear- headed educational campaigns on the hazards of smoking. Voluntary agencies may also supplement services provided by official health agencies. For instance, some voluntary agencies provide transportation to clinics, respite care, special equip- ment, and other ancillary services.

Advocacy for the public’s health is a major role for voluntary agencies. For example, a voluntary agency may campaign against reduction of health care services due to budget cuts. In this role, voluntary agencies often promote legislation related to health. In one community, for example, a collaborative organization of residents and service providers was successful in promoting legislation to prevent tenants from being evicted without cause and to extend required eviction notice from 30 to 60 days. Vol- untary agencies may also assist official agencies in determining health care needs in the population and in planning programs to address those needs. They also support and conduct research related to interventions to address population health problems.

Levels of care in the population health sector. Health care delivery in the United States takes place at local, state, and national levels. Each level has certain responsibilities with respect to the health of the population. Both official and voluntary agencies exist at each level, but official agencies are the focus of this discussion. Public health agencies at each of the three levels—local, state, and national—perform the essential public health services, but the degree to which they are emphasized varies from level to level.

Although official health agencies at all three levels address public health needs, state governments hold primary respon- sibility for preserving and protecting the health of the public. The power to protect the safety and welfare of the public is re- served to the states by the United States Constitution. In fact, any power not specifically delegated to the federal government by the Constitution remains within the purview of state gov- ernments. In the same way that the states, through the Con- stitution, have delegated certain responsibilities to the federal government, they may also delegate some health-related func- tions and responsibilities to agencies at the local level (Golds- teen & Goldsteen, 2012).

The Local Level. A local public health system is defined as “the collection of public, private and voluntary entities, as well as indi- viduals and informal associations, that contribute to the public’s health within a jurisdiction” (NPHPSP, n.d., p. 24). The official agency at the local level is usually the local health department. Some local public health agencies are large health systems serv- ing the populations of major jurisdictions such as New York City or Los Angeles County. Many, however, serve smaller popula- tions and do not have the resources to perform all of the essential public health services. The local health department’s authority is derived, in part, from responsibilities delegated by the state. For example, the state delegates to the local level the responsibility for collecting statistics on births and deaths. Because this responsibil- ity has been legally delegated, the local health department has the authority to ensure that a death certificate is filed for every death that occurs. The local agency also derives authority from local health ordinances. For instance, local government might pass an ordinance requiring all residential rental units to have function- ing smoke detectors. Enforcement of this ordinance might then become the responsibility of the local health department.

Funding at the local level comes from both local taxes and state and federal subsidies. A portion of local public health agency funding comes from the state, including federal pass-through funds, money granted to the states by the fed- eral government that is allocated to local government agencies. Other operating funds derive from local revenues, including local taxes. A small percentage of funding comes directly from federal monies (excluding Medicaid and Medicare funds). In recent years, local health departments have attempted to aug- ment revenue sources by providing personal care services re- imbursable under Medicare and Medicaid. Another small percentage of local health department funding is derived from client fees, private health insurance, regulatory fees, and so on.

Figure 7-2• depicts the typical organizational structure of a local health department. The staff and programs included will vary from place to place. In some areas, the district health of- ficer might also fulfill the role of administrative officer. Small counties or districts may not be able to afford the full-time services of some types of personnel, and the services of nu- tritionists, social workers, dentists, and other personnel might be shared by several counties or provided at the state level. Nurses and clerical staff would be found in almost any local

M07_MARY9591_06_SE_C07.indd 173 06/09/14 6:38 PM

174 Unit 2 influences on Population health

health department. Other personnel who may be available in- clude environmental specialists, physical therapists, psycholo- gists, laboratory and X-ray technicians, and pharmacists.

Because delegation of specific responsibilities to local ju- risdictions is the function of the state, the responsibilities as- sumed vary from state to state. Local responsibilities may also vary within regions of a particular state, depending on the lo- cal jurisdiction’s capabilities and resources. Within the context of the core public health functions, local health agencies assess and monitor local health needs and resources, develop policies that foster local involvement in decision making and equitable allocation of resources, and assure availability of high-quality services to meet local health needs. The assurance function also includes educating the community on how to access avail- able services. Typical responsibilities performed by local health agencies include collection of vital statistics, communicable dis- ease control, disease screening and surveillance, immunization, and health education. Other responsibilities include chronic disease control, sanitation, school health and maternal–child health programs, and population health nursing services. Local public health services may or may not include mental health services and primary care services for the indigent. Specific ser- vices provided by local public health agencies will depend, in large part, on the needs of local populations.

The state level. A state public health system is “the state public health agency working in partnership with other state govern- ment agencies, private enterprises, and voluntary organizations that operate statewide to provide services essential to the health of the public” (NPHPSP, n.d., p. 37). The official agency at the state level has traditionally been a state department of health. As noted above, the state, not the federal government or the

local jurisdiction, has primary authority in matters relating to health. The state retains the ultimate responsibility for the health of the public and possesses essential power to make laws and regulations regarding health.

The state health department derives funding from state tax rev- enues and may also receive monies from the federal government. A general organizational schema for a state department of health is depicted in Figure 7-3•. The various divisions coordinate ser- vices at the state level and provide assistance to the local level.

Because of their primary responsibility for the health of the population, state public health agencies have more mandated functions related to health than the federal government. General areas of responsibility for state health agencies include, for example, regulation and quality assurance for health care pro- viders and facilities, health care planning, regulation of insur- ance companies, and workplace and environmental protection (Goldsteen & Goldsteen, 2012). Some state health departments also provide direct services to selected population, and as we saw in Chapter 6 , state health agencies fund a significant portion of care provided under the Medicaid program.

The national level. Because the Constitution makes no reference to any responsibilities of the federal government regarding health, the federal government has no direct authority to regulate health-related matters. The authority of the federal government with respect to health is derived indirectly from two other constitutional powers (Goldsteen & Goldsteen, 2012). The first of these is the power to regulate foreign and interstate commerce. For example, because most cosmetics are transported across state lines, the federal Food and Drug Administration has the authority to establish standards of purity for the manufacture of cosmetics.

Figure 7-2 Typical Organizational Structure of a Local Health Department

COUNTY BOARD OF HEALTH

Administrative of�cer

District health of�cer

Dental services

Environmental services

Clerical services

Health education services

Public health investigative

services

Nursing services

Social services

Nutrition and other services

M07_MARY9591_06_SE_C07.indd 174 06/09/14 6:38 PM

chaPter 7 health System influences on Population health 175

The second constitutional source of authority over health matters is the power to levy taxes and spend to promote the gen- eral welfare. For example, it can be argued that such programs as Medicaid and Medicare promote the general welfare and are therefore within the authority of the federal government.

The official health agency at the national level is the United States Department of Health and Human Services (USDHHS or HHS), created in 1980 with the division of the former Department of Health, Education, and Welfare into two sepa- rate departments. The head of the agency is the Secretary of Health and Human Services, who fills a cabinet post and acts in an advisory capacity to the president in matters of health. The Office of the Secretary incorporates staff divisions, operating di- visions, and ten regional offices. The staff divisions oversee the overall operations of the department, provide guidance, and see that funding allocations are used appropriately and that legal requirements are met. The 11 operating divisions of HHS in- clude eight agencies within the U.S. Public Health Service and three human service agencies. The regional offices oversee pro- gram implementation in specific regions throughout the coun- try (USDHHS, n.d.a). Within HHS, the Office of the Assistant Secretary for Health (ASH) oversees a variety of public health- related agencies, including 12 core public health offices (US- DHHS, n.d.b, n.d.c, 2011). These agencies are summarized in Table 7-1•. ASH also oversees the provision of services by the U.S. Public Health Services Commissioned Corps, an agency that provides health care personnel to meet the needs of specific underserved populations (USDHHS, 2013a).

Operating divisions within HHS are depicted in Figure 7-4• and include the Administration for Children and Families,

Figure 7-3 Typical Organizational Structure of a State Health Department

STATE BOARD OF HEALTH

State health of�cer

Health institution

services

Research services

Professional education services

Public health education services

Health care

services

Laboratory services

Environmental health services

Administrative services

Accrediting bodies

Vital statistics

Veterinary services

Dental services

Medical services

Nursing services

Medical social

services

Nutrition and other services

Legal counsel

Administration for Children and Families (ACF)

Administration for Community

Living (ACL)

Food and Drug Administration (FDA)

Health Resources and Services Administration

(HRSA) Agency for Healthcare Research and Quality

(AHRQ) Indian Health Service (HIS)

Agency for Toxic Substances and Disease

Registry (ATSDR National Institutes of

Health (NIH) Centers for Disease

Control and Prevention (CDC)

Substance Abuse and Mental Health Services

Administration (SAMHSA) Centers for Medicare and Medicaid Services (CMS)

Other Administrative Agencies, Of�ces, and

Centers

U.S. Department of Health and Human Services

Figure 7-4 Operating Divisions of the u.S. Department of Health and Human Services

M07_MARY9591_06_SE_C07.indd 175 06/09/14 6:38 PM

176 Unit 2 influences on Population health

Agency function

National Vaccine Program Office (NVPO) http://www.hhs.gov/nvpo

Provides information on childhood, adolescent, and adult immunizations and ensures collaboration among federal agencies dealing with immunization activities

Office of Adolescent Health http://www.hhs.gov/ash/oah/ Coordinates adolescent health promotion and disease prevention programs across HHS

Office of Disease Prevention and Health Promotion (ODPHP) http://odphp.osophs.dhhs.gov

Provides leadership, coordination, and policy development related to public health and prevention activities. Leads the Healthy People initiative

Office of HIV/AIDS and Infectious Disease Policy (OHAIDP) http://www.hhs.gov/ash/ohaidp/

Coordinates, integrates, and directs HHS policies, programs and activities related to HIV/AIDS, viral hepatitis, and other infectious diseases, and blood safety and availability

Office for Human Research Protections (OHRP) http://www.hhs.gov/ohrp

Provides leadership and oversight in the protection of human subjects in HHS-supported research

Office of Minority Health (OMH) http://minorityhealth.hhs.gov/

Addresses health status and quality of life for U.S. minority populations

Office of Population Affairs (OPA) http://www.hhs.gov/opa/ Advises HHS officials regarding reproductive and other population issues Office of Research Integrity (ORI) http://ori.hhs.gov/ Promotes integrity in intramural and extramural Public Health Service research and

addresses allegations of research misconduct Office on Women’s Health (OWH) http://www.womenshealth.gov/owh/

Advances a comprehensive women’s health agenda throughout HHS to improve the health of women

Presidential Commission for the Study of Bioethical Issues (PCSBI) http://www.bioethics.gov/

Advises on ethical issues related to biomedical science and technology

President’s Council on Fitness, Sports, and Nutrition (PCFSN) http://www.fitness.gov/

Advises on issues related to fitness, sports, and nutrition

Data from: U.S. Department of Health and Human Services. (n.d.b). Office of the Assistant Secretary of Health. Retrieved from http://www.hhs.gov/ash/

TAbLe 7-1 Agencies Under the Assistant Secretary of Health

Administration for Community Living, Agency for Healthcare Research and Quality, Agency for Toxic Substances and Dis- ease Registry, Centers for Disease Control and Prevention, and the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration). Other health-related agencies in the department are the Food and Drug Adminis- tration, Health Resources and Services Administration, Indian Health Service, National Institutes of Health, and the Substance Abuse and Mental Health Services Administration (USDHHS, 2013b). These agencies, along with their primary functions and Internet addresses, are presented in Table 7-2•.

Although HHS is the agency primarily responsible for na- tional health, other agencies within the federal government are also involved in addressing health issues. For example, the Department of Defense provides health care for military per- sonnel, dependents, and retirees, and the Department of the In- terior and the Environmental Protection Agency address health concerns related to environmental pollution. Similarly, the Department of Labor and the Occupational Safety and Health Administration are concerned with occupational health as well as other employment concerns, and the Treasury Department is actively involved in efforts to control drugs subject to abuse.

Federal health-related agencies have a variety of responsi- bilities including support for research and dissemination of health-related information, developing national objectives and priorities for health, and assurance related to actions and services in the interests of national public health. In addition, the federal

government provides assistance to state agencies in the form of technical assistance and funding to support state health initia- tives. One of the major ways in which the federal government enacts its knowledge development and dissemination function is through the activities of the National Institutes of Health (NIH). NIH consists of the Office of the Director, 20 research institutes, 6 centers, and the National Library of Medicine. The institutes and many of the centers fund and conduct research related to specific health problems, conditions, and susceptible populations (National Institutes of Health, 2014). Figure 7-5• depicts the in- stitutes and centers that comprise NIH.

U.S. Health System Reform Due to the complexity and multicentric nature of the U.S. health care system, the system is frequently deficient in meet- ing the third core function of public health, assuring avail- ability and provision of needed care, and in achieving desired health-related outcomes. As we saw earlier, significant por- tions of the U.S. public are uninsured and have limited access to care. In the 2011 National Interview Survey, 19.9 million people or 6.5% of the U.S. population did not receive needed medical care due to cost, and another 27.3 million delayed ob- taining care (Adams, Kirzinger, & Martinez, 2012). In interna- tional comparisons, the United States lags behind many other developed nations with respect to health care outcomes. Some of these comparisons will be discussed in more detail later in this chapter.

M07_MARY9591_06_SE_C07.indd 176 06/09/14 6:38 PM

chaPter 7 health System influences on Population health 177

The relative lack of effectiveness of the U.S. health care system mandates significant reform, and reform efforts have a long, and generally unsuccessful, history. Reform propos- als have been put forward since 1912 when Teddy Roosevelt’s Progressive Party promoted the concept of social insurance, to include health insurance coverage. Efforts to promote compul- sory health insurance at a national level were promulgated as early as 1915 by the American Association for Labor Legisla- tion. During the Depression, Franklin Delano Roosevelt cre- ated a Commission on Economic Security to address medical care and health insurance as well as other economic issues. As a result, the Social Security Act was passed, but health insurance initiatives failed (Kaiser Family Foundation, 2011b).

During the 1940s, renewed calls for compulsory national health insurance were defeated due to fears of socialism and reluctance to grant a significant role to the federal government in health care matters. Similar initiatives continued to fail in the 1950s, but in 1965 the Medicare and Medicaid programs were initiated with federal legislation, and the neighborhood health centers program was established to provide care in poor and medically underserved communities. For the next 35 years, numerous plans for a national health insurance system were put forth and rejected, often in the name of cost containment.

Pay-for-performance, a system of rewards for meeting preestablished outcomes related to quality and efficiency, is one approach that has been taken in the attempt to control health care costs while improving outcomes. Some health care

funders have instituted financial incentives to reward provid- ers and systems that meet or exceed designated outcomes. Performance measures tend to be of four types: process mea- sures, outcome measures, patient experience measures, and structure measures. Process measures address the extent to which demonstrated best-practice activities have been incorpo- rated into care (e.g., annual eye exams for people with diabe- tes). Outcome measures reflect the effects of care on the client’s health status (e.g., the extent of hypertension control achieved). Patient experience measures assess client’s perceptions of the quality of care and satisfaction with that care. Finally, struc- ture measures address how health care delivery is structured, for example, whether or not electronic health records are in place (Pay for Performance, 2012). The Human Resources and Services Administration (HRSA) has suggested adherence to evidence-based guidelines for care as a measure of provider or system performance rather than patient outcomes, which are less influenced by external factors (e.g., patient compliance with medication) (HRSA, n.d.).

Other agencies have taken the opposite approach and sanctioned providers and systems that do not meet established benchmarks. For example, as we saw in Chapter 6 , the Centers for Medicare and Medicaid Services (CMS) has developed a set of adverse events, termed “never events,” for which it will not reimburse hospitals for care. Positive reimbursement for performance is exemplified in the CMS Value-based Purchasing program expanded by the Affordable Care Act. This program

Agency function

Administration for Children and Families (ACF) http://www.acf.hhs.gov

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

Administration for Community Living (ACL) http://www.acl.gov

Combines the former Administration on Aging, Administration of Developmental Disabilities, and Office on Disabilities to promote access to community support and resources to meet the needs of the elderly and people with disabilities

Agency for Healthcare Research and Quality (AHRQ) http://www.ahrq.gov

Supports research to improve the quality of health care, decrease costs, promote safety, and broaden access to services for all Americans

Agency for Toxic Substances and Disease Registry (ATSDR) http://www.atsdr.cdc.gov

Prevents harmful exposures and disease related to toxic environmental substances

Centers for Disease Control and Prevention (CDC) http://www.cdc.gov

Promotes health and quality of life by preventing and controlling disease and other preventable conditions

Centers for Medicare and Medicaid Services (CMS) http://www.cms.hhs.gov

Oversees the federal health care programs under Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Health Insurance Marketplace

Food and Drug Administration (FDA) http://www.fda.gov

Protects the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, national food supply, cosmetics, and products that emit radiation

Health Resources and Services Administration (HRSA) http://www.hrsa.gov

Improves access to quality health care for the uninsured, isolated, or medically vulnerable

Indian Health Service (IHS) http://www.ihs.gov

Provides comprehensive health services to American Indians and Alaska Natives to the highest level

National Institutes of Health (NIH) http://www.nih.gov

Supports and conducts biomedical and behavioral research and promotes dissemination of medical knowledge

Substance Abuse and Mental Health Services Administration (SAMHSA) http://www.samhsa.gov

Provides leadership for the prevention and treatment of mental and addictive disorders

Data from: U.S. Department of Health and Human Services. (2013b). Operating divisions. Retrieved from http://www.usphs.gov/aboutus/

TAbLe 7-2 Operating Divisions Within the Department of Health and Human Services

M07_MARY9591_06_SE_C07.indd 177 06/09/14 6:38 PM

178 Unit 2 influences on Population health

National Institute of Diabetes and

Digestive and Kidney

Disorders

Eunice Kennedy Shriver

National Institute of

Child Health and Human

Development

National Institute on Deafness and

Other Communication

Disorders

Fogarty International

Center

National Institute of Neurological Disorders and

Stroke

National Center for Complementary

and Alternative Medicine

National Institute of General

Medical Sciences

Center for Information Technology

National Institute on

Alcohol Abuse and Alcoholism

National Institute of Biomedical Imaging and Bioengineering

National Institute of Minority Health and

Health Disparities

National Institute of Allergy and

Infectious Diseases

National Institute of Arthiritis and Musculoskeletal

and Skin Diseases

National Institute

of Mental Health

National Institute of Dental and Craniofacial

Research

National Center for Advancing

Translation Sciences

National Institute

of Nursing Research

National Human Genome

Research Institute

National Heart, Lung and Blood Institute

National Institute

on Drug Abuse

NIH Clinical Center

National Cancer Institute

National Library of Medicine

National Institute on Aging

National Institute of Environmental Health Sciences

National Eye

Institute

Center for Scienti�c Review

NA TI

O N

A

L INSTITUTES O

F HEALTH

links incentive payments to hospitals’ ability to perform on a designated set of quality measures. Until recently, CMS also provided incentive payments to physicians who voluntarily re- ported specific quality data. In 2015, however, the incentives will cease and physicians who fail to report quality data will

receive reduced Medicare payments. Pay-for-performance ini- tiatives have been shown to have some effect on both the costs and quality of care, but have been criticized for the potential for unintended negative effects (Pay for Performance, 2012). Pay- for-performance was explored in more detail in Chapter 6 .

Figure 7-5 institutes and Centers of the National institutes of Health

M07_MARY9591_06_SE_C07.indd 178 06/09/14 6:38 PM

chaPter 7 health System influences on Population health 179

In March of 2010, President Barack Obama signed the Patient Protection and Affordable Health Care Act in an ef- fort to improve health care access and system function in the United States (Kaiser Family Foundation, 2011b). Provi- sions of the act are designed for incremental implementation through 2019. The provisions are far reaching and include a number of different initiatives. Major categories of initiatives include requirements for all U.S. citizens to have some form of health insurance coverage; employer requirements for cov- erage of employees; expansion of public insurance programs under Medicare, Medicaid, and the Children’s Health Insur- ance Program (CHIP); provision of premium and cost-sharing subsidies to individuals and families with incomes between 133% and 400% of the federal poverty level and to small busi- nesses; taxation of individuals without insurance coverage and of pharmaceutical, health insurance, and medical device com- panies; creation of state-based health insurance exchanges to assist in the purchase of coverage by individuals and small businesses; and creation of an “essential benefits” package. Ad- ditional provisions of the bill prohibit insurance companies from placing lifetime limits on coverage and denying cover- age for preexisting conditions. The act also expands the role of state government in providing insurance coverage, promotes

cost-containment initiatives, supports research on improving system quality and performance, promotes prevention and wellness initiatives and long-term care coverage, and supports health care workforce development, community- and school- based health centers, trauma care, and disaster preparedness (Kaiser Family Foundation, 2011a). For further information about the provisions of ACA, see the External Resources sec- tion of the student resources site.

Other National Health Care Systems As we noted above, The U.S. health care system compares un- favorably with several other national health systems, in large part because of the lack of universal coverage of all its citizens. The United States is the only developed nation that does not have some form of universal health care coverage.

Public Health Functions: An International Perspective In Chapter 1 , we examined the core functions and essential public health services developed for the U.S. health care sys- tem. Similar descriptions have been developed elsewhere in the world. For example, the Pan American Health Organization (PAHO, 2011) developed a list of essential public health func- tions and defined them as “the fundamental set of actions that should be performed in order to achieve public health’s cen- tral objective: improving the health of populations” (para. 1). PAHO also developed a methodology to evaluate public health capacity within a given country (PAHO, 2011). The essential functions and related public health activities are presented in Table 7-3•. Features of Selected National Health Systems Nations throughout the world have developed unique organi- zational structures for delivering health care services to their peoples. Although no two health systems are alike, they tend to have certain commonalities. For example, all health systems are designed to address three major considerations: how care

Assuring availability of health services is one of the core functions of public health. (Wavebreakmedia/Shutterstock)

Global Perspectives

People come to the United States from all over the world for many different purposes. Some intend only a short stay; others plan to relocate here permanently. What are some of the barriers within the U.S. health care system to obtaining care for those from other parts of the world? How might these barriers be eliminated or modified to improve their access to necessary care?

barriers to Obtaining U.S. Health Care

M07_MARY9591_06_SE_C07.indd 179 06/09/14 6:38 PM

180 Unit 2 influences on Population health

will be organized and delivered, how services will be funded, and the mechanisms to be used for reimbursing providers. In addition, national health systems have to address a number of policy dilemmas. These include balancing the need for regional or national coordination with the requirement to meet local health needs, distributing available resources equitably, bal- ancing professional practice autonomy with accountability for

population health outcomes, promoting the use of evidence- based best practices and guidelines, and addressing health disparities among subgroups in the population. Additional dilemmas faced by national health systems include assuring access to care in the face of cost constraints, balancing cura- tive technology with allocations for prevention and promo- tion, maintaining a qualified health care workforce, ensuring

TAbLe 7-3 essential Public Health functions of National Health Systems, Pan American Health Organization

function Related Activities

Monitoring, evaluation, and analysis of health status

• Evaluating health status, trends, and determinants, and identifying inequalities in risks, threats, and  access to health services.

• Identifying population health needs, health risks, and demand for services. • Managing important statistics and the situation of high-risk and/or specific groups. • Producing information to evaluate health services performance. • Identifying resources from outside the health sector that can improve health promotion and the 

quality of life. • Developing technology and methods to manage, interpret, and communicate information to public 

health’s decision makers, external actors, suppliers, and citizens. • Defining and developing agencies to evaluate the quality of the collected data.

Surveillance, research, and control of risks and threats to public health

• Developing capacity for research and surveillance of epidemic outbreaks and communicable and non- communicable diseases models, behavioral factors, accidents, and exposure to toxic substances or environmental agents detrimental to health.

• Developing a public health structure to support epidemiological research. • Supporting public health laboratory capacity to perform rapid analyses and process large volumes of 

tests to identify and control new health threats. • Implementing programs for epidemiological surveillance and infectious disease control. • Creating capacity to connect with international networks to better tackle the health problems of 

greatest concern. • Strengthening the ability to conduct surveillance at a local level and produce rapid responses to 

control health problems or risks. Health promotion • Promoting changes in lifestyle and environmental conditions that promote development of a health 

culture. • Strengthening intersectoral partnerships to make health promotion actions more effective. • Assessing the impact of public policies on health. • Developing educational actions and social communication that promote healthy conditions, lifestyles, 

behaviors, and environments. • Reorienting health services to develop models of care that support health promotion.

Social participation in health • Empowering citizens to change their own lifestyles and take an active role in developing healthy  behaviors and environments.

• Facilitating organized community participation in decisions and actions related to programs of  prevention, diagnosis, treatment, and rehabilitation.

Development of policy and institutional capacity for planning and management in public health

• Defining measurable public health objectives at all levels, consistent with a framework of values that  promote equality.

• Developing, monitoring, and evaluating political decisions concerning public health, through a  participatory process consistent with the political and economic context of the decisions.

• Creating institutional capacity to manage public health systems, including strategic planning to solve  the population’s health problems.

• Developing decision-making capacity based on evidence that incorporates planning, evaluation,  leadership, effective communication, organizational development, and resource management.

• Developing public health capacity for international cooperation. Strengthening of institutional capacity for regulation and enforcement in public health

• Creating institutional capacity to develop regulatory frameworks necessary to monitor and protect the  population’s health.

• Developing the capacity to create new laws and regulations to improve population health and promote  the development of healthy environments.

• Protecting citizens in their relationship with the health system. • Ensuring compliance with the standards in a timely, correct, congruent, and complete manner.

M07_MARY9591_06_SE_C07.indd 180 06/09/14 6:38 PM

chaPter 7 health System influences on Population health 181

TAbLe 7-3 (Continued)

function Related Activities

Evaluation and promotion of equitable  access to necessary health services

• Promoting equitable access to necessary health services for all citizens. • Developing actions to overcome access barriers to public health interventions and link vulnerable 

groups to health services. • Monitoring and evaluating access to necessary public and private health services, adopting a 

multisectoral, multitechnical and multicultural approach in conjunction with various agencies and institutions to resolve the injustices and inequalities in the utilization of services.

• Fostering close collaboration with governmental and non-governmental organizations to promote  equitable access to necessary health services.

Human resources training and development in public health

• Determining human resource profiles needed to provide public health services. • Educating, training, and evaluating public health personnel to identify public health services needs, 

effectively face pressing public health issues, and adequately evaluate action. • Defining accreditation requirements for general health professionals and fostering continuous quality 

improvement programs for public health services. • Constructing active partnerships with professional development programs that expose participants 

to relevant experiences in public health, as well as continuing human resources education for management and leadership development in the area of public health.

• Developing capacities for interdisciplinary and multicultural work in public health. • Providing ethical training for public health personnel, with special attention to the values of solidarity, 

equality, and respect for human dignity. Quality assurance in personal and population-based health services

• Promoting the implementation and improvement of evaluation systems. • Promoting the development of standards for quality assurance and improvement systems, as well as 

monitoring providers for compliance with these standards. • Defining, explaining, and guaranteeing service user’s rights. • Developing an evaluation system for health technologies that can assist in health system decision 

making and that contributes to improving the quality of the health system as a whole. • Using scientific methods to evaluate health interventions of various degrees of complexity. • Implementing systems to evaluate user satisfaction and using these assessments to improve the 

quality of health services. Research • Conducting rigorous research to increase the knowledge that supports decision-making at various levels.

• Developing and implementing innovative public health solutions, and measuring and evaluating their  impact.

• Establishing partnerships with research centers and academic institutions, both within and outside  the health sector, to conduct studies to support the NHA’s decision-making process.

Reduction of the impact of emergencies and disasters on health

• Developing policy and planning and implementing measures to prevent, mitigate, reduce, and  prepare for the impact of disasters on public health.

• Developing integrated approaches to the threats and the etiology of each possible emergency or  disaster within the country.

• Promoting health system-wide participation and broad intersectoral/interinstitutional collaboration in  reducing the impact of emergencies and disasters.

• Managing intersectoral and international cooperation in solving health problems caused by  emergencies and disasters.

Data from: Pan American Health Organization. (2011). Esssential public health functions. Retrieved from http://www.paho.org/HQ/index.php?option=com_content&view= category&id=3175&layout=blog&Itemid=3617&lang=en

community participation in policy making, and reaching hard- to-serve populations (Fried & Gaydos, 2012). Unique features of selected health care systems in other countries indicate the many approaches that can be taken to address the consider- ations and dilemmas presented above. In 2012, the Common- wealth fund published a report providing profiles of several national health care systems (Thompson, Osborn, Squires, & Jun, 2012). Key features of those health systems are summa- rized below.

The United Kingdom has a National Health Service (NHS) under which the majority of health services is provided through a government-run system that is operated slightly differently

in each of four administrative units (England, Scotland, Wales, and Northern Ireland), with separate administrative structures for the Isle of Man and the Channel Islands. Funding is derived from national taxes and care is free to all residents with the ex- ception of some prescription, optical, and dental charges. In 2013, the NHS in England underwent a major reorganization. Health care is under the direction of the Secretary of State for Health and is funded through Parliamentary allocations to the Department of Health. Funding is derived from taxation (NHS Choices, 2013a).

NHS England is an independent body from the government designed to improve health outcomes in the population. The

M07_MARY9591_06_SE_C07.indd 181 06/09/14 6:39 PM

182 Unit 2 influences on Population health

former Primary Care Trusts that administered the majority of the health care budget were abolished and replaced with Clini- cal Commissioning Groups (CCGs). All general practice physi- cians are employed by a particular CCG, which also includes other health professionals, including nurses. The CCGs are responsible for providing hospital, rehabilitative, and urgent/ emergent care, as well as most community health services and mental health and learning disability services. CCGs can also incorporate outside entities that meet established standards (NHS Choices, 2013b). Health and Wellbeing Boards are being established at local levels to coordinate public health services and reduce health disparities (Harrison, 2012). The Health and Wellbeing Boards will also provide avenues for consumer in- put into strategic decisions and coordinate health and social services (NHS Choices, 2013b).

Until recently, the emphasis at the NHS has been on per- sonal health care. However, the reorganization included the creation of a new entity, Public Health England (PHE), which is charged with coordinating a national public health service and delivering some services, creating an evidence base to sup- port local public health services, supporting healthy choices by members of the public, and providing leadership to the public health delivery system. PHE is also responsible for supporting public health workforce development (NHS Choices, 2013b).

Canada’s “Medicare” system is a single-payer system in which services are provided by a variety of public and private providers, but are co-funded by the federal and provincial or territorial governments. Health care service delivery is pri- marily the responsibility of provincial and territorial systems under federal standards for hospital, diagnostic, and physi- cian services (Allin, 2012). Coverage is universal for medi- cally necessary physician and hospital services, and in-patient prescription drugs; essential services are free (Health Canada, 2014). Services are funded by a combination of federal and pro- vincial or territorial funds derived through personal and cor- porate income taxes. Some provinces provide supplementary benefits to certain groups of people (e.g., the elderly and low- income residents). People who do not qualify for supplemen- tary benefits may obtain them through out-of-pocket payment, employment-based group insurance, or individual private insurance coverage. Federal monies are allocated to the pro- vincial and territorial governments, who then pay for services provided (Health Canada, 2012). Two thirds of residents are covered under private insurance as well for services not covered under the national system (Allin, 2012). The basic service pack- age for hospital, physician, and prescription drug coverage is mandated by the federal government, but provinces may cover additional services as well (Canadian Health Care, n.d.).

Like the United Kingdom, the Canadian system has been focused on personal health care service delivery with less at- tention to public health. In 2004, in response to the severe acute respiratory syndrome (SARS) outbreak of the previ- ous year, Canada created the new Public Health Agency of Canada (PHAC). The designated functions of PHAC include

population health assessment, surveillance, health promo- tion and disease and injury prevention, health protection, and public health emergency preparedness and response. These changes have led to an increased focus on health promotion and initiatives to address social determinants of health and ill- ness (Stachenko, Legowski, & Geneau, 2009).

In Australia, the health care system is financed and regulated by the federal government, with oversight and autonomous ad- ministration of health services by states and territories. Cover- age is universal, funded by taxes, patient fees, and other private sources. The national Medicare system covers both physician and hospital services as well as prescription medications, men- tal health care, and some dental care and allied health services if referred by a physician. Care is provided in a mix of public and private facilities, although most physicians are in private practice or combine a salary for seeing public patients with fee- for-service income from private clients. Approximately half of Australians also have private health insurance to assist with services not covered under the national plan. Private insurance coverage may involve “lifetime health coverage” for a fixed pre- mium based on one’s age at the time of enrollment. Recent foci in health care planning include targeted health issues, such as workforce planning, primary care, preventive care, hospital re- form, and disability services funding (Healy, 2012). In the past, health promotion, in general, has received less emphasis, and there was little systematic attention to social determinants of health (Davis, Lin, & Gauld, 2009).

The New Zealand health care system is tax funded and provides universal coverage for physician and hospital care, medications, and a broad range of other health and disability services. About one third of the population also has private in- surance coverage to cover cost-sharing expenses and for other services. Services are provided under District Health Boards and public hospitals. System reforms resulted in a network of self-employed provider groups that provide primary care ser- vices to the majority of the population on either a fee-for-ser- vice or capitated (prepaid per enrollee) basis. Specialists tend to work in both public and private hospitals and in their own private practices. There has been a growing emphasis on social determinants of health in New Zealand (Gauld, 2012).

As of 2009, health insurance coverage is mandatory for all German citizens and permanent residents. Health care services in Germany are provided within a system of non- governmental “sickness funds.” Employer (or pension fund) and employee con- tributions are collected in a national fund that is then distributed to local sickness funds based on risk-adjusted capitation formu- las. The sickness funds provide a universal benefit package with a wide array of preventive and curative services determined by the federal government. Some residents may opt out of the system in favor of substitutive private insurance, and private insurance may also be used for additional services. Providers are paid primarily on a fee-for-service basis negotiated between sickness funds and regional medical provider associations. Hospitals may be either private or public, but their physicians are usually salaried and

M07_MARY9591_06_SE_C07.indd 182 06/09/14 6:39 PM

chaPter 7 health System influences on Population health 183

are not permitted to see outside patients. Evidence-based disease management programs are in place for several chronic condi- tions, and sickness funds contract with providers for their imple- mentation (Blümel, 2012).

Comparing Health System Outcomes Each year, the Organization for Economic Cooperation and Development collects data on more than 1,200 health system performance measures for 34 industrialized countries. The Commonwealth Fund uses that data to rate the performance of the U.S. health care system (Squires, 2011). In 2012, the Commonwealth Fund examined U.S. health care system per- formance in five general areas: health care spending and cover- age, health care supply and utilization, health promotion and disease prevention services, quality of care and patient safety, and the price of care. Highlights of the analysis in each of these areas are presented below.

HeALTH CARe SPeNDINg AND COveRAge. In 2012, the United States ranked first in terms of average per capita spending on health care in comparison with 12 other countries. U.S. per capita spending was $8,233, more than 50% higher than the next highest ranked country, Norway, at $5,388 and 2.7 times higher than New Zealand with the lowest per capita expenditures ($3,022). In addition, the United States expends more of its gross domestic product (17.6%) on health care than any other country, again nearly 50% higher than Denmark, with next highest ranking (12%). Despite this level of expenditure, as we will see, health care outcomes in the United States lag far behind those of other countries in most areas addressed (Squires, 2013).

In comparisons of out-of-pocket spending for health care, the United States ranks second only to Switzerland ($970 and $1,325, respectively). Similarly, U.S. spending on pharmaceuti- cals was the highest among 14 nations at $983 per person, and was more than 30% higher than in Canada and 3.4 times higher than pharmaceutical expenditures in New Zealand.

HeALTH CARe SUPPLy AND UTILIzATION. U.S. residents make extensive use of costly health care services. For example, rates of coronary bypass surgery are higher in the United States (79 per 100,000 population) than in any country than Germany (116 per 100,000). These figures are most likely a function of a lack of preventive care in these systems. Similarly, the availability of magnetic resonance imaging units in the United States (31.6 per million population) is surpassed only by Japan (Squires, 2013).

As a measure of access to care, the United States ranked third lowest in terms of the average number of physician visits per person at 3.9, compared to highest ranking Japan at 13.1 visits per capita (Squires, 2013). In addition, the United States ranked next to last in terms of the number of practicing physi- cians per 1,000 people at 2.4, compared to first ranked Norway at 4.1. The number of hospital beds in the United States is only slightly higher at 2.6 beds per 1,000 population, lower than seven other countries and less than a third of the number of available beds in Japan (Squires, 2013).

HeALTH PROmOTION AND DISeASe PReveNTION. Only on two indicators in this area did the United States perform fairly well. With respect to cervical cancer screening rates, the United States ranked higher than another country with 85% of women screened in 2010. Similarly, the U.S. rate for adult smokers was second lowest, surpassed only by Sweden. On other measures, U.S. health system performance is less than stellar. For example, the United States ranked in the middle of the countries assessed with respect to influenza immunization among adults 65 years of age and older, and ranked highest in terms of obesity among adults, 29% higher than New Zealand, the second ranked country (Squires, 2013).

QUALITy AND SAfeTy. As a measure of health care quality, the United States lagged behind 15 other nations with the highest rate of mortality preventable by adequate health

evidence-based Practice

The medical Home One approach to the delivery of both preventive and curative services is the patient-centered medical home (PCMH) model. The Agency for Healthcare Research and Quality (AHRQ, n.d.a) has defined PCMH as a model of organization for primary care that encompasses the following functions and attributes: patient centeredness, comprehensive care, coordinated care, superb access to care, and a systems-based approach to qual- ity and safety. The Patient-Centered Primary Care Collabora- tive reported on a review of evidence related to the outcomes of implementing patient- centered medical home interventions

in the United States. The review indicated improved quality of care and reduced hospitalization and emergency department use leading to reduced costs of care. The review explored cost and quality outcomes for integrated delivery system models, private payer initiatives, Medicaid-sponsored initiatives, and other PCMH programs (Grumbach & Grundy, 2010). In addition, AHRQ has collected multiple reports of studies of outcomes related to the PCMH model (AHRQ, n.d.b). For further information related to study findings, see the External Resources section of the student resources site.

M07_MARY9591_06_SE_C07.indd 183 06/09/14 6:39 PM

184 Unit 2 influences on Population health

care. Similarly, the United States had the second highest rate of lower extremity amputations due to diabetes, at 32.9 per 100,000 population, second only to Germany at 33.7 per 100,000. With respect to in-hospital mortality due to myocardial infarction, the U.S. rate was at the mid-point of the comparison nations, nearly twice the rate of best performing Denmark, but less than half of the rate for Japan. Conversely, the United States had the highest rate of any country for five-year breast cancer survival (Squires, 2013).

Measures of patient safety reported in the Commonwealth Fund analysis included the rate of foreign bodies left in a pa- tient’s body during a procedure and the rate of postoperative sepsis. With respect to foreign bodies, the United States had the fourth best rate at 4.9 instances per 100,000 hospital discharges, but still nearly three times higher on this indicator than best performing Denmark. The U.S. rate for postoperative sepsis was the third highest among the comparison countries at 1,077 per 100,000 hospital discharges, more than three times that of Switzerland (Squires, 2013).

PRICeS. Health care in the United States is much more costly than in any of the comparison health systems in the Commonwealth Fund analysis. For example, U.S. prices for the 30 most commonly prescribed drugs are 23% higher than Canadian prices and three times higher than those in New Zealand. Similarly, U.S. prices for diagnostic imaging such as MRI and CT scans are higher than any of the comparison countries, and average hospital pending per discharge was 30% higher than the next highest country. In part these high costs are a function of physician incomes and reimbursement rates. For instance, physician fees from public payment sources for hip replacement amounted to $1,634 in the United States, compared to $652 in Canada. Fees charged to private payers were more than twice as much. Similarly, the average income for an orthopedic surgeon in the United States was $442,450, nearly three times the income of a French orthopedic surgeon.

Similar differences in incomes are noted for primary care physicians with U.S. incomes twice those of Australian primary care physicians (Squires, 2013).

Another performance measure comparing the U.S. health care delivery system to other national systems is infant mortal- ity, in which the United States ranked last among eight nations. Similarly, sicker adults in the United States are more likely to report difficulty in getting care after hours without going to an emergency department than residents of most other com- parison countries. The United States also performed worst in terms of people who reported being unable to access care due to costs in 2010. In addition, the percentage of U.S. primary care physicians using electronic medical records in 2009 was below that for all the comparison countries except Canada ( Commonwealth Fund, 2011).

Generally speaking, deficits in the U.S. health care system have been identified with respect to the quality of care provided, access to care, efficiency, equity, and indicators of healthy life. Quality issues include safety, care coordination, and the effec- tiveness of chronic disease management. Areas of concern with respect to access include inability to afford care due to costs and the extent of out-of-pocket expenditures by Americans for health care. Efficiency reflects the extent of the GDP allocated to health care expenditures, and equity is related to disparities in access to care as well as to disparities in health status across population groups in the United States. Major indicators of healthy life on which the United States performs abysmally in- clude infant mortality, preventable mortality, and healthy life expectancy after age 60. U.S. health care system performance in all of these areas is considerably less than desired. Many of these areas are designed to be addressed by the Healthy People 2020 initiatives discussed throughout this book. The provisions of the Affordable Care Act are also intended to address issues of access, equity, quality, and efficiency. The success of these endeavors, however, remains to be seen.

Health care delivery in the United States occurs in multiple set- tings at multiple levels. The primary divisions of the U.S. health care system are the popular, complementary or alternative, and scientific health care subsystems. Care in the popular subsystem is provided by individuals to themselves or family members. Complementary or alternative care is provided by recognized

ethnic healers or providers, while care in the scientific subsys- tem is based on research evidence.

The scientific health care subsystem includes the personal health care sector, which focuses on care to individuals, and the public health care sector, which emphasizes the health of population groups. Within the public health care sector, care is

CHAPTeR ReCAP

M07_MARY9591_06_SE_C07.indd 184 06/09/14 6:39 PM

chaPter 7 health System influences on Population health 185

Design a health care delivery system that would meet the health needs of the U.S. public. Diagram the organizational structure of the system, making sure that your system ad- dresses the core functions and essential services of public health as well as the goals of medical care. Address the follow- ing questions: 1. What features (if any) would you incorporate from other na-

tional health care delivery systems? 2. How would you fund your system? How would health care

providers be reimbursed? Why?

3. Would you offer comprehensive health care services? What would be included in the basic health services package? Would this basic coverage be available to all residents? Why or why not?

4. How would your system address the four levels of health care (health promotion, prevention, resolution, and restora- tion)? Would one level receive priority over the others? Why or why not?

5. What political, economic, and social changes would need to occur before your proposed system could be implemented in the United States?

The Ideal Health Care SystemCASe STUDy

Adams, P. F. Kirzinger, W. K., & Martinez, M. E. (2012). Summary health statistics for the U.S. population: National Health Interview Survey, 2011. Retrieved from http://www.cdc.gov/nchs/data/series/sr_10/sr10_255.pdf

Agency for Healthcare Research and Quality. (n.d.a). Defining the PCMH. Retrieved from http://pcmh.ahrq.gov/page/defining-pcmh

Agency for Healthcare Research and Quality. (n.d.b). Evidence and evaluation. Retrieved from http://pcmh.ahrq.gov/page/evidence-and-evaluation

Allin, S. (2012). The Canadian health care system, 2012. In S. Thompson, R. Osborn, D. Squires, & M. Jun (Eds.). International profiles of health care systems, 2012: Australia, Canada, Denmark, England, France, Germany, Iceland, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States (pp. 19–25). Retrieved from http:// www.commonwealthfund.org/~/media/Files/Publications/Fund%20 Report/2012/Nov/1645_Squires_intl_profiles_hlt_care_systems_2012.pdf

Alper, J. (Rapporteur), Round Table on Population Health Improvement, Board on Population Health and Public Health Practice. (2013). Population health implications of the Affordable Care Act. Retrieved from http://www.nap.edu/ download.php?record_id=18546

Blümel, M. (2012). The German health care system, 2012. In S. Thompson, R. Osborn, D. Squires, & M. Jun (Eds.). International profiles of health care systems, 2012: Australia, Canada, Denmark, England, France, Germany, Iceland, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States (pp. 46–52). Retrieved from http:// www.commonwealthfund.org/~/media/Files/Publications/Fund%20 Report/2012/Nov/1645_Squires_intl_profiles_hlt_care_systems_2012.pdf

Budrys, G. (2012). Our unsystematic health system (3rd ed.). Lanham, MD: Rowman & Littlefield.

Canadian Health Care. (n.d.). Retrieved from http://www.candian-healthcare.org Commonwealth Fund. (2011). Why not the best? Results from the national

scorecard on U.S. health system performance, 2011. Retrieved from http:// www.commonwealthfund.org/~/media/Files/Publications/Fund%20 Report/2011/Oct/1500_WNTB_Natl_Scorecard_2011_web_v2.pdf

Cover the Uninsured. (2009). Overview . Retr ieved from http:// covertheuninsured.org/content/overview

Davis, P., Lin, V., & Gauld, R. (2009). Public health in Australia and New Zealand. In R. Beaglehole & R. Bonita (Eds.), Global public health: A new era (2nd ed., pp. 225–247). Oxford, UK: Oxford University Press.

Fried, B. J., & Gaydos, L. M. (2012). Preface. In B. J. Fried & L. M. Gaydos (Eds.), World health systems: Challenges and perspectives (2nd ed., pp. ix–xii). Chicago: Health Administration Press.

Gauld, R. (2012). The New Zealand health care system, 2012. In S. Thompson, R. Osborn, D. Squires, & M. Jun (Eds.). International profiles of health care systems, 2012: Australia, Canada, Denmark, England, France, Germany, Iceland, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States (pp. 79–85). Retrieved from http:// www.commonwealthfund.org/~/media/Files/Publications/Fund%20 Report/2012/Nov/1645_Squires_intl_profiles_hlt_care_systems_2012.pdf

Goldsteen, R., & Goldsteen, K. (2012). An introduction to the U.S. health care system (7th ed.). New York, NY: Springer.

Grumbach, K., & Grundy, P. (2010). Outcomes of implementing patient-centered medical home interventions: A review of the evidence from prospective evaluation studies in the United States. http://www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf.

Harrison, A. (2012). The English health care system, 2012. In S. Thompson, R. Osborn, D. Squires, & M. Jun (Eds.). International profiles of health

RefeReNCeS

provided by both official and voluntary organizations. Official health agencies are the offices within local, state, or federal gov- ernments that are responsible for health issues and concerns. Voluntary agencies supplement the efforts of official health agencies.

Due to major concerns with quality, efficiency, and cost, there have been numerous attempts to reform the U.S. health care system, the most recent being the enactment of the Patient Protection

and Affordable Health Care Act in 2010. Pay-for- performance is another strategy that has been employed to improve the quality of care provided and the efficiency of the system.

The United States is the only developed nation without some form of national health care system that provides universal cov- erage for its citizens. The health systems of other nations vary across a number of parameters, but are fairly consistently ranked more highly than the U.S. system on a number of outcomes.

M07_MARY9591_06_SE_C07.indd 185 06/09/14 6:39 PM

186 Unit 2 influences on Population health

care systems, 2012: Australia, Canada, Denmark, England, France, Germany, Iceland, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States (pp. 32–38). Retrieved from http:// www.commonwealthfund.org/~/media/Files/Publications/Fund%20 Report/2012/Nov/1645_Squires_intl_profiles_hlt_care_systems_2012.pdf

Health Canada. (2012). Canada’s health care system. Retrieved from http:// www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2011-hcs-sss/index-eng.php

Health Canada. (2014). Health care system. Retrieved from http://www.hc-sc. gc.ca/hcs-sss/index-eng.php

Health Resources and Services Administration. (n.d.). What is pay-for- performance? Retrieved from http://www.hrsa.gov/healthit/toolbox /HealthITAdoptiontoolbox/QualityImprovement/whatispay4perf.html

Healy, J. (2012). The Australian health care system, 2012. In S. Thompson, R. Osborn, D. Squires, & M. Jun (Eds.). International profiles of health care systems, 2012: Australia, Canada, Denmark, England, France, Germany, Iceland, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States (pp. 11–18). Retrieved from http:// www.commonwealthfund.org/~/media/Files/Publications/Fund%20 Report/2012/Nov/1645_Squires_intl_profiles_hlt_care_systems_2012.pdf

Institute for Healthcare Improvement. (2014). Triple Aim for populations: Overview. Retrieved from http://www.ihi.org/Topics/TripleAim/Pages/Overview.aspx

Institute of Medicine. (2011). Board on population health and public health practice. Retrieved from http://www.iom.edu/About-IOM/Leadership- Staff/Boards/Board-on-Population-Health-and-Public-Health-Practice. aspx

Institute of Medicine, Committee on Assuring the Health of the Public in the 21st Century. (2003). The future of the public's health in the 21st century. Washington, DC: National Academies Press.

Kaiser Family Foundation. (2010). Uninsured and untreated: A look at uninsured adults who received no medical care for two years. Retrieved from http:// www.kff.org/uninsured/8083.cfm

Kaiser Family Foundation. (2011a). Summary of the Affordable Care Act. Retrieved from http://kaiserfamilyfoundation.files.wordpress. com/2011/04/8061-021.pdf

Kaiser Family Foundation. (2011b). Timeline: History of health reform in the U.S. Retrieved from http://kaiserfamilyfoundation.files.wordpress. com/2011/03/5-02-13-history-of-health-reform.pdf

Koslow, J. (2011). Encyclopedia of public health: Lemuel Shattuck. Retrieved from http://www.enotes.com/public-health-encyclopedia/shattuck-lemuel/print.

Lemuel Shattuck Biography (1793–1859). (2011). Retrieved from http://www. faqs.org/health/bios/27/Lemuel-Shattuck.html

Lemuel Shattuck. (1793–1859): Prophet of American public health. (1959). American Journal of Public Health, 49, 676–677.

London School of Hygiene and Tropical Medicine. (2010). Behind the frieze— Lemuel Shattuck (1793-1859). Retrieved from http://www.lshtm.ac.uk/ library/archives/history/frieze/shattuck.html

McMichael, A., & Beaglehole, R. (2009). The global context for public health. In R. Beaglehole & R. Bonita (Eds.), Global public health: A new era (2nd ed., pp. 1–22). Oxford, UK: Oxford University Press.

NHS Choices. (2013a). The NHS in England: About the National Health Service (NHS). http://www.nhs.uk/NHSEngland/thenhs/about/Pages/overview.aspx

NHS Choices. (2013b). The NHS in England: The NHS structure explained. Retrieved from http://www.nhs.uk/NHSEngland/thenhs/about/Pages /nhsstructure.aspx

National Institutes of Health. (2014). Institutes, centers, and offices. Retrieved from http://www.nih.gov/icd

National Public Health Performance Standards Program. (n.d.). Acronyms, glossary, and reference terms. Retrieved from http://www.cdc.gov/od/ ocphp/nphpsp/PDF/glossary.pdf

Pan American Health Organization. (2011). Essential public health functions. Retrieved from http://www.paho.org/HQ/index.php?option=com_content& view=category&id=3175&layout=blog&Itemid=3617&lang=en.

Pay for performance. (2012). Retrieved from https://www.healthaffairs.org/ healthpolicybriefs/brief.php?brief_id=78

Shattuck, L. (1850). Report of a general plan for the promotion of public and person health: Devised, prepared and recommended by the commissioners appointed under a resolve of the Legislature of Massachusetts relating to a sanitary survey of the state. Boston, MA: Dutton and Wentworth State Printers. Retrieved from http://biotech.law.lsu.edu/cphl/history/books/sr/index.htm

Squires, D. (2011). The U.S. health system in perspective: A comparison of twelve industr ialized nations. Retrieved from http://www .commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011 /Jul/1532_Squires_US_hlt_sys_comparison_12_nations_intl_brief_v2.pdf

Squires, D. (2013). Multinational comparisons of health systems data, 2012. Retrieved from http://www.commonwealthfund.org/~/media/Files/Publications/In%20 the%20Literature/2012/Nov/PDF_2012_OECD_chartpack.pdf

Stachenko, S., Legowski, B., & Geneau, R. (2009). Improving Canada's response to public health challenges: The creation of a new public health agency. In R. Beaglehole & R. Bonita (Eds.), Global public health: A new era (2nd ed., pp. 123–137). Oxford, UK: Oxford University Press.

Sultz, H. A., & Young, K. M. (2014). Health care USA: Understanding its organization and delivery (8th ed.). Burlington, MA: Jones and Bartlett.

Thompson, S., Osborn, R., Squires, D., & Jun, M. (Eds.). (2012). International profiles of health care systems, 2012: Australia, Canada, Denmark, England, France, Germany, Iceland, Italy, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United States. Retrieved from http:// www.commonwealthfund.org/~/media/Files/Publications/Fund%20 Report/2012/Nov/1645_Squires_intl_profiles_hlt_care_systems_2012.pdf

U.S. Census Bureau. (2013). Income, poverty, and health insurance coverage: 2012. Retrieved from http://www.census.gov/hhes/www/hlthins/data/ incpovhlth/2012/index.html

U.S. Department of Health and Human Services. (n.d.a). HHS family of agencies. Retrieved from http://www.hhs.gov/about/foa/index.html

U.S. Department of Health and Human Services. (n.d.b). Office of the Assistant Secretary of Health. Retrieved from http://www.hhs.gov/ash/

U.S. Department of Health and Human Services. (n.d.c). Public health offices. Retrieved from http://www.hhs.gov/ash/public_health/indexph.html

U.S. Department of Health and Human Services. (2011). Office of Disease Prevention and Health Promotion. Retrieved from http://www.aids.gov /federal-resources/federal-agencies/hhs/office-of-the-assistant-secretary- for-health/office-of-disease-prevention-and-health-promotion/

U.S. Department of Health and Human Services. (2013a). About the U.S. Public Health Service Commissioned Corps. Retrieved from http://www.usphs.gov /aboutus/

U.S. Department of Health and Human Services. (2013b). Operating divisions. Retrieved from http://www.usphs.gov/aboutus/

World Health Organization. (2014). Health systems: About health systems. Retrieved from http://www.who.int/healthsystems/topics/en/

M07_MARY9591_06_SE_C07.indd 186 06/09/14 6:39 PM

chaPter

bilateral agencies

burden of disease

civil society

civil society organizations (CSOs)

Declaration of Alma-Ata

disability-adjusted life year (DALY)

elimination

eradication

ethical poverty line

food insecurity

Global Alliance for Leadership in Nursing Education and Science (GANES)

global governance

global health

global health governance

globalization

gross domestic product (GDP)

health diplomacy

health governance

healthy life expectancy (HALE)

International Council of Nurses (ICN)

international health

millennium development goals (MDGs)

multilateral agencies

non-governmental organizations (NGOs)

Pan American Health Organization (PAHO)

policy

policy communities

primary health care (PHC)

sector-wide approaches (SWAPs)

Sigma Theta Tau International

World Health Organization (WHO)

Key Terms

Learning Outcomes

After reading this chapter, you should be able to:

1. Discuss the dimensions of globalization.

2. Describe factors contributing to the globalization of population health issues.

3. Distinguish between international and global health.

4. Discuss U.S. involvement in global health initiatives.

5. Describe recent global health initiatives.

6. Discuss the concept of global health governance and its effects on population health.

7. Describe health care organization at global and international levels.

8. Discuss selected global issues related to population health status and determinants of health.

9. Describe nursing involvement in global health.

Global Influences on Population Health8

M08_MARY9591_06_SE_C08.indd 187 06/09/14 6:39 PM

188

ICN: Global Advocacy for Nurses

ICN, the International Council of Nurses, arose out of concerns for women’s rights, health care reform, and the development of professional nursing practice. In 1899, three international nurs- ing leaders, Ethel Gordon Fenwick (England), Lavinia Dock (USA), and Agnes Karll (Germany) established the first international organization for women and health care providers. Initiated as a federation of national nursing organizations, such as the American Nurses Association, ICN was often funded by the personal funds of participants (ICN, 2013c). Throughout its more than 100- year history, ICN has advocated for nurses around the world. Two examples of its activities are particularly salient.

At the start of World War II, the German Nurses Association, one of the founding members of ICN, was disbanded by National Socialist (Nazi) Party. Similar action was taken against the Italian National Nurses Association (ICN, 2013c). As a result of the war, more than 3,000 nurses were displaced, often without proof of their nursing credentials. In 1950, ICN took over from the International Refugee Organization, the task of verifying the credentials of these nurses and as- sisting them in obtaining the documents needed to practice their profession in their new countries of residence (Center for the Study of the History of Nursing, School of Nursing, University of Pennsylvania, n.d.).

More recently, in 1973, ICN challenged one of its older members, the South African Nurses Association, to integrate the organization. As ICN was preparing for a vote on expulsion of the South African Nurses Association, the association abruptly withdrew its membership. Today, a fully integrated South African association is once again an active member of ICN.

A d

vo ca

cy T

h en

A d

vo ca

cy N

ow Holy Innocents Children’s Hospital—A Nurse-Initiated Venture in Uganda

In August 2006, Fr. Bonaventure from Mbarara, Uganda, visited the University of San Diego and its School of Nursing to see if we could help him and the Archbishop realize a dream. That dream was to build a hospital to help save the 17,000 children under the age of 5 who died in their com- munity in Uganda every year. As a nurse and a pediatric nurse practitioner, how does one say “no” to such a plea?

With the support of the university, six MSN students and I traveled to Mbarara, Uganda to conduct a needs assessment, identifying existing services, needs, in-country resources, the con- sequences of and barriers to intervening, and the lay and professional communities’ perspectives. After traversing 600 square miles, conducting over two dozen focus groups with diverse lay and professional groups, we identified a place to build a hospital, developed plans for the hospital, and presented a proposal to the Archbishop and his community. The proposal was taken back to the San Rafael Catholic Church in Rancho Bernardo, California and parishioners who were interested in helping the Archbishop realize his dream.

The report we developed was used as the foundation for an NGO to finance the building of the first children’s hospital. The organization’s tax-deductible, 503-status, was acquired in May 2007, its website was developed (www.holyinnocentsuganda.org), and fund-raising began. By March 2008, enough money had been raised to break ground for the hospital in Uganda. A 60-bed hos- pital, outpatient department, and administrative wing were informally opened on July 4, 2009. By the time of the official opening on July 4, 2010, over 16,000 patients had been treated at Holy Innocents Children’s Hospital.

M08_MARY9591_06_SE_C08.indd 188 06/09/14 6:39 PM

189

Because the Uganda health care system uses the British model of care, all health professionals are educated accordingly. To be responsive to this health care orientation, Dr. Hunter contacted her nursing experts in Northern Ireland for input into the development of the hospital and its early leadership. As of January 2011, both the Medical Director and the Hospital Administrator are Ugandans.

From April 2007 to July 4, 2010 I made seven trips to Mbarara with over 100 nursing, chemis- try, and business students and faculty from USD and health professionals from Children’s Hospital, Oakland. Our purpose has been to conduct environmental, developmental, and business needs as- sessments, provide nurse and physician and lay community educator training, and initiate partner- ships with the Mbarara University of Science and Technology Medical School and Business School and other entities in the community.

Nursing has advocated for the most vulnerable in Uganda, the age group birth–12 years, by helping to build the only children’s hospital in Uganda. As of January 2011, over 25,000 children have been treated in both the inpatient and outpatient departments. Our patients are critically ill and in the United States would be categorized as pediatric intensive care unit (PICU) patients, yet there is no PICU due to financial constraints. A neonatal intensive care unit of sorts has been cre- ated that serves the needs of the critically ill neonates in this resource-poor environment. Nursing and medicine have now joined forces to help meet the hospital’s mission—the sister relationship with Children’s Hospital, Oakland will help solidify the standards of care necessary to provide pe- diatric care, and the ongoing affiliations with the schools of nursing committed to this project will help ensure the more global well-being of the children, their families, and the community.

The mission of the hospital is to provide health care services to improve the health of the chil- dren and their families and to promote opportunities for their future. This nursing initiative was de- veloped around the framework of global health diplomacy, whereby partnerships between multiple disciplines, including medicine, nursing, environmental science, agriculture, politics, and business have been created to advocate for change, build local capacity, address factors that contribute to poor health, and promote stability in this community.

Anita Hunter, Phd, RN, PNP, FAAN

We live in a small world that can be circum-navigated in a matter of hours, increasing the potential for the spread of disease, ideas, and technological advances. Today you are a nurs- ing student in one country; six months or a year from now you may be working or vacationing in another. Or you may be car- ing for a client from a distant part of the world. Health prob- lems cross national boundaries, and their solutions will need to cross boundaries as well. For all these reasons, population health nurses need to be well versed in the global context in which health problems arise and health care is delivered.

Globalization The interaction of health and other issues in multiple parts of the world arises from increasing globalization. Although there is no universally accepted definition of globalization, a useful definition from the World Health Organization (WHO), is a

“process of growing interdependence that represents a funda- mental change from a world of individual and independent states to a world of state interdependence” (WHO, 2014c, para.4). The results of globalization are reflected in a simi- lar definition as a “process of increasing interconnectedness between societies such that events in one part of the world increasingly have effects on peoples and societies far away” (Fidler, 2001/2009, p. 125).

Dimensions of Globalization Globalization has spatial, temporal, cognitive, and social di- mensions. The spatial dimension reflects international trade, global political initiatives, communication, and increased cul- tural exchange. Similarly, movement back and forth across na- tional borders is common and increasingly easy. The temporal dimension addresses changes in our experiences of time and the increased speed of transactions, political change, and resource depletion. For example, I can be in San Diego this morning and

M08_MARY9591_06_SE_C08.indd 189 06/09/14 6:39 PM

190 Unit 2 influences on Population health

in Taiwan by late evening. Interchanges among people in dif- ferent parts of the world may need to account for time changes. The cognitive dimension of globalization reflects thoughts about ourselves and our world. Positive effects of globalization in this dimension include expansion of democratic principles and support for human rights. Additionally, in order to work effectively to address worldwide problems, we need to begin to think of ourselves more as global citizens than as citizens of a specific nation. The social dimension of globalization is re- flected in its effects on people in terms of its impact on culture, employment, working conditions, income, security, family life, and other aspects of social interaction, as well as redistribution of power from states to international bodies (WHO, 2014c).

Economic interconnectedness has been described as a core component of globalization that is fueled by technology and has a variety of societal effects. For example, a global economy is viewed by some as an impetus to increased productivity and standards of living based on economies of scale. Conversely, globalization of the economy may lead to destruction in jobs due to increased competition from low-wage countries. Other concerns related to globalization include loss of national sover- eignty and self- determination and inequitable distribution of its benefits (WHO, 2014c).

Although international interchanges have occurred since ancient times, in the past they tended to take place between

one nation and another, frequently between sovereign and in- dependent national governments. Today’s “new” globalization, on the other hand, is characterized by new entities that have a certain amount of authority over national governments (e.g., the World Trade Organization [WTO]). In addition, globaliza- tion is influenced by multinational business corporations with tremendous power to influence world events, global networks of non-governmental organizations (NGOs), new rules of gov- ernance such as international agreements, new modes of com- munication, and global movement among people.

Health Effects of Globalization Globalization has a number of effects on the health of the world’s populations, some of which are positive and some neg- ative. Positive effects include broader dissemination of health care technology that permits prevention and cure of illness. The existence of multinational corporations may also lead to improvements in labor standards and wages in developing na- tions. Similarly, globalization may also have the effect of glo- balizing concern for human rights.

Negative effects include the increased potential for the spread of communicable diseases with increasing interna- tional travel (Association of State and Territorial Health Offi- cials, 2013). Changes in culture and lifestyle have led to dietary changes, increased sedentary behaviors, and increased tobacco and alcohol use that contribute to the growing worldwide in- cidence of noncommunicable conditions. Growing reliance on motor vehicle transportation, combined with industrialization, and population growth has also led to global climate change, which in turn affects weather patterns, potential for natural disaster, and crop production.

Globalization also affects social determinants of health. For example, although the number of people in extreme poverty (persons living on incomes less than $1 a day) has decreased, globalization has increased disparities between the rich and the poor, with the poor being disproportionately affected by the negative consequences of globalization (Ezeani, 2012). Per capita income has increased substantially for some na- tions, but not as rapidly in others. For example, China, once one of the poorest nations in the world, now has a per capita income higher than 50% of the rest of the world (Ross, 2013). The gap between poor and middle-income countries has in- creased; Sub-Saharan Africa remains the poorest region in the world, with a 29% increase in per capita income from 2000 to 2010 compared to a 63% increase in middle-income countries (Stadtfeld, 2012).

Another negative effect of globalization has been the de- creasing ability of national governments to address health is- sues because multiple factors affecting health lie outside the authority of the government health sector. These effects of glo- balization will be addressed in more detail in our discussion of specific global health issues later in this chapter. Some of the positive and negative effects of globalization are summarized in Table 8-1•.

Many health concerns transcend national boundaries and require international cooperation. (Steve Gorton/Dorling Kindersley)

M08_MARY9591_06_SE_C08.indd 190 06/09/14 6:39 PM

chaPter 8 Global influences on Population health 191

TAbLe 8-1 Positive and Negative effects of Globalization

Positive effects Negative effects

Promotion of economic growth Increasing inequities between and within groups Greater employment or entry into the workforce for some segments of the population

Job loss for some segments of the population

Positive environmental effects (e.g., safer water supplies) Negative environmental effects (e.g., environmental degradation and increased resource consumption)

Greater financial prosperity and health for some Creation of unhealthful working conditions Rapid dissemination of health innovations and information Marketing of unhealthful products (e.g., tobacco) Development of global standards related to health (e.g., food safety standards)

Lack of access to available health innovations (e.g., antiretrovirals)

Changes in views of population health from a nation-specific perspective to a subgroup perspective across national boundaries

A shift away from the focus on social justice to an emphasis on market economies and efficiency

Positive effects of geoculture development (e.g., increasing autonomy for women)

Ease of spread of communicable diseases Ease of illicit trade in harmful substances Difficulty of keeping up with new developments and potential for information overload Increased time needed for decision making to incorporate input from diverse groups Negative effects of geoculture development (e.g., dissemination of poor health habits)

International and Global Health Perspectives At this point, we need to make a distinction between inter- national health activities and global health. International health involves health matters that affect two or more coun- tries. Global health, on the other hand, involves multina- tional efforts to address health problems that cross national borders, and has been defined as “collaborative transnational research and action for promoting health of all” (Beaglehole & Bonita, 2010, p. 5142). Global health is also concerned with factors that affect the capacity of individual nation-states to deal with the determinants of health and illness. Global health issues are beyond the capability of one nation to resolve and require multinational cooperation.

Trends in Global Health Collaboration Early international collaborative efforts related to health con- sisted primarily of attempts to control the international spread of epidemics. In 1903, these efforts led to the adoption of the International Sanitary Regulations, better known as Interna- tional Health Regulations.

In 1946, the United Nations (UN) established the World Health Organization (WHO) to address global health issues. Over the years, WHO has adopted a number of international conventions, or agreements, related to health issues. These conventions are not legally binding and member nations can refuse to accept an entire convention or opt out of certain provisions of a convention. WHO activities were predicated on three primary strategies, each of which has been less than

successful: global surveillance, transnational control measures, and multilateral funding. Global surveillance initiatives were designed to promote early identification of communicable disease outbreaks. Until recently, they have been largely un- successful because developing nations either did not have the public health infrastructure needed to conduct surveillance activities or were afraid to report outbreaks for fear of eco- nomic consequences associated with decreased trade or tour- ism. Transnational control measures have been unsupported by developed countries, which were able to care for their sick and were less concerned about the spread of disease, and de- veloping countries that feared initiation of “excessive mea- sures” that might, again, restrict trade. Finally, the concept of multilateral funding was largely unsuccessful because the developed nations that provided most of the funding did not trust recipient countries to use them wisely. Two WHO initia- tives that have been successful are the worldwide elimination of smallpox and eradication of polio from significant portions of the globe.

From the 1990s onward, there has been greater multilateral cooperation on health issues due to the emergence of new dis- eases with increased potential for worldwide spread. In 2005, the International Health Regulations were revised, and WHO has taken a more active role in prescribing effective interven- tion for disease outbreaks that have been implemented by most of the international community (WHO, 2014c). There has also been a marked expansion of multilateral health aid, particu- larly from non-governmental organizations. In addition, some international agreements have been modified to address their health consequences. For instance, under the TRIPS agreement

M08_MARY9591_06_SE_C08.indd 191 06/09/14 6:39 PM

192 Unit 2 influences on Population health

on Trade Related Aspects of Intellectual Property Rights, World Trade Organization (WTO) members are required to protect intellectual property rights, but that protection can be abrogated to address public health issues. As an example, member countries can issue compulsory licenses mandating in-country production of a necessary drug and avoid the high cost of importation from the country in which it was developed (WTO, 2014).

One particular WHO initiative that has changed over the years is the concept of primary health care and the goal of “health for all by 2000.” The “health for all” concept arose out of the 1977 World Health Assembly. The central goal of the “health for all” movement was the provision of basic health care to all peoples of the world by the year 2000. Its three main objectives were promotion of healthy lifestyles, prevention of preventable conditions, and therapy for ex- isting conditions. The strategy to achieve health for all cen- tered on the concept of primary health care as described in the Declaration of Alma-Ata, a report generated by the International Conference on Primary Health Care held in Alma-Ata in 1978.

Primary health care (PHC) is an approach to provid- ing health care resources that focuses on provision of es- sential health care using socially acceptable and affordable methods and technology, accessibility, public participation in policy development, and intersectoral collaboration. In 1978, the Declaration of Alma-Ata proposed a set of core activities to be included in primary health care and tailored to the needs of a particular population. These activities included:

• Education to prevent and control major health problems in the area

• Promotion of nutrition and a safe and sufficient food supply

• Provision of safe water and basic sanitation • Provision of maternal and child health care, including family

planning services • Immunization • Prevention and control of endemic diseases • Adequate treatment of common illnesses and injuries • Provision of essential medications (Hixon & Maskarinec,

2008).

Basic values of PHC include equity, universal access to care, people-centeredness, and communities that provide conditions conducive to health. Unfortunately, these values have been largely subverted by the effects of hospitalcen- trism, commercialism, and fragmentation within health care systems. Hospitalcentrism refers to health care systems built around hospitals and specialty care rather than primary care. Commercialism has been defined by WHO (2008) as unregu- lated sale of health care services for purposes of profit. Under the values of PHC, health care services should not be a source of profit for individuals, businesses, or governments. Frag- mentation of health care systems reflects a focus on “priority”

programs, projects, and issues, rather than a comprehensive approach to health.

To address these issues, WHO has suggested four areas for reform in PHC initiatives. These include universal cover- age reforms, service delivery reforms, public policy reforms, and leadership reforms. Universal coverage reforms include strategies to move toward access to health care services for all members of all populations, regardless of income or insurance status. Three approaches have been suggested to achieve uni- versal access: (a) reducing cost sharing by recipients of care, (b) expanding the services covered by health care service plans, and (c) expanding the populations covered to include all resi- dents (WHO, 2008).

Service delivery reform suggestions reflect the need for health care services to be socially relevant and to respond to the needs of the population. Such reforms would lead to people-centered care characterized by a focus on health needs of the population, enduring relationships between provid- ers and clients, comprehensive and continuous care, and re- sponsibility for the health of the total population as well as for determinants that affect health status and partnerships with recipients of care (WHO, 2008).

Public policy reform is needed to integrate public health initiatives with primary care services. There is also a need to develop policies across all sectors that support health and strengthen national and transnational health initiatives (WHO, 2008). Such policy development will require what has been re- ferred to as sector-wide approaches. Sector-wide approaches (SWAPs) are approaches to the resolution of health-related problems through attention to conditions in the broader social and economic sectors that affect health (WHO, 2014b). An ex- ample of a sector-wide approach might be efforts to provide access to safe, drinkable water in a developing nation. Assis- tance might be sought from an NGO to build a water purifica- tion system, but local government initiatives will be required to support system maintenance. There may also be a need for cooperation from local agricultural businesses to prevent wa- ter contamination with agricultural runoff. At the same time, legislation might be needed that prohibits the dumping of hu- man wastes within a prescribed distance of a water supply. For the safe water system to be developed and continue to function, activities will be required in several aspects of the health, social, and economic sectors.

Leadership reforms are needed to replace authoritarian or laissez-faire governmental approaches to health issues with participatory approaches (WHO, 2008). The aims of PHC will not be achieved without input from those affected in the planning and development of health care services. Other changes in the PHC approach suggested by WHO include an expanded focus on all members of the population rather than subpopulations such as mothers and children, promotion of healthier lifestyles and attention to social determinants of health, use of a primary health care team, comprehensive health care services rather than narrow foci on “priority” issues, adequate

M08_MARY9591_06_SE_C08.indd 192 06/09/14 6:39 PM

chaPter 8 Global influences on Population health 193

funding for comprehensive PHC, and care coordination across levels of preventive and curative services (WHO, 2008).

U.S. Involvement and Global Health The United States has long been actively involved in global health initiatives, but that involvement has been changing. In the past, much of U.S. involvement has occurred through fed- eral government activities, but more recently there has been increased activity by U.S.-based non-governmental organiza- tions and multinational corporations. In 2009, the Institute of Medicine (IOM) made five recommendations for U.S. action within the global health enterprise. These recommendations included the following:

• Expanding existing governmental and non-governmental interventions to achieve greater gains, with particular foci on supporting the achievement of the Millennium Development Goals (MDGs) (discussed below), preparation for emerging communicable and noncommunicable health challenges, and promoting health infrastructure and work- force development in developing nations.

• Generating and sharing knowledge to solve global health problems.

• Investing in global capacity building in line with local prior- ities. One suggested strategy is the creation of a global health service corps in which U.S. health care providers would serve in other nations much as they do in medically under- served areas of the United States.

• Increasing the U.S. commitment to funding global health ini- tiatives by meeting existing commitments and increasing aid spending, moving from a treatment to a health promotion and illness prevention focus, and funding global health research.

• Setting an example for respectful partnerships by address- ing the needs and concerns of partner nations and highlight- ing health as an integral component of foreign policy (IOM, 2009).

A 2010 report by the Kaiser Family Foundation noted that the United States was a party to only 36 of 50 recent interna- tional agreements. The study found the U.S. government to be most likely to participate in agreements related to control of specific diseases, trade and intellectual property, and security and international preparedness. The United States is not a party to several agreements related to environmental issues (e.g., the Kyoto Protocol to the United Nations Framework Convention on Climate Change and the WHO Framework Convention on Tobacco Control) and protection of some specific vulnerable populations such as the Convention on the Rights of Children and the Convention on the Elimination of All Forms of Dis- crimination Against Women. Greater U.S. involvement in such international efforts may be heralded by the Obama Admin- istration’s proactive stance on international partnerships for health and development (Kates & Katz, 2010).

For the first time, the Healthy People 2020 objectives include a focus on global health. To a large extent, the objectives related to this focus area emphasize protection of the United States from global threats to health. Some of the objectives, however, are aimed at developing global health competencies that will benefit the rest of the world as well. The global Healthy People 2020 objectives, with baseline data and target figures as well as related data sources for monitoring their achievement, are pre- sented on the next page.

Global Health Initiatives A number of global health initiatives have been recently un- dertaken, two of which will be addressed here. Other initiatives will be discussed in the context of global health issues to which they relate. The two initiatives to be presented here are the millennium development goals and the contributions of the G7/G8 nations to global health efforts.

MILLeNNIUM DeVeLOPMeNT GOALs. In 2000, the UN General Assembly developed its millennium development goals (MDGs), a set of goals for international development that address issues of health status and social determinants of health. Three of the goals, reducing child mortality, promoting maternal health, and combating HIV/AIDS, malaria, and other diseases address health directly. The other goals address determinants of health. Each goal encompasses one or more targets to be achieved by the international community. Specific indicators for achievement of each target have also been identified (United Nations, 2012). Table 8-2• summarizes the millennium development goals and specific targets. Like the U.S. Healthy People 2020 objectives, the MDGs provide consensus on the most important goals to be accomplished in the coming years as well as a comprehensive agenda for international development to achieve and sustain those goals. Information on progress in attaining the MDGs is published annually by the United Nations (UN, 2013). For information on annual progress in meeting the goals, see the External Resources section of the student resources site.

Many national health care systems incorporate advanced medical technology. (EPSTOCK/Fotolia)

M08_MARY9591_06_SE_C08.indd 193 06/09/14 6:39 PM

194 Unit 2 influences on Population health

G7/G8 CONTrIbUTIONs TO GLObAL HeALTH INI- TIATIVes. The United States is one of a group of six national governments formed in 1975 in response to a global oil crisis. Because of their monetary contributions to global initiatives, these organizations, which numbered eight until Russia became plagued with internal issues and now number seven, have greater voting strength in a number of world decision-making bodies such as World Bank, International Monetary Fund (IMF), and World Trade Organization. The seven countries that currently make up the group labeled G7 include Canada, France, Germany, Italy, Japan, the United Kingdom, and the United States. These seven nations account for nearly 40% of the world’s total gross domestic product, with China and India accounting for another 20% (Quandl, 2014). The gross domestic product (GDP) is the total monetary value of all goods and services produced by a na- tion in a given period.

The G7 nations have committed themselves to contributing to the achievement of the millennium development goals. Un- fortunately, that commitment has not been met, and only one country has lived up to its commitment to date.

A contribution of 0.1% of the GDP of all affluent countries would raise an estimated $35 trillion, roughly $35 per person for the one million people throughout the world who need as- sistance. In addition, low-income countries would be expected to dedicate 15% of their national budgets to address internal health issues (MacDonald, 2009). It is estimated, however, that achievement of the MDGs would require $40 to $70 billion more than is currently being contributed in annual aid and a goal of increasing aid contributions to 0.7% of affluent coun- tries’ GDP has been advanced. There is a need for considerably greater support of global health initiatives by the G7 nations and other relatively affluent countries before the MDGs can be realized.

Global Health Governance Another perspective on global health that is undergoing rela- tively rapid change is the concept of global governance. Health governance is defined as “the actions and means adopted by a society to organize itself in the promotion and protection of the health of its population (Dodgson et al., 2002/2009,

Healthy People 2020

Objectives for Global Health

ObjECTIvE

bASELINE (YEAr)

TArGET

CurrENT DATA (YEAr)

DATA SOurCE

GH-1: Reduce the number of new cases of malaria reported in the United States

1,298 cases (2008)

999 cases 1,691 (2010) National Notifiable Disease Surveillance System (NNDSS), CDC/ PHSIPO, National Malaria Surveillance System (NMSS), CDC/CGH

GH-2: Decrease the tuberculosis (TB) case rate for foreign-born persons living in the United States

20.3 cases per 100,000 population (2008)

14 cases per 100,000 population

17.2 cases per 100,000 population (2011)

National Tuberculosis Indicators Project (NTIP), CDC

GH-3: Increase the number of Global Disease Detection (GDD) Regional Centers worldwide to detect and contain emerging health threats

7 centers (2009)

18 centers 8 centers (2012)

GDD Monitoring and Evaluation Database, CDC

GH-4: Increase the number of public health professionals trained by the Global Disease Detection (GDD) programs worldwide

37,221 health pro- fessionals (2009)

300,000 health professionals

73,905 (2012)

GDD Monitoring and Evaluation Database, CDC

GH-5: Increase diagnostic testing capacity in host countries and regionally through the Global Disease Detection (GDD) Regional Centers

156 tests estab- lished or improved (2009)

1000 tests 232 tests (2012)

GDD Monitoring and Evaluation Database, CDC

Data from: U.S. Department of Health and Human Services. (2013). Global health. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview. aspx?topicid=16

M08_MARY9591_06_SE_C08.indd 194 06/09/14 6:39 PM

chaPter 8 Global influences on Population health 195

p. 440). Global governance is defined by the World Health Organization as “an international process of consensus-forming which generates guidelines and agreements that affect national governments and international corporations” (WHO, 2014b, para. 2). Global health governance is the application of in- ternational laws, norms, and expectations to the management of health issues that cross international boundaries (WHO, 2014b). Global health governance requires the ability to in- fluence health determinants outside the control of national governments due to the cross-border nature of many health is- sues and their contributing factors. International cooperation related to health risks began in the mid-19th century (Fidler, 2001/2009), and the International Sanitary Regulations dis- cussed above constituted an early attempt at global health gov- ernance. These regulations were revised by the World Health Assembly as the International Health Regulations (IHRs) in 2005 and became binding international law as of June 2007. The purpose of the regulations is to prevent the spread of pub- lic health emergencies, particularly communicable diseases, without undue disruption of trade and travel. The regulations required WHO member states to develop national surveil- lance and response systems by 2012, specifying mechanisms for identification, reporting, and management of international health emergencies (WHO, 2014e).

International agreements such as the IHRs are the prod- uct of health diplomacy, which is the art of negotiating and reaching agreement with respect to competing health needs and goals. Most global governance does not involve the

development of binding international law, but, instead, takes the form of accepted conventions or agreements that may ex- ist between specific nations or a global collective of countries. Such international and global agreements have implications for national policy and vice versa (WHO, 2014b). For example, the waivers possible under the TRIPS Agreement discussed earlier have implications for intellectual property rights as recognized by U.S. law.

Some authors have noted that the world is in the process of transitioning from a system of international relations between specific countries to a “system of global politics” (Bartsch, Hein, & Kohlmorgen, 2007, p. 19). Such a system often involves direct action between non-governmental factors functioning independently rather than through national governments as negotiators. In addition, a global political system is character- ized by multilevel modes of governance and regulation that involve power sharing among different groups or actors, in- cluding partnerships between public and private sectors, and a lack of central authority for enforcement of agreements. Only rarely does this system result in international law.

Several types of power play a role in global governance, and different actors involved in negotiation may exhibit different forms of power. Particular forms of power that may be involved include discursive power, decision-making power, legal power, and resource-based power. Discursive power reflects the abil- ity to shape discourse regarding an issue or to set an agenda for negotiation. Decision-making power involves the ability to participate in decision making and formal norm setting. As

Goal selected Targets

1. Eradicate extreme poverty and hunger • Halve the proportion of people living on less than $1 per day • Halve the proportion of people suffering from hunger

2. Achieve universal primary education • Ensure that all boys and girls are able to complete a full course of primary education 3. Promote gender equality and empower women • Eliminate gender disparity in primary and secondary education by 2005 and at all levels

by 2018 4. Reduce child mortality • Reduce by two thirds the mortality rate among children under 5 years of age 8. Improve maternal health • Reduce by 75% the maternal mortality ratio 6. Combat HIV/AIDS, malaria, and other diseases • Halt and begin to reverse the spread of HIV/AIDS

• Halt and begin to reverse the incidence of malaria and other major diseases 7. Ensure environmental sustainability • Integrate principles of sustainable development into national policies and programs and

reverse the loss of environmental resources (e.g., reduce energy use and carbon dioxide emissions)

• Halve the proportion of people without sustainable access to safe drinking water and basic sanitation

• Achieve significant improvement in lives of at least 100 million slum dwellers (e.g., adequate sanitation and secure housing tenure)

8. Develop a global partnership for development • Develop an open, rule-based, predictable, non-discriminatory trading and financial system • Address the special needs of the least developed and land-locked and island countries • Deal with developing countries’ debt • Make available the benefits of new technologies, especially information and

communication

Data from: United Nations. (2012). The Millennium Development Goals report 2012. Retrieved from http://mdgs.un.org/unsd/mdg/Resources/Static/Products/Progress2012 /English2012.pdf

TAbLe 8-2 Millennium Development Goals (MDGs) and selected Targets

M08_MARY9591_06_SE_C08.indd 195 06/09/14 6:39 PM

196 Unit 2 influences on Population health

noted earlier, the relative financial contribution of the G7 na- tions to global initiatives gives them a more decision-making power than is held by other countries involved in those insti- tutions. Legal power is based on legal structures and laws and rarely is brought to bear in global health governance. Finally, resource-based power is power derived from the ability of a negotiator to provide both material and immaterial resources needed to achieve goals. Material resources might include money or personnel, while immaterial resources might involve knowledge and information resources (Bartsch et al., 2007).

Essential elements of global health governance include de- territorialization of thinking and the elimination of national boundaries in addressing health issues and their solutions. Global health governance also requires definition of health determinants from a multisectoral perspective, not from a bio- medical outlook. For example, access to clean drinking water is a health issue that lies beyond the health care sector. In addi- tion, global health governance necessitates the involvement of a variety of actors and interests, including governmental and non-governmental players, public and private sectors, and so on (Dodgson et al., 2002/2009).

Several challenges must be overcome in order for global health governance to be achieved. First, there is a need for con- sensus on the moral and ethical principles that should under- gird global health governance. Decision makers need to agree on what are considered basic human rights related to health and health care and work toward support of those rights. Second, there is a need to define leadership and authority (Dodgson et al., 2002/2009). As noted earlier, the International Sanitary Regulations were largely ignored, in part due to a lack of sanctions for failure to follow them, in addition to other fac- tors. What sanctions might be applied to the United States, for example, if it fails to uphold agreed upon provisions of the Framework Convention on Tobacco Control or agreements on human trafficking?

The third, and perhaps most significant, challenge to achiev- ing global health governance is the need for resources needed to support global health cooperation. Funding is needed to organize and carry out agreed upon health-related initiatives. For example, the campaign to eradicate smallpox was a labor- intensive and costly endeavor, fortunately funded by a com- bination of WHO funds and money from donor countries. Overcoming national sovereignty concerns is another area that impedes global health governance. Nation-states are under- standably reluctant to cede power to control health issues to international groups. There is also a need to agree on enforce- ment of agreements at the global level. Finally, there is a need to involve wider participation in global health governance, not just national governments, the traditional negotiators in inter- national interactions (Dodgson et al., 2002/2009). In the end, developing global health governance structures will depend on achieving a balance between increased interdependence and desires to pool resources to address common problems and fears of loss of autonomy for individual nations (Kickbush, 2000/2009).

Some authors envision an expanded role for WHO in the development of a system of global health governance. Potential functions might include ensuring a reliable information base related to health issues, safeguarding global security through global response protocols and creation of a rapid response net- work to deal with emerging threats to health, supporting the competence of developing nations in addressing health issues, and acting as a global health broker in the creation of coopera- tive regulations and negotiation of health-related conflicts. In addition, WHO might function as an oversight body monitor- ing health-related networks and partnerships and could cre- ate a UN spokesperson on human rights and health to draw the attention of the international community to health issues (Kickbush, 2000/2009).

At present, however, three gaps exist that interfere with the development of global health policy and governance. The first of these is a jurisdictional gap. No organization or body has ju- risdiction to enforce global health regulations or agreements. The second is a participation gap in that there is minimal rep- resentation of developing nations or citizens in policy devel- opment. Finally, there is an incentive gap. Many countries do not see the benefits to development and enforcement of global health-related policy and fear loss of autonomy related to in- ternal affairs as they influence global health issues (Kickbush, 2000/2009).

Development of a true system of global health governance will require the accomplishment of several tasks to fill these gaps. The first of these is convincing the nations of the world that global health policy serves their needs and is of benefit to them. The second requirement is to widen the support base for global health, particularly in terms of funding sources. Finally, global health governance will require a shift to a moral argu- ment for accountability for the health of the entire world and a focus on populations across national boundaries (e.g., the poor, children, the elderly, etc.) (Kickbush, 2000/2009).

Health Care Organization at Global and International Levels There are a variety of agencies that undertake global or inter- national health efforts. These agencies can be loosely grouped as bilateral agencies, multilateral agencies, and civil society or- ganizations. Bilateral and multilateral agencies tend to be asso- ciations of member nations represented by official government health-related agencies. Multilateral agencies are those that involve several countries in joint activities related to health, whereas bilateral agencies are health-related agencies that generally involve only two countries in any single project.

Bilateral Agencies A number of bilateral organizations with health emphases ex- ist throughout the world. Virtually all developed countries provide some form of health-related aid to underdeveloped countries, with the contribution of some countries far in excess

M08_MARY9591_06_SE_C08.indd 196 06/09/14 6:39 PM

chaPter 8 Global influences on Population health 197

of that provided by the United States. This section will focus on the bilateral organizations involving the United States. One of the federal agencies concerned with international health is the United States Agency for International Development (USAID), which administers all federally financed projects for foreign de- velopment, including those that are health related. This agency is housed in the U.S. Department of State, and its twofold purpose is to promote U.S. foreign policy through expansion of democracy and free markets and to improve life in the de- veloping world. To these ends, the agency supports economic growth, agriculture, and trade; global health; and democracy, conflict prevention, and humanitarian aid (USAID, 2014).

The U.S. Department of Health and Human Services in- cludes several agencies with international foci. One is the Office of Global Affairs (OGA) which “promotes the health and well- being of Americans and of the world’s population by advancing global strategies and partnerships in the coordination of global health policy” (OGA, n.d., para. 1). The second is the Center for Global Health within the Centers for Disease Control and Prevention (CDC). This center is involved in both bilateral and multilateral health activities sending health experts to specific countries in need of assistance and providing representation in multilateral organizations such as WHO, the World Bank, and the International Red Cross. CDC is involved in a number of global health initiatives related to control of specific diseases such as HIV/AIDS, malaria, influenza, measles, and polio, as well as programs related to environmental health, reproductive health, road safety, violence prevention, and food safety, to name a few areas of focus (Center for Global Health, n.d.). For further information on global health initiatives undertaken by CDC, see the External Resources section of the student resources site.

Within the National Institutes of Health (NIH), the Fogarty International Center (n.d.) focuses on international health research. Other branches of the NIH (e.g., the Geographic Medicine Branch of the Institute of Allergy and Infectious Diseases) are involved in activities that are international in fo- cus. Many of the programs of the Peace Corps, the federal in- ternational volunteer program, have a health focus.

Some federal agencies that function primarily at the na- tional level also have some international aspects to their roles. For example, the U.S. Food and Drug Administration (2014) houses the Office of International Programs, which focuses on bilateral as well as multilateral regulatory initiatives related to safe food and drug supplies throughout the world. In ad- dition, federally chartered institutions such as the Institute of Medicine and the National Science Foundation are also con- cerned with problems of international health as well as with domestic problems.

Bilateral or binational initiatives are particularly needed along the U.S.–Mexico border. There are 15 million people in 44 U.S. countries and 90 Mexican municipalities who live along the border, and this number is expected to rise to 23 million by 2030 (McDonald, Mojarro, Sutton, & Ventura, 2013). The United States–Mexico Border Health Commission (n.d.) was established to address health needs in the border

populations. Particular areas of emphasis include obesity and diabetes, strategic planning, research, data collection, and aca- demic alliances.

Multilateral Agencies The World Health Organization (WHO) is “the directing and coordinating authority on international health within the United Nations’ system” (WHO, 2014a, para. 1), and is the primary multilateral agency dealing with global health issues. WHO was established in 1948 and is responsible for provid- ing leadership in global health initiatives, supporting health-re- lated research and setting a global research agenda, monitoring global health trends, and providing technical assistance in the control of health problems that threaten the global community (WHO, 2014a). WHO is funded through “dues” and dona- tions by member nations and focuses on health promotion and disease prevention, cure of illness, health systems and health resources development, and health-related international re- search. The World Health Assembly is the governing body for WHO and sets global health policy (WHO, 2014a). For further information about WHO, see the External Resources section of the student resources site.

The Pan American Health Organization (PAHO) is the multilateral agency that deals with health-related concerns in the Americas and provides an avenue for collective efforts to promote the health status of people in all nations in the Western Hemisphere. PAHO is the oldest of the global health organizations and celebrated its 100th anniversary in 2002. PAHO originated in 1902 as the International Sanitary Bureau. Its original focus was the development of uniform sanitary regulations and laws in North and South America. In 1958, the organization expanded its focus to address broader health issues and changed its name to the Pan American Health Organization (PAHO, 2011, 2013).

One of PAHO’s significant achievements is the development of the Regional Core Health Data Initiative, which monitors achievement of health goals in PAHO member states (PAHO, 2014b). To date, the data generated have been used to create health profiles for 47 jurisdictions, including the United States and Puerto Rico (PAHO, 2014c). Data collected provide direc- tion for programs to enhance health status in the region of the Americas. For further information about PAHO and current indicator status for member nations, see the External Resources section of the student resources site.

Other multilateral agencies include the health components of the North Atlantic Treaty Organization (NATO) and the Southeast Asia Treaty Organization (SEATO). The United Nations International Children’s Emergency Fund (UNICEF) and the United Nations Educational, Scientific, and Cultural Organization (UNESCO) are two other agencies within the UN that provide assistance with matters of global health. The Food and Agricultural Organization (FAO) is a multilateral agency designed to enhance the world’s food supply. Finally, the World Bank provides both funding and technical assistance in dealing with health problems around the world.

M08_MARY9591_06_SE_C08.indd 197 06/09/14 6:39 PM

198 Unit 2 influences on Population health

Civil Society Organizations Civil society is one of three aspects of society, with the other two aspects being government and the economy. The defi- nition of civil society adopted by the World Bank is as fol- lows: “the wide array of non-governmental and not-for-profit organizations that have a presence in public life, expressing the interests and values of their members or others, based on ethical, cultural, political, scientific, religious or philanthropic considerations” (World Bank, 2013, para. 5). Civil society, then, determines the culturally acceptable directions for po- litical and economic decisions. Civil society organizations (CSOs) are “community groups, non-governmental organi- zations (NGOs), labor unions, indigenous groups, charitable organizations, faith-based organizations, professional associa- tions, and foundations” that represent the voice of the people in societal decision making (World Bank, 2013, para. 5). CSOs occur at local and national, as well as international, levels of society.

CSOs are characterized by their nonprofit nature, their organizational and financial independence from govern- ment, and, like voluntary agencies, their reliance on voluntary membership and contributions. CSOs carry out a variety of functions with respect to global health governance. These func- tions include raising awareness of health problems caused by economic or political factors, agenda setting, developing us- able knowledge, monitoring problem status and policy imple- mentation, rule making, and norm development. Additional functions include policy verification through scrutiny of policy initiatives and their implementation, capacity building in terms of technology transfer and organizational skill development, and financing (Lee, 2010).

There are several types of CSOs that are somewhat similar to the types of voluntary agencies discussed in Chapter 7 . One distinct type of CSO that has no parallel among voluntary agencies is a social movement. Social movements are informal networks and groups who work for societal change, sometimes independently of each other. Social movements are usually is- sue-focused and frequently work through campaigns to educate the public and influence policy makers. Other types of CSOs include non-governmental organizations, social membership organizations (e.g., unions or professional organizations), na- tional and ethnic organizations and movements, and founda- tions. Faith-based organizations are related to CSOs, but arise from religious groups to provide certain social and advocacy services while conducting related missionary activities.

Non-governmental organizations (NGOs) are nonprofit, voluntary, citizens’ agencies outside of the official government- sponsored agencies that work toward the public good. NGOs differ from social movements in that they have a professional and sustainable organizational structure. They are characterized by their function of advocacy for the interests of others and the translation of private resources into public goods. Their foci are self-determined and are generally limited to one or more spe- cific and related issues (e.g., women’s rights, tobacco control, prevention of human trafficking, etc.) (NGO Global Network, n.d.). A great deal of humanitarian aid is contributed by NGOs, with much of it being disaster-related. Humanitarianism is based on a strongly held belief that all human life has value wherever it is found, in affluent countries or developing nations. Humanitarianism embodies both beneficence/charity and duty/ justice perspectives (Walzer, 2011).

Social membership organizations focus on the interests of their members. Examples of social membership organizations include unions and professional organizations, both of which may engage in health-related initiatives to improve the public good as well as efforts to promote the interests of their mem- bership. The final type of CSO is foundations. Foundations may be nonprofit organizations established by for-profit enti- ties for the purpose of promoting the public good. For example, the Bill & Melinda Gates Foundation (n.d.), which is supported by profits from Bill Gates’ technological enterprises, as well as some other donations, has undertaken significant efforts related to global development as well as global health issues

Hand washing is one of the most effective means of preventing communicable diseases. (fotocociredef73/Fotolia)

M08_MARY9591_06_SE_C08.indd 198 06/09/14 6:39 PM

chaPter 8 Global influences on Population health 199

such as communicable disease control and immunization, fam- ily planning, and nutrition. The Susan G. Komen Foundation (2014), on the other hand, was established in memory of Susan Komen, who battled breast cancer and campaigned for support of women with breast cancer. The foundation is a grassroots network of cancer survivors and advocates supported by dona- tions from a variety of individual, organizational, and corpo- rate sources.

Global Health Issues There are a number of issues that affect the health status of the world’s population. Although it is beyond the scope of this chapter to address them all, we will explore selected health is- sues in two major areas: issues related to population health sta- tus and those related to determinants of health.

Health Status Issues General categories of global issues related to the health status of the world’s population to be addressed here include life ex- pectancy, maternal and child health, communicable diseases, and noncommunicable conditions.

LIfe exPeCTANCy AND MOrTALITy. In spite of overall gains in life expectancy over the last several decades, there is a significant disparity in life expectancy between high- and low-to-moderate-income countries. For example, in 2011 overall life expectancy at birth ranged from 47 years in Sierra Leone to 83 years in Japan and Switzerland. From 1990 to 2011, life expectancy for both sexes actually decreased by 11 years in Zimbabwe (WHO, 2013c). U.S. life expectancy in 2011 was 79 years. Differences in healthy life expectancy (HALE), or the number of years of life one can expect to attain in a state of relatively good health, were equally pronounced.

Differences in mortality rates are also substantial. Among adults between 15 and 60 years of age, the 2011 worldwide mortality was 190 deaths per 1,000 population. For low-income nations, however, the mortality rate was more than two times higher than the mortality experience of high-income countries for men and more than six times higher for women (WHO, 2013c).

WOMeN’s AND CHILDreN’s HeALTH. Most child caretakers throughout the world are women; therefore, the health of women and that of children is intimately connected. Women’s health is a major area of concern in global health care. Maternal mortality continues to be high in many parts of the world. In 2010, maternal mortality ranged from 2 (Estonia) to 1,100 maternal deaths per 100,000 births (Chad) (WHO, 2013c). Many other women suffer complications of pregnancy and childbirth that lead to injury and disability.

Because of the biological effects of reproduction, women are more vulnerable to related health problems, but reproductive biology is only one of the reasons for poor health status among the women of the world. Gender inequities that contribute

to discrimination and poverty are experienced by women throughout the world. For example, women are more vulner- able to the effects of poverty than men, primarily because they are less likely to be employed outside the home. Even when employed for pay, women may earn as much as 40% less than men, and women are often employed in low-paying, high-risk jobs. In many countries, women retain responsibility for the care of homes and children while shouldering the additional burden of out-of-home labor. Increased participation in the labor force has the advantage of increased material and social support, but also leads to increased workload and greater po- tential for occupational exposures. Even women working in the home experience greater environmental risks due to increased use of carbon-based cooking fuels (WHO, 2009b).

Traditional gender roles may also place women at higher risk for HIV infection due to the inability to negotiate condom use or other elements of sexual activity. In 2004, HIV/AIDS was the leading cause of death worldwide among women aged 20 to 59 years, contributing to 835,000 deaths or 13.3% of all mortal- ity in this age group. Other causes of mortality in middle adult women included heart disease and stroke (12.5%), tuberculosis (5%), breast cancer (3.5%), suicide (3.2%), lower respiratory in- fection (3%), and road traffic accidents (2.7%). Among women over 60 years of age, the greatest causes of mortality included heart disease and stroke (39.7%), chronic obstructive pulmo- nary disease (8.2%), cancers (5.4%), lower respiratory infection (5.3%), diabetes mellitus (3.3%), and Alzheimer’s and other de- mentias (2%) (WHO, 2009b).

Violence against women is another area of growing inter- national concern. A WHO study found that as much as 71% of women in some countries had been subjected to intimate partner violence at some point in their lives (as much as 54% in the prior year). In addition, 40% to 70% of murders of women in countries such as Australia, Canada, Israel, South Africa, and the United States are perpetrated by their male partners (WHO, 2009b). Laws in many countries do not recognize in- timate partner violence (IPV) as a crime. Even when they do, they may not include IPV that occurs outside of marriage (e.g., dating violence). IPV will be discussed in more detail in Chapter 30 .

International trafficking in human beings, which affects pri- marily women and young girls and boys, is another source of societal violence. An estimated 600,000 to 800,000 individuals are trafficked across international borders each year, and thou- sands more are enslaved in their own countries. More than 12 million people are believed to be enslaved in forced labor and sexual servitude throughout the world. Much of the human trafficking is for the purpose of sexual exploitation, but trafficking also involves involuntary servitude. In the 2000 Trafficking Victims Protection Act, severe forms of trafficking in persons were defined as:

(a) sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age; or

M08_MARY9591_06_SE_C08.indd 199 06/09/14 6:39 PM

200 Unit 2 influences on Population health

(b) the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. (U.S. Department of State, 2013, p. 8)

Approximately 12.3 million persons, mostly women and children, have been forced to provide labor or become pros- titutes throughout the world, and nearly 2 in every 1,000 peo- ple in the world, including 1.2 million children a year, may be victims of trafficking (National Human Trafficking Resources Center, 2010). Unfortunately, far too many cases are unre- ported. For example, in 2012, more than 46,000 trafficking victims were identified worldwide, yet only 7,705 cases were prosecuted and only 4,746 perpetrators were convicted (U.S. Department of State, 2013). Trafficking of persons will be dis- cussed in more detail in Chapter 30 .

Because of income differentials, new health-related prod- ucts and effective treatments may not be available to women. Women have also become a new global market for harm- ful products such as tobacco and products that undermine healthful behaviors, such as prepared formulas used in place of breast-feeding.

Many of the efforts related to global health have been prompted by the plight of the world’s children. In spite of mil- lions of dollars of international assistance, however, in 2012 children under 5 years of age in low-income countries had a mortality rate of 96 per 1,000 live births compared to only 6 per 1,000 for high-income nations (WHO, 2013c). Even in devel- oped countries, children living in poverty have worse outcomes than their wealthier counterparts. Causes of inequalities in child health include financial barriers to health care and other necessities and lack of access to quality care.

In 2010, 7.6 million children under the age of 5 died. Three conditions accounted for 45% of these deaths: pneumonia, di- arrheal diseases, and prematurity (WHO, 2013c). Maternal or child malnutrition was a significant contributing factor in many of these deaths.

Vaccine preventable diseases play a significant role in child- hood mortality. Considerable progress has been made in pro- viding routine immunizations for the children of the world. In 2011, however, 16% of the world’s children under one year of age remained unimmunized for measles, 17% for diphtheria, tetanus, and pertussis (DTP), 25% for hepatitis B, and 43% for Hib (WHO, 2013c). The worldwide immunization rate for pneumococcal diseases was only 19% in 2012, and only 11% of young children had been immunized against rotoviruses. In 2012, an estimated 22.6 million children, half of them in three countries (India, Indonesia, and Nigeria) had not received rou- tine immunization services (WHO, 2014d).

Diarrheal diseases are the leading cause of morbidity and mortality in children under 5 years of age. Diarrheal death rates have decreased somewhat due to the use of oral rehy- dration therapy, but this strategy has not been employed as widely as needed. Diarrheal diseases are not likely to be well

controlled, however, until improvements in water quality and sanitation are achieved worldwide. Each day 1,400 children die of diarrheal diseases caused by contamination of drinking wa- ter, inadequate sanitation, and poor hygiene (United Nations Children’s Fund [UNICEF], 2014).

Like their mothers, many children are subjected to unsafe and unhealthy working conditions and violence. An estimated 150 million children 5 to 14 years of age are engaged in child labor worldwide, and 500 million to 1.5 billion children have been affected in some way by violence (UNICEF, 2009).

In 2004, members of the WHO-World Bank Child Health and Poverty Working Group suggested that a simple set of six preventive activities and two therapeutic activities could signif- icantly decrease the extent of disease burden among children. Basic preventive activities include prenatal care, breast- feeding, birth spacing, hygiene, immunization, and insect control. Recommended therapeutic interventions include effective home management of illness and prompt medical attention when needed. Unfortunately, much work needs to be done to implement these activities worldwide.

COMMUNICAbLe DIseAses. Considerable progress has been made with respect to control of some communicable diseases throughout the world. For example, global eradication of smallpox was certified in 1979. Ironically, the last case of naturally occurring smallpox occurred in a smallpox vaccinator who received ineffective vaccine in Somalia in 1977 (WHO, 2014h). Eradication is the reduction of the worldwide incidence of a disease to zero through specific efforts to control its spread. Elimination is the same phenomenon on a smaller scale; that is, reduction of the incidence of the disease in question to zero in a specific area of the world. Development of effective vaccines is not sufficient for successful disease eradication. There is also a need for systematic worldwide campaigns to deliver immunization services to susceptible individuals (Centers for Disease Control and Prevention [CDC], 2013).

Health care workers often travel to remote villages to provide immunization services. (Erichon/Fotolia)

M08_MARY9591_06_SE_C08.indd 200 06/09/14 6:39 PM

chaPter 8 Global influences on Population health 201

At present there are two perspectives regarding eradication efforts. From one perspective, eradication is an appropriate goal if it can be achieved. Feasibility is based on four primary premises:

• Eradication is biologically feasible (e.g., an effective vaccine or other strategy exists).

• Financial resources are sufficient to mount a worldwide campaign.

• Sufficient political will and commitment exist to implement the campaign.

• Social benefits go beyond the mere eradication of disease (e.g., improved economic productivity due to better health).

The second perspective is that eradication provides an avenue for later use of biologic agents as bioterrorist strategies and that global eradication campaigns divert resources away from other broader health and social problems. In 2003, CDC rec- ommended smallpox vaccination for a small group of provid- ers designated as first responders and caregivers for persons infected with smallpox in each U.S. hospital. Vaccination of people who will be handling or administering smallpox vaccine in an emergency situation has been recommended since 2009 (CDC, 2009).

Diseases currently targeted for worldwide eradication in- clude dracunculiasis (guinea worm disease), poliomyelitis, filariasis, mumps, rubella, and pork tapeworm. Several of these efforts will be discussed here. In 1986, the World Health Assembly adopted a resolution to eradicate dracunculiasis, a disease spread by ingestion of contaminated water that causes skin lesions on the lower extremities through which worms up to a meter long exit the host. These lesions often become sec- ondarily infected, causing considerable disease burden. There is no cure for the disease, but it can be prevented by filtering drinking water or treating it with a larvicide and encouraging infected persons to stay out of bodies of water when worms are emerging. At the time of the resolution, there were 3.5 million infected persons in 20 countries where the disease was endemic. By 2009, only 17 countries, all in Africa, continued to report cases of endemic dracunculiasis, and the number of cases reported worldwide had decreased to 3,185 (Division of Foodborne, Waterborne, and Environmental Diseases, 2010).

A similar initiative was undertaken in 1988 to eradicate po- liomyelitis. The WHO strategy for polio eradication consisted of three aspects: (a) interruption of worldwide transmission of the disease, (b) global certification of eradication, and (c) prep- aration for the cessation of routine use of oral polio vaccine (Global Immunization Division, 2004). In 2013, the strategy expanded to address four aspects: (a) stopping all wild polio virus (WPV) transmission and circulating vaccine-derived polio virus (cVDPV) outbreaks, (b) hastening interruption of all polio virus transmission and strengthening immunization systems, (c) certifying all world regions as polio free and safely containing polio virus stocks, and (d) ensuring the permanence of a polio-free world (WHO, 2013c). From 1988 to 2013, the number of reported cases decreased by more than 99%, from

350,000 to 206 (WHO, 2014f). As of 2012, 84% of the world’s children under 1 year of age had received three doses of oral polio vaccine. In 2014, the number of countries with endemic polio had decreased to three—Pakistan, Afghanistan, and Nigeria (WHO, 2014f). Similarly, the worldwide incidence of rubella declined 82% from 2000 to 2009 due, in large part, to increasing immunization levels (Strebel, Dabbaugh, Gacic- Dobo, Reef, & Cochi, 2010). The last case of endemic transmis- sion of rubella in the Americas occurred in 2009, and experts are currently in the process of verifying its elimination from the region (PAHO, 2012).

Reduction of measles mortality is another global initiative related to communicable disease control The number of cases of measles has declined globally, but more than 354,000 still oc- curred in 2011, and nearly 54% of those cases occurred in the African Region (WHO, 2013e).

In 1994, the WHO Region of the Americas agreed on the goal of eliminating endemic measles by 2000, and the Pan American Health Organization set a goal of 95% vaccination coverage with two doses of measles vaccine among children in the Americas. From 2001 to 2014, more than 1.1 million children have been immunized, and 13.8 million deaths were averted worldwide between 2000 and 2012 due to measles im- munization (Global Health, 2014). No cases of endemic mea- sles have been reported in the Americas since 2002 (PAHO, 2014a). The potential for importation of new cases and possible epidemics remains high unless current immunization rates are maintained.

Despite these impressive successes, communicable diseases remain a significant problem affecting global health status. Changing patterns of communicable disease are creating in- creasing global concern. These changes include the emergence of new diseases, many of which are zoonotic viral diseases (those acquired from animals), such as H1N1 and avian influ- enza, Ebola virus, and others. A second change that impairs control strategies is the increasing development of antibiotic resistance in a number of disease-causing agents (Michael & Beaglehole, 2009).

Lower respiratory infection, diarrheal disease, HIV/AIDS, tuberculosis, neonatal infection, and malaria were among the top 10 causes of death in low-income countries. Vaccine pre- ventable diseases remain a problem despite concerted efforts to increase immunization levels. In 1974, WHO began its Ex- panded Program on Immunization. At that time, less than 5% of the world’s children under 1 year of age were effectively immunized with available agents. Current estimates suggest, however, that more than 23 million infants still do not receive routine immunizations (Department of Immunization, Vac- cines, and Biologicals, World Health Organization, 2010), and vaccine preventable diseases continue to be a worldwide concern.

Other diseases that contribute significantly to the global disease burden include HIV/AIDS, tuberculosis (TB), and ma- laria. In 2007, HIV/AIDS was responsible for 30 deaths per 100,000 population with 174 deaths per 100,000 in the African

M08_MARY9591_06_SE_C08.indd 201 06/09/14 6:39 PM

202 Unit 2 influences on Population health

region. It is estimated that one child under 15 years of age dies and another is infected with HIV virus each day throughout the world (MacDonald, 2009). As many as 700,000 infants may be infected with HIV virus by their mothers, approximately 40% through contaminated breast milk. International guide- lines recommend discontinuing breast-feeding in the face of disease if other safe feeding methods are available, but this is often not the case.

HIV/AIDS has a variety of consequences other than mor- bidity and mortality. HIV infection and AIDS impairs peo- ple’s ability to earn enough money to feed their families and diminishes the productive workforce in many high-incidence countries. For example, by 2015, an estimated 20% of the agri- cultural workforce in Africa will have died from AIDS. Societal and family repercussions from the HIV/AIDS epidemic will be felt for generations in many parts of the world (MacDonald, 2009).

During the 20th century, the incidence of tuberculosis de- clined in most of the developed world. At the same time, it in- creased in the rest of the world to the point where the World Health Organization has declared an international emergency. Worldwide tuberculosis killed 1.3 million people in 2010, and 8.6 million others developed the disease. Twenty-two high-bur- den countries account for 80% of tuberculosis cases worldwide, but 11 of them are on target to reach 2015 goals for reduced incidence. More than 75% of tuberculosis occurs in developing areas of the world; 29% in the Asian region alone. Not all cases of TB occur in poorer nations, however. In 2012, more than 360,000 cases occurred in Europe and another 280,000 in the region of the Americas. A significant portion of the tubercu- losis in developed nations occurs in foreign-born individuals who migrate. Treatment of tuberculosis is complicated by the growing incidence of HIV co-infection, with approximately 1.1 million co-infections occurring in 2012 (WHO, 2013b).

Malaria is another significant cause of death; 219 million cases led to 660,000 deaths in 2010. The burden of malaria is significantly higher in some areas than others. An estimated 80% of cases in 2010, for example, occurred in 17 countries, and 80% of deaths occurred in only 14 countries (WHO, 2013e).

Despite higher standards of living and better medical care, the effects of malaria are felt in wealthy countries as well. Be- cause of the limited incidence of malaria, residents in non- endemic areas such as the United States lack the protective immunity acquired from living in malaria-prone areas. In ad- dition, providers are often unfamiliar with the diagnosis and treatment for the disease, leading to misdiagnosis or ineffective therapy. Malaria was virtually eliminated in the United States in the 1950s, but is now reemerging as a condition of concern due to international travel, transport of mosquitoes via trade, and land use changes that have produced new mosquito breed- ing grounds. Approximately 1,500 cases of malaria occur each year in the United States (CDC, 2012b).

Malaria interacts with malnutrition and common respira- tory diseases to increase death rates, particularly among chil- dren. In fact, an estimated 32% of malaria deaths in girls under

5 years of age are attributable to malnutrition (WHO, 2009b). Malaria also increases the risk of maternal and fetal deaths and low birth weight in infants (CDC, 2012b). Elimination of malaria-causing mosquitoes or protection of the population from their bites is an effective preventive strategy for malaria, yet from 2000 to 2008 only 17% of those at risk for malaria in Africa and 5% in the Mediterranean region slept under insecticide-treated nets (WHO, 2010).

Other communicable diseases continue to contribute to worldwide mortality. For example, emerging diseases, such as Ebola virus and Hantavirus infections, have no known cure and result in significant mortality throughout the world. There is also increasing global concern for biological agents that might be used in bioterrorist attacks. Bioterrorism is discussed in more detail in Chapter 25 . CDC has identified three foci for global security related to infectious diseases: preventing the likelihood of outbreaks, detecting threats early, and respond- ing rapidly. Prevention includes immunization, preventing the spread of disease, and preventing the development of antimi- crobial-resistant organisms, as well as promoting food safety. Detection involves linking global surveillance networks, devel- oping rapid specimen testing capacities, and training a biosur- veillance workforce. Elements of response include developing an interconnected global response network and improving worldwide access to medical and nonmedical countermeasures during health emergencies (CDC, 2014).

NONCOMMUNICAbLe CONDITIONs. Noncommunicable conditions are fast approaching communicable diseases as the pri- mary causes of death throughout the world. In 2011, six of the top ten causes of death worldwide were related to noncommunicable diseases. These causes of mortality included, in rank order, coro- nary heart diease; stroke; chronic obstructive pulmonary disease (COPD); cancers of the trachea, bornchus, and lungs; and diabetes mellitus (WHO, 2013d). This shift is predicted to continue until the vast majority of worldwide deaths will be related to noncom- municable conditions. In 2012, coronary heart disease and stroke

Malnutrition is a serious world health concern. (Erichon/Fotolia)

M08_MARY9591_06_SE_C08.indd 202 06/09/14 6:39 PM

chaPter 8 Global influences on Population health 203

together accounted for more than 29% of global mortality (WHO, 2013d).

Another measure of the effects of noncommunicable dis- eases on world health is the disability-adjusted life year. A dis- ability-adjusted life year (DALY) is 1 year of “healthy” life lost as a result of disease (WHO, 2009a) and reflects the burden of disease due to noncommunicable conditions that are often not fatal. Globally, the burden of disease can be considered the gap between current global health status and the ideal of achieving a healthy, disease- and disability-free old age for all the world’s populations (WHO, 2009a).

Despite the growing burden of noncommunicable condi- tions, there is little recognition of its effects in global health efforts, which continue to focus heavily on control of com- municable diseases. Factors that contribute to the increase in noncommunicable conditions include an aging global popu- lation, changes in dietary habits, increased tobacco use, and decreased physical activity (Beaglehole & Yach, 2003/2009). Increases in motorized transportation and subsequent ac- cidents are other contributing factors. In 2011, for example, road injuries accounted for 1.3 million deaths worldwide (WHO, 2013d).

Much of the global burden of noncommunicable disease can be attributed to tobacco use. Globalization affects national economies, frequently making more income available for pur- chase of “luxury” goods such as tobacco. In addition, global ac- cess to technology permits widespread tobacco advertising and targeting of marketing messages to world markets (Beaglehole & Yach, 2003/2009). These factors will require global efforts to control tobacco marketing and consumption. Unfortunately,

these efforts are often undermined by the tobacco industry and by nations, such as the United States, that benefit from global exportation of tobacco products.

Similar global effects are noted with respect to dietary con- sumption, with limitations placed on importation of fresh products from other countries and changes from high fruit and vegetable diets to increasing consumption of fast food and high carbohydrate diets (Beaglehole & Yach, 2003/2009).

Many noncommunicable health conditions are not fatal, but significantly decrease people’s quality of life due to disability. Like causes of death, causes of disability differ markedly among high-, middle-, and low-income countries. For example, de- pression and hearing loss are the leading causes of disability in persons from birth to 59 years of age in high-income countries. Hearing loss is also the most significant cause of disability in middle-income countries, but vision problems are the most common contributor to disability in low-income countries. Worldwide, the most common causes of disability in order of frequency are hearing loss, refractive vision problems, depres- sion, cataracts, unintentional injury, osteoarthritis, alcohol de- pendence and abuse, infertility related to unsafe abortion and sepsis, macular degeneration, and chronic obstructive pulmo- nary disease, all of which caused a significant burden of disease (Mathers & Bonita, 2009).

Social Determinants of Health A number of social factors play a significant role in global health. Among these are poverty, food and water resources, tobacco and alcohol control, motor vehicle traffic, climate

evidence-based Practice

Malaria Malaria is one of the health problems affecting a significant portion of the world’s population. CDC (2012b, 2012d) rec- ommends the use of evidence-based malaria control strate- gies. Commonly used approaches include first line treatment of infected individuals, intermittent preventive therapy (IPT— giving full doses of medication at prescribed intervals) or chemoprophylaxis (use of medications to prevent a condition from occurring), and routine use of insecticide-treated mos- quito nets (ITNs).

First line treatment effectiveness is influenced by the extent of drug resistance in the population and by the funding avail- able for treatment with more or less expensive drugs. The report details the relative effectiveness and potential harmful effects of several individual drugs and drug combinations in the treat- ment of malaria in children. Evidence from systematic reviews of several, randomized controlled trials has indicated that sulf- adoxine-pyrimethamine is an effective approach to both IPT and

chemoprophylaxis, but that use of chloroquine, the most common prophylactic agent, is generally ineffective due to widespread drug resistance of the causative parasite. In other systematic re- views, ITNs were found to be effective in preventing malaria in children, but were less so in protecting pregnant women. In addi- tion, the evidence indicated that relatively few persons at risk had access to or used ITNs.

1. How might population health nurses be involved in the selection of appropriate drugs for malaria treatment?

2. How could they advocate for access to both curative and preventive drug treatment for underserved populations?

3. How could population health nurses in high-risk areas for malaria promote the use of ITNs?

4. How might this information on evidence-based control strategies for malaria be of relevance to population health nurses in the United States?

M08_MARY9591_06_SE_C08.indd 203 06/09/14 6:39 PM

204 Unit 2 influences on Population health

change, and immigration, each of which is briefly discussed below. Disaster, another social determinant of health, which has increasingly dire global ramifications, is discussed in Chapter 25 .

POVerTy. Poverty affects health in a number of ways, from reduced access to health care to inability to afford necessary food, housing, and other requisites for health. The World Bank has defined extreme poverty as an income less than $1.25 per day. By 2010, the millennium development goal of halving the number of people in poverty had been achieved. Even so, 21% of people in the developing world still live in extreme poverty, and 2.4 billion people live on less than $2 per day (World Bank, 2014). It has been suggested that these figures probably underestimate the extent of the world poverty because they do not reflect the income level required for an acceptable standard of living. When one considers the concept of an ethical poverty line, the level of income below which life expectancy is shortened; it is more likely that most of the world’s population falls into this income category (McCoy, 2011).

fOOD AND WATer. Globalization has had a number of effects on food and water supplies. Increasing transportation of food products has had the advantage of opening markets to produce grown in other parts of the world, thus increasing revenues from exportation. At the same time, the advent of global food processors has often undermined local agricultural economies and put small growers out of business. In addition, there is the increased potential for contamination of foodstuffs due to lack of safe production standards.

Beyond the concern for contamination of food is the prob- lem of insufficient food. According to the United Nations Food and Agricultural Organization, 854 million people through- out the world, 60% of whom are women, do not have enough food to eat, and the number of chronically hungry people in- creases by about 4 million persons per year. It is estimated that a child dies of starvation approximately every 5 seconds, and 350 to 400 million of the world’s children are undernour- ished, 70% of them in just ten countries. Although overall poverty in the world declined by 20% in the 1990s, the num- ber of hungry people increased by 18 million in the same time frame (MacDonald, 2009). The term currently used to describe chronic hunger is food insecurity, which is defined as a persis- tent lack of nutritionally adequate and safe food in one’s diet resulting from a “nonsustainable food system that interferes with optimal self-reliance and social justice” (Kregg-Byers & Schlenk, 2010).

Growing hunger is a result of two phenomena: increases in the world’s population and the increasing cost of food. World population estimates are expected to increase by 50% to 9 bil- lion people by 2050. Even by 2030, it is estimated that we will need 50% more food than current requirements, yet food pro- duction is decreasing rather than increasing in many areas. Climate change has led to drought and poor crop yields in many parts of the world. At the same time, the increased use of

biofuels and diversion of food crops to biofuel production has decreased the availability and increased the price of food-based oils necessary for human consumption. For example, the cost of palm oil, a significant source of calories in the developing world, increased 70% in 2007 alone. Maldistribution of food availability is also a factor with the richest 20% of the world’s population consuming 16 times as many calories as the poorest 20% (MacDonald, 2009).

Changes in food consumption patterns and specific nutrient deficiencies are also of concern. For example, meat consump- tion is increasing in many developing countries. Meat is an inefficient source of calories because raising meat sources con- sumes significant amounts of grain crops which could provide better sources of food calories if eaten by humans than animals (MacDonald, 2009). Trade liberalization has also led to in- creased availability of high-calorie, low-nutrient foods such as fast food and processed foods that are contributing to obesity and other chronic health problems. Severe nutrient deficien- cies are also noted in many areas of the world. An estimated 684,000 deaths per year could be prevented, for example, with diets adequate in vitamin A and zinc, and 180 million children under 4 years of age are iron deficient (MacDonald, 2009).

Availability of fresh drinking water is another area of global concern. Long perceived as a public good, water resources are being increasingly privatized in both developed and developing parts of the world. When water resources are publicly owned, guarantee of wholesome supplies with effective sanitation at rea- sonable costs is easier to achieve than when water is considered a profitable commodity. Privatization of water resources often leads to increased costs to consumers. For example, privatization in Bolivia let to a 35% increase in consumer costs, approximately 20% of some family incomes (MacDonald, 2009).

Although some progress has been made in providing safe drinking water and effective sanitation throughout the world, significant portions of the world’s population still do not have clean water supplies. In 2011, safe drinking water was available to only 89% of the world’s population. This figure meets the 11% target of the millennium development goals, but 768 mil- lion people remain without access to improved water sources (WHO & UNICEF, 2013).

Similar findings are noted for access to effective sanitation facilities. Sanitation coverage was at 64% in 2011 and is not ex- pected to meet the MDG goal of 75% by 2015. Approximately 2.5 million people do not have access to sanitation facilities, and 15% continue to practice open defecation, increasing the risk of infectious diseases (WHO & UNICEF, 2013).

Lack of water for hygiene and efforts required to obtain water have a variety of other effects as well. For example, nu- merous deaths occur each year from diarrheal and respiratory illnesses that could be prevented with adequate hand washing. In addition, time spent by family members in fetching water from distant sources decreases time for education or employ- ment. Women, in particular, may experience sexual assault while traveling long distances to obtain water or defecating in open areas. These dangers may lead to attempts to withhold

M08_MARY9591_06_SE_C08.indd 204 06/09/14 6:39 PM

chaPter 8 Global influences on Population health 205

bodily functions resulting in constipation and urinary tract in- fections. Water is also needed for effective treatment of HIV/ AIDS and tuberculosis, and standing water provides breeding grounds for mosquitoes that spread malaria and other diseases.

Some jurisdictions are implementing the safe water man- agement systems developed by CDC to promote access to clean water. Such programs incorporate several components, includ- ing: (a) household water treatment with chlorine disinfectant powder, solar irradiation, or ceramic or slow sand filtration, (b) safe water storage in vessels that prevent contamination, and (c) behavior change to promote hygiene and safe food and water handling practices. These low-cost programs have been found to be effective in improving water quality and decreasing the incidence of disease (CDC, 2012a).

TObACCO AND ALCOHOL CONTrOL. One in ten adult deaths, or a total of 4 million deaths each year, is attributable to tobacco use, and this figure is expected to rise to one in six deaths by 2030. Over the years, the burden of tobacco-related disease has shifted from high-income to low-income countries. By 2030, for example, an estimated 70% of tobacco-related deaths will occur in low-income nations (Collin, Lee, & Bissell, 2002/2009).

Much of this shift is the result of the globalization of the to- bacco trade with increased access to international markets due to trade liberalizations, greater telecommunication marketing, economies of scale resulting from production by large multi- national corporations, and the ability of transnational compa- nies to undermine local anti-tobacco regulations (Collin et al., 2002/2009).

The WHO Framework Convention on Tobacco Control was initiated as a binding treaty designed to foster to- bacco control legislation by signatory nations (Collin et al., 2002/2009). Unfortunately, the United States, a significant producer of tobacco products, has refused to sign the treaty, thereby undermining its effectiveness. The tobacco industry at large has undertaken a variety of measures to weaken the provisions of the convention. These include initiating ineffec- tive youth smoking education and prevention activities to gain public good will, promoting government endorsement of such activities to draw attention away from effective control pro- grams, and detracting from serious consideration of control measures by focusing attention on “more important” public health issues such as communicable diseases and terrorism (Collin et al., 2002/2009).

Unlike many other global public health issues, tobacco control, and control of other harmful substances such as ille- gal drugs, will require more than public education. Such ac- tivities are often undermined by the efforts of special interest groups such as the tobacco industry and the manufacturers and suppliers of illicit drugs. International regulatory efforts con- trolling advertising, sale, and use of such substances will be re- quired. Such efforts, even within a single jurisdiction, may have cross-border effects. For example, California tobacco control policies related to no-smoking legislation, taxes, advertising

limitations, community involvement, media campaigns, and smoking cessation assistance in border areas have decreased tobacco use in neighboring Tijuana, but not farther south in Mexico (Martinez-Donate et al., 2008).

MOTOr VeHICLe TrAffIC. Globalization, in general, depends on mobility, which is fostered by use of motorized transportation, including cars and air planes. The automotive industry was one of the first to become globalized, with cars being mass produced and mass consumed. Unfortunately, the increase in automobile availability is often not accompanied by road infrastructure development, resulting in increased traffic congestion and environmental deterioration.

Although car ownership is beneficial at the individual level, its population effects are less advantageous. As noted earlier, increasing use of motor vehicles for transportation decreases physical activity among the population, contributing to obe- sity and other related noncommunicable conditions. Increased consumption of fuel oil to transport people and goods, has also led to a growing energy crisis, and as we saw earlier, has re- sulted in the diversion of food crops to the creation of biofuels. Greater use of motor vehicles also contributes to air pollution, noise, and environmental degradation.

In addition, the incidence of motor vehicle accidents has in- creased tremendously, resulting in significant trauma-related morbidity and mortality. More than 1.2 million deaths occur each year, and traffic fatalities are expected to become the fifth leading cause of death by 2030 (WHO, 2013a).

In response to this growing problem, the United Nations has initiated road safety collaboration. Recommendations for dealing with the problem of motor vehicle accidents have been grouped into four safety areas: safer transport and land use pol- icies, safer roads, safer vehicles, and safer people. Safer trans- port and land use policies address the need for reduction of motor vehicle traffic and use of safer modes of transportation, including mass transportation systems. Such policies should also focus on restrictions in motor size and power, driving age restrictions, and the use of graduated licenses, so that new drivers receive adequate supervision. The recommendations also call for safer roads that incorporate safety features in their designs. Such features might include sidewalks for pedestrian protection, bicycle lanes, and speed reduction and traffic calm- ing strategies such as speed bumps and traffic lights (WHO, 2013a).

Recommended features of safer vehicles include automatic day-time headlight use, safety testing for vehicles, and safety standards and requirements (e.g., seat belts, air bags). Finally, measures to develop “safer people” include restrictions and sanctions for driving under the influence of drugs or alcohol, no speeding, and use of protective helmets for motorcycle and scooter riders (WHO, 2013a).

CLIMATe CHANGe. Global climate changes have had a significant impact on population health throughout the world. The effects of climate change on health are both direct and

M08_MARY9591_06_SE_C08.indd 205 06/09/14 6:39 PM

206 Unit 2 influences on Population health

indirect. Direct effects include the impact of increased heat, flooding, and drought that lead to changes in the distribution of vector- and waterborne diseases. The effect of climate change on food production was addressed earlier. Indirect effects are a result of the social upheaval that occurs with food scarcity, leading to violence and conflict, and changes in refugee and migration streams. These and other effects of climate change were addressed in Chapter 4 .

IMMIGrATION. Population movement is a salient feature of globalization. Transient movement related to business, industry, and tourism may have beneficial effects on national and global economies. Other forms of immigration, however, arise from and create social problems that cause people to migrate from one place to another. It is estimated that there were approximately 232 million legal and illegal immigrants throughout the world in 2013, and the growth in the immigrant population has been about 1.6% per year since 2010. Half of the world’s immigrant population lives in ten countries, with the United States having the largest number of immigrants. Nearly half of the immigrant population is composed of women (United Nations Population Division, 2013).

Migration may be forced or voluntary. People engage in vol- untary migration when they choose to move from one place to another, often in search of better employment opportunities, better climate, or other factors. Forced migration arises out of conflict, persecution, natural or environmental disasters (such as famine or chemical or nuclear accidents), or the results of “development projects” as when people are displaced by dams that cause flooding in their original location. In 2013, there were an estimated 15.7 million refugees worldwide (United Nations Population Division, 2013). Unfortunately, developing countries, that are themselves poor, house 90% of the world’s refugee population (66%% of them in Asia and nearly 19% in Africa (United Nations Population Division, 2013).

Migration sometimes occurs from developing to developed nations. For example, in 2012, more than 1 million people en- tered the United States as legal permanent residents and an- other 58,000 were admitted as refugees. In addition, more than 165.5 million non-immigrants arrived in the United States for limited periods of time, primarily on business, for study, or as tourists. Finally, more than 643,000 persons were apprehended entering illegally (Office of Immigration Statistics, 2013). An unknown number of undocumented immigrants also cross U.S. borders each year, contributing to the economy but also to the risk for health problems.

People engaged in both voluntary and forced migration may experience better opportunities, but they may also be sub- jected to exploitation and abuse because of their vulnerability and lack of familiarity with the laws and customs of their new homelands. Although they may be healthier than those who remain in their countries of origin, immigrants tend to be at greater risk for health problems than the native-born popula- tions of their new homes. Immigrants tend to use health care services less than their native-born counterparts, particularly

mental health services, and may have less access to care or be unaware of eligibility for services. In some immigrant popula- tions, the incidence of mental health problems has increased with subsequent generations in the United States, possibly as a result of discrimination, social stress, and downward social mobility. They are also frequently less likely to engage in health promotion and illness prevention behaviors, although their preferred diets are often healthier at entry.

Mental health problems created by hardships during im- migration may be compounded by social isolation and dis- crimination experienced in the host country (Park, Cho, Park, Bernstein, & Shin, 2013). Discrimination may lead to socioeco- nomic disadvantage and greater exposure to environmental hazards, pollution, and stress, and perceptions of discrimination have been associated with increased incidence of chronic dis- eases such as heart disease and respiratory illness. Perceived dis- crimination is also related to depression (Sirin, Ryce, Gupta, & Rogers-Sirin, 2013). In their new countries, immigrants may experience poverty and poor living and working conditions. In fact, immigrants may be at greater risk for workplace fatali- ties than the general population because of employment in the most dangerous jobs.

Poorer health status among refugee populations may also put the general population of the host country at risk. For ex- ample, legal requirements for vaccination do not apply to U.S. refugees, but they must be immunized prior to applying for permanent residence. Whether immigrants should be immu- nized before or after their arrival has long been debated, but the potential costs of both vaccination and care for those who become infected suggest that pre-arrival immunization would be of greater benefit to society. Failure to immunize immigrant populations may have other serious and costly consequences. For example, debilitated refugees may be subject to a variety of communicable diseases that may spread to the larger popula- tion. For all of these reasons, population health nurses should be involved in the delivery of services and development of pol- icy related to immigrant health.

Population Health Nursing and Global Health Why should a nurse working in a particular country, such as the United States, be concerned about globalization and global health issues? The most obvious answer to this question, of course, is to be able to understand the effects of global health issues on the health status of the local population, but there are other reasons as well. Some of these include delivery of health services to an international clientele, policy development, and involvement in global health issues through international nursing organizations.

Service Delivery Nurses in most countries will encounter clients from a variety of other nations. These clients may need assistance in navi- gating the health system differences between their countries

M08_MARY9591_06_SE_C08.indd 206 06/09/14 6:39 PM

chaPter 8 Global influences on Population health 207

of origin and their current countries of residence. Knowledge of these other health systems will allow nurses to better edu- cate clients with respect to similarities and differences between health systems and how to navigate the system in their country of residence. Similarly, knowledge of the health problems prev- alent in their countries of origin can assist population health nurses in assessing the health status of individuals from other parts of the world.

At some point population health nurses may also work or travel in other countries, and knowledge of health systems and prevalent health problems can help them to better protect their own health or meet the health needs of their host countries. Finally, population health nurses may find themselves working with nurses from other countries, either at home or in interna- tional arenas, and knowledge of their health care systems will permit more effective collaboration in addressing the health care needs of all of the world’s populations.

Framing Global Policy Issues Health policy issues are those that rise to the consciousness of policy makers. Policy is a set of principles determining the direction for action and allocation of resources to achieve an identified prioritized goal. Many serious health problems, how- ever, never rise to the level of policy issues. What, then, distin- guishes these problems from identified policy issues?

Some authors have noted that attracting and sustaining at- tention from the global community to specific issues depends upon how they are framed. The point has been made that pol- icy issues are not always related to the severity or impact of the problem, but to “institutions that create, negotiate, promote, and sustain” portrayals of the issues that keep attention cen- tered upon them (Shiffman, 2009, p. 610). Institutions, in this context, are not specific organizations or agencies, but are the “rules, norms, and strategies adopted by individuals within or across organizations” (quoted in Shiffman, 2009, p. 610). At- tention to specific issues may be mediated by social interpreta- tions or understandings of the issue.

Many issues are backed by powerful institutions that may be preexisting or be created specifically to draw attention to issues (Shiffman, 2009). For example, we will see in Chapter 9 that the tobacco industry is a powerful institution that tries to frame the issue of tobacco use in ways that will not lead to restriction of sales. Other institutions are purposefully created to address a particular issue; for instance, time-limited political action groups arise to support or oppose specific ballot initiatives and then disappear after the election.

Institutions mobilize resources, initiate programs, and sup- port research related to the problem of interest, but may also cre- ate portrayals of the problem that sustain the interest of the public or influential policy makers (Shiffman, 2009). For example, if the public is concerned about national security, framing an immu- nization issue around the concept of the potential for terrorist- engendered epidemics may promote public support and federal funding for vaccine development and immunization services.

Policy issues are framed by members of policy communi- ties, which are defined as “networks of individuals (including researchers, advocates, policy makers and technical officials) and organizations (including governments, non-governmen- tal organizations, United Nations agencies, foundations, and donor agencies) that share a concern for a particular issue” (Shiffman, 2009, p. 608). Issues that are successful in gaining the sustained attention of global policy makers “may be ones in which policy community members have discovered frames— ways of positioning an issue—that resonate with global and na- tional political elites, and then established institutions that can sustain these frames” (Shiffman, 2009, p. 608).

Population health nurses can help to frame global health problems in ways that attract the attention of the public and policy makers. In general, there are five ways of framing health issues to focus attention on them. The first approach is to frame health problems as security issues that may contribute to risk of infection or political and economic instability. What, for example, would be the nutritional and economic effects of worldwide contamination of food with chemical toxins?

Health problems can also be framed as development issues or as desired outcomes of global economic development. For example, provision of clean water supplies easily accessible may free women from onerous household chores to join a la- bor force severely depleted by illness, in addition to preventing the spread of waterborne diseases. Thus, a health-related inter- vention can promote economic development as well as popula- tion health status.

A third approach to framing health issues is as global public goods. This approach lauds the collective benefit of interven- tion over individual gain, and promotes the good as something open to all that does not lessen its availability to others. Health- related issues can also be framed as “commodities” or tradable goods. For example, research to find newer and more effective medications for a variety of conditions have been supported as an avenue to increased profit. This approach to framing an is- sue may actually have negative health effects by limiting access to the resulting medications to those who can pay for them.

Global Perspectives

The role of population health nurses differs from one part of the world to another. Select another country in which you are interested and explore the role of population health nurses in that country. How does the role differ from that of population health nurses in your own area? What factors contribute to those differences? How easy or difficult would it be for a population health nurse educated in the United States to engage in population health nursing in that country? What factors would influence a U.S. nurse’s ability to function in the expected population health role?

The Population Health Nursing role

M08_MARY9591_06_SE_C08.indd 207 06/09/14 6:39 PM

208 Unit 2 influences on Population health

Finally, health issues may be framed in terms of a human right leading eventually to international rights agreements. Unfortunately, such agreements are difficult to enforce and require equal access to care and provision of access to basic survival needs. In actual fact, a combination of all of the above approaches (except the commodity approach) may be what is needed to frame health-related problems in such a way that they attain and sustain global attention and efforts to resolve them. There is a need for combined discussion of moral, legal, and economic parameters in the framing of global health issues, and population health nurses can help to support all of these levels of discussion.

International Nursing Organizations Population health nurses are supported in their international activities by several agencies and organizations. WHO recog- nizes the importance of nursing (and midwifery) services to the accomplishment of global health objectives and so maintains a Nursing and Midwifery Office to assist with nursing develop- ment throughout the world. The division has outlined several strategic directions for its efforts including:

• Developing action plans to incorporate nursing and mid- wifery as an integral part of national health plans

• Forging strong interdisciplinary health teams to resolve pri- ority health issues

• Improving nursing and midwifery education • Collaborating with nursing and midwifery professions to

strengthen regulatory processes • Strengthening datasets on nursing and midwifery as an inte-

gral part of workforce information systems • Utilizing the expertise of nursing and midwifery researchers • Actively engaging nurses and midwives in health care plan-

ning, implementation, and evaluation and policy formation • Implementing strategies to enhance interprofessional educa-

tion and collaborative practice • Including nurses and midwives in the development of strat-

egies for recruitment and retention and improved working conditions

• Implementing the WHO Global Code of Practice on the International Recruitment of Health Personnel (WHO, n.d.).

Another avenue for international involvement by com- munity health nurses is the International Council of Nurses (ICN). ICN is a federation of national nurses’ associations, in- cluding the American Nurses Association, representing nurses in more than 130 countries. Established in 1899, ICN was the first international organization for health professionals (ICN, 2013a). The organization was established to address three pri- mary goals:

• To promote worldwide nursing exchange • To advance the nursing profession • To influence global health policy

In its efforts to achieve these three goals, ICN works to standard- ize professional nursing practice worldwide and to improve

the socioeconomic welfare of nurses. ICN’s mission is to “represent nursing worldwide, advancing the profession and influencing health policy” (ICN, 2013b). One of the major ways in which ICN works to achieve this mission is through the creation of nursing networks that serve as avenues for the exchange of nursing knowledge and expertise in specific areas. Current ICN initiatives focus on professional nursing practice, nursing regulation, and the socioeconomic welfare of nurses. Specific practice foci include the International Classification for Nursing Practice (ICNP), advanced nursing practice, entrepreneurship, women’s health, primary health care, family health, safe water, and HIV/AIDS, tuberculosis, and malaria (ICN 2013b). For further information about ICN and its activities, see the External Resources section of the stu- dent resources site.

Sigma Theta Tau International is another international nursing organization. Established in 1922 by six U.S. nursing students, Sigma Theta Tau’s goal is to provide leadership and support scholarship related to nursing practice, education, and research to improve the health of the world’s population. The organization was the first funder of nursing research in the United States and currently supports a variety of nurs- ing education and research initiatives. In 1985, the organiza- tion was incorporated as Sigma Theta Tau International, Inc. to better connect the worldwide network of scholars who promote health worldwide. Membership currently embraces nurses in 86 countries throughout the world (Sigma Theta Tau International, n.d.).

One final international nursing organization to be dis- cussed here is the Global Alliance for Leadership in Nursing Education and Science (GANES). GANES is an organization of national associations of nursing deans and schools of nursing established to support health care pol- icy makers and nurse educators throughout the world. Its mandate is to “work in partnership with global and national organizations to raise awareness of the key role of nurse education in the improvement of global health and quality of care” (GANES, n.d.b). The founding members of GANES include the national nursing education organizations of the United Kingdom, Canada, the United States, and Australia and New Zealand. GANES activities include promoting sharing among nurse educators around the world, provid- ing information and advice to global policy makers related to nursing education issues, and supporting development of a sound evidence base for nursing practice and education (GANES, n.d.a). For additional information about Sigma Theta Tau and GANES, see the External Resources section of the student resources site.

Population health nurses may also be actively involved in a wide variety of international nursing and multidisciplinary organizations that address special focus areas such as violence against women, menopause, child health, HIV/AIDS, fam- ily health, and so on. As we have seen, a wide variety of health problems cross national boundaries, and global approaches must be taken to resolve them.

M08_MARY9591_06_SE_C08.indd 208 06/09/14 6:39 PM

chaPter 8 Global influences on Population health 209

Peace Corps volunteers (PCVs) in one small village in India in the 1960s initiated an immunization program for DTP and po- lio immunizations in the local Primary Health Center and its five substations in outlying villages. The volunteers got funding for an initial supply of vaccines from the International Rotary Club. Vaccines were purchased in Bombay, a trip of 250 miles from the health center, and transported on ice to the village. This trip needed to be made every 6 weeks because of the lim- ited shelf-life of the oral polio vaccine.

Since the health center only possessed two syringes, the PCVs acquired used disposable syringes and needles from Peace Corps headquarters in Bombay. This equipment was of the type that could be resterilized by boiling and several hun- dred syringes were used each year to update immunizations for volunteers in the region. A very small fee was charged for each immunization. This revenue was used to pay for sub- sequent vaccine purchases and the program was essentially self-funding.

The PCVs gave the immunizations themselves, both in the health center itself and on specific immunization days in the subcenters. Immunizations were also begun in the local school. Unfortunately, after the first dose of DTP in the school setting,

many of the children developed mild inflammation and sore- ness at the injection sites. Their parents complained to the physician director of the health center who stopped further immunization in the school setting. One member of the health center staff, whose daughter had been nursed by the volunteers through a life-threatening episode of typhoid, became a local proponent for immunization in the village. Many of her friends and family came to the health center requesting immunizations. Unfortunately, she was of lower-class status and did not have influence with upper-class residents.

Just before the volunteers were scheduled to leave India, they took one of the host-country staff to Bombay and showed him where to purchase the vaccines. They left a supply of syringes and needles that could be used by the staff of the health center to continue the program. The program was sustained for a year or so after the volunteers left, but then dwindled away.

1. What might the Peace Corps volunteers have done differ- ently to create a sustainable immunization program in this village?

2. How might the program have been expanded to encompass other villages in the region?

CAse sTUDy

Globalization is affecting population health as well as other is- sues throughout the world. Globalization occurs within four dimensions, the spatial, temporal, cognitive, and social dimen- sions. Globalization has both positive and negative effects on population health. Positive health effects derive from dissemi- nation of new knowledge and effective interventions, develop- ment of international standards, and increasing concern for global social justice. Negative effects include the rapid spread of disease, dietary and activity changes, increased substance abuse, traffic accidents, and global warming.

Global health differs from international health in its broader scope. Where international health issues usually lie between two countries, global health issues cross multiple international boundaries and affect large segments of the globe. Several

global and international health organizations work to address global health issues including WHO and PAHO.

A number of current issues affect the health of the world’s population. These include life expectancy, communicable and chronic diseases, poverty, safe food and water resources, tobacco and alcohol control, motor vehicle accidents, violence, climate change, immigration, and disaster response. Many of these is- sues center on the Global Millennium Development Goals, which are similar to the Healthy People 2020 objectives in the United States. Population health nurses can be involved in the resolu- tion of these issues through direct service delivery, policy for- mation, and participation in international professional nursing organizations such as ICN, Sigma Theta Tau, and GANES, and other organizations designed to address global health issues.

CHAPTer reCAP

Cooperation for Polio elimination

M08_MARY9591_06_SE_C08.indd 209 06/09/14 6:39 PM

210 Unit 2 influences on Population health

Association of State and Territorial Health Officials. (2013). Global infectious disease. Retrieved from http://www.astho.org/programs/infectious-disease /refugee-health/global-infectious-disease---impact-on-state-and-territorial- health/

Bartsch, S., Hein, W., & Kohlmorgen, L. (2007). Interfaces: A concept for the analysis of global health governance. In W. Hein, S. Bartsch, & L. Kohlmorgen (Eds.), Global health governance and the fight against HIV/ AIDS (pp. 18–37). New York, NY: Palgrave Macmillan.

Beaglehole, R., & Bonita, R. (2010). What is global health? Global Health Action, 3, 5242. doi: 10.3402/gha.v3i0.5142

Beaglehole, R., & Yach, D. (2003/2009). Globalisation and the prevention and control of non-communicable disease: The neglected chronic diseases of adults. The Lancet, 362, 903–908. Reprinted in J. J. Kirton (Ed.), Global health (pp. 137–142). Farnham, Surrey, UK: Ashgate.

Bill & Melinda Gates Foundation. (n.d.). Global health program. Retrieved from http://www.gatesfoundation.org/global-health/Pages/overview.aspx

Center for the Study of the History of Nursing, School of Nursing, University of Pennsylvania. (n.d.). International Council of Nurses Records, 1946–1970 (MC # 112). Retrieved from http://www.nursing.upenn.edu/history /Documents/ICN_MC112_Brief_Description.pdf

Centers for Disease Control and Prevention. (2009). Questions and answers about smallpox vaccine. Retrieved from http://emergency.cdc.gov/agent /smallpox/faq/characteristics.asp

Centers for Disease Control and Prevention. (2012a). CDC and the safe water system. Retrieved from http://www.cdc.gov/safewater/PDF/SWS- Overview-factsheet508c.pdf

Centers for Disease Control and Prevention. (2012b). Malaria: Frequently asked questions. Retrieved from http://www.cdc.gov/malaria/about/faqs.html

Centers for Disease Control and Prevention. (2013). Preferred usage. Retrieved from http://wwwnc.cdc.gov/eid/pages/preferred-usage.htm

Centers for Disease Control and Prevention. (2014). Medicare and Medicaid research review/ 2013 statistical supplement. Retrieved from http://www.cdc .gov/globalhealth/security/ghsagenda.htm

Collin, J., Lee, K., & Bissell, K. (2002/2009). The Framework Convention on Tobacco Control: The politics of global health governance. Third World Quarterly, 23, 265–282. Reprinted in J. J. Kirton (Ed.), Global health (pp. 137–142). Farnham, Surrey, UK: Ashgate.

Center for Global Health. (n.d.). Global health: Who we are. Retrieved from http://www.cdc.gov/globalhealth/index.html

Department of Immunization, Vaccines, and Biologicals, World Health Organization. (2010). Global routine vaccine coverage, 2009. Morbidity and Mortality Weekly Report, 59, 1367–1371.

Division of Foodborne, Waterborne, and Environmental Diseases. (2010). Progress toward global eradication of dracunculiasis, January 2009–June 2010. Morbidity and Mortality Weekly Report, 59, 1239–1242.

Dodgson, R., Lee, K., & Drager, N. (2002/2009). Global Health Governance, a Conceptual Review, Discussion Paper No. 1, Centre on Global Change and Health, London School of Hygiene and Tropical Medicine, Department of Health and Development, World Health Organization, 5–17. Reprinted in J. J. Kirton (Ed.), Global health (pp. 137–142). Farnham, Surrey, UK: Ashgate.

Ezeani, K. O. (2012). Globalization, poverty, and inequality. Retrieved from http://www.academia.edu/1829893/Globalisation_Poverty_and_Inequality

Fidler, D. P. (2001/2009). The globalization of public health: The first 100 years of international health diplomacy. Bulletin of the World Health

Organization, 79, 842–849. Reprinted in J. J. Kirton (Ed.), Global health (pp. 125–132). Farnham, Surrey, UK: Ashgate.

Global Alliance for Leadership in Nursing Education and Science. (n.d.a). GANES: Global Alliance for Leadership in Nursing Education and Science., from http://www.ganes.info/documents/GANESBrochure310.pdf

Global Alliance for Leadership in Nursing Education and Science. (n.d.b). Mission. Retrieved from http://www.ganes.info/About.php

Global Health. (2014). Measles & rubella: Eliminating measles, rubella & con- genital rubella syndrome (CRS) worldwide. Retrieved from http://www.cdc. gov/globalhealth/measles/

Global Immunization Division, National Immunization Program. (2004). Global polio eradication initiative strategic plan, 2004. Morbidity and Mortality Weekly Report, 53, 107–108.

Hixon, A. L., & Maskarinec, G. G. (2008). The Declaration of Alma Ata on its 30th anniversary: Relevance for family medicine today. Family Medicine, 40, 585–588. No doi:

Institute of Medicine. (2009). The U.S. commitment to global health: Recommen- dations for the public and private sectors. Washington, DC: The National Academies Press.

International Council of Nurses. (2013a). About ICN. Retrieved from http:// www.icn.ch/about-icn/about-icn

International Council of Nurses. (2013b). The ICN story—1899–1999. Retrieved from http://www.icn.ch/about-icn/the-icn-story-1899-1999

International Council of Nurses. (2013c). Our mission. Retrieved from http:// www.icn.ch/about-icn/icns-mission

Fogarty International Center. (n.d.). About the Fogarty International Center. Re- trieved from http://www.fic.nih.gov/About/Pages/default.aspx

Kates, J., & Katz, R. (2010). U.S. global health policy: U.S. participation in in- ternational health treaties, commitments, partnerships, and other agreements. Retrieved from http://www.kff.org/globalhealth/8099.cfm

Kickbush, I. (2000/2009). The development of international health policies— Accountability intact? Social Science & Medicine, 51, 979–989. Reprinted in J. J. Kirton (Ed.), Global health (pp. 396–405). Farnham, Surrey, UK: Ashgate.

Kregg-Byers, C. M., & Schlenk, E. A. (2010). Implications of food insecurity on global health policy and nursing practice. Journal of Nursing Scholarship, 42, 278–285.

Lee, K. (2010). Civil society organizations and the functions of global health governance. Global Health Governance, III (2). Retrieved from http://blogs .shu.edu/ghg/files/2011/11/Lee_Civil-Society-Organizations-and-the- Functions-of-Global-Health-Governance_Spring-2010.pdf

MacDonald, T. H. (2009). Removing the barriers to global health equity. Abingdon, UK: Radcliffe.

Martinez-Donate, A. P., Hovell, M. F., Hofstetter, C. R., Gonzalez-Perez, G. J., Kotay, A., & Adams, M. A. (2008). Crossing borders: The impact of the California tobacco control program on both sides of the US–Mexico bor- der. American Journal of Public Health, 98, 258–267.

Mathers, C., & Bonita, R. (2009). Current global health status. In R. Beaglehole & R. Bonita (Eds.), Global public health: A new era (2nd ed., pp. 23–61). Oxford, UK: Oxford University Press.

McCoy, D. (2011). Humanitarianism – Moving beyond medical rescue to poverty reduction, sustainable development and justice? Retrieved from http://www .phmovement.org/en/node/6254

McDonald, J. A., Mojarro, O., Sutton, P. D., & Ventura, S. J. (2013). A binational overview of reproductive health outcomes among US Hispanic and Mexican women in the border region. Preventing Chronic Disease, 10, 130019. doi: http://dx.doi.org/10.5888/pcd10.130019

refereNCes

M08_MARY9591_06_SE_C08.indd 210 06/09/14 6:39 PM

chaPter 8 Global influences on Population health 211

Michael, A., & Beaglehole, R. (2009). The global context for public health. In R. Beaglehole & R. Bonita (Eds.), Global public health: A new era (2nd ed., pp. 1–22). Oxford, UK: Oxford University Press.

National Human Trafficking Resources Center. (2010). Human trafficking sta- tistics: Polaris report. Retrieved from http://www.handsacrosstheworldmn .org/resources/Human+Trafficking+Statistics.pdf

NGO Global Network. (n.d.). Definition of NGOs. Retrieved from www.ngo .org/ngoinfo/define.html

Office of Global Affairs. (n.d.). Who we are. Retrieved from http://www.global- health.gov/about-us/

Office of Immigration Statistics. (2013). 2012 yearbook of immigration statis- tics. Retrieved from https://www.dhs.gov/sites/default/files/publications/ ois_yb_2012.pdf

Pan American Health Organization. (2011). Values, vision and mission of the Pan American Sanitary Bureau. Retrieved from http://new.paho.org/hq /index.php?option=com_content&task=view&id=95&Itemid=163

Pan American Health Organization. (2012). Experts start verifying measles, ru- bella elimination from the Americas. Retrieved from http://www.paho.org /hq/index.php?option=com_content&view=article&id=4558%3Aexperts- start-verifying-measles-rubella-elimination-americas&catid=1637%3Afgl- 03-measles-featured-items&Itemid=1711&lang=en

Pan American Health Organization. (2013). About PAHO. Retrieved from http://new.paho.org/hq/index.php?option=com_content&task=view&id=9 1&Itemid=220

Pan American Health Organization. (2014a). No endemic transmission of measles in the Americas since 2002. Retrieved from http://www.paho.org/hq./index .php?option=com_content&view=article&id=9318%3Ano-endemic- transmission-of-measles-in-the-americas-since-2002&catid=1443%3 Anews-front-page-items&Itemid=358&lang=fr

Pan American Health Organization. (2014b). Regional Core Health Data Initiative. Retrieved from http://www.paho.org/HQ/index.php?option= com_content&view=article&id=2151&Itemid=1876&lang=en

Pan American Health Organization. (2014c). Regional Core Health Data Initiative: Profiles by country. Retrieved from

Park, S. Y., Cho, S., Park, Y., Bernstein, K. S., & Shin, J. (2013). Factors asso- ciated with mental health service utilization among Korean American immigrants. Community Mental Health Journal, 49, 765-773. doi: 10.1007/ s10597-013-9604-8

Quandl. (2014). GDP as share of world GDP at PPP by country. Retrieved from http://www.quandl.com/economics/gdp-as-share-of-world- gdp-at-ppp-by-country

Ram, P. K., Kelsey, E., Ratsoatioana, M. R. R., Rakotomalala, O., & Dunstan, C. (2007). Bringing safe water to remote populations: An evaluation of a portable point-of-use intervention in rural Madagascar. American Journal of Public Health, 97, 398–400.

Ross, J. (2013). Only 30% of the world now has a higher GDP per capita than China. Retrieved from http://ablog.typepad.com/keytrendsinglobalisation /2013/05/only-30-of-the-world-now-has-a-higher-gdp-per-capita-than- china.html

Shiffman, J. (2009). A social explanation for the rise and fall of global health issues. Bulletin of the World Health Organization, 87, 608–613. doi:10.2471/ BLT.08.06749

Sigma Theta Tau International. (n.d.). Organizational fact sheet. Retrieved from http://www.nursingsociety.org/aboutus/mission/Pages/factsheet.aspx

Sirin, S. R., Ryce, P., Gupta, T, & Rogers-Sirin, L. (2013). The role of accultura- tive stress on mental health symptoms for immigrant adolescents: A longi- tudinal investigation. Developmental Psychology, 49, 736-748. doi: 10.1037/ a0028398

Stadtfeld, R. (translator). (2012). The evolution of the per capital income lev- els in the world. Retrieved from http://www.inequalitywatch.eu/spip .php?article102

Strebel, P., Dabbaugh, A., Gacic-Dobo, M., Reef, S. E., & Cochi, S. (2010). Progress toward control of rubella and prevention of congenital rubella syndrome—Worldwide, 2009. Morbidity and Mortality Weekly Report, 59, 1307–1310.

Susan G. Komen Foundation. (2014). About us. Retrieved from http://ww5 .komen.org/AboutUs/AboutUs.html

United Nations. (2012). The Millennium Development Goals report 2012. Re- trieved from http://mdgs.un.org/unsd/mdg/Resources/Static/Products/ Progress2012/English2012.pdf

United Nations. (2013). Millennium development goals and beyond 2015. Re- trieved from http://www.un.org/millenniumgoals/reports.shtml

United Nations Children’s Fund. (2009). The state of the world’s children, Special edition: Executive summary. Retrieved from http://www.unicef .org/rightsite/sowc/pdfs/SOWC_SpecEd_CRC_ExecutiveSummary_ EN_091009.pdf

United Nations Children’s Fund. (2014). The state of the world’s children 2014 in numbers: Every child counts: Revealing disparities, advancing chil- dren’s rights. Retrieved from http://www.unicef.org/sowc2014/numbers/ documents/english/SOWC2014_In%20Numbers_28%20Jan.pdf

United Nations Population Division. (n.d.). International migration. Retrieved from http://esa.un.org/unmigration/wallchart2013.htm

United States-Mexico Border Health Commission. (n.d.). Overview. Retrieved from http://www.borderhealth.org/about_us.php

U.S. Agency for International Development. (2014). Who we are. Retrieved from http://www.usaid.gov/who-we-are

U.S. Department of Health and Human Services. (2013). Global health. Re- trieved from http://www.healthypeople.gov/2020/topicsobjectives2020 /overview.aspx?topicid=16

U.S. Department of State. (2013). Trafficking in persons report June 2013. Re- trieved from http://www.state.gov/documents/organization/210737.pdf

U.S. Food and Drug Administration. (2014). International programs. Retrieved from http://www.fda.gov/internationalprograms/default.htm

Wagstaff, A., Bustreo, F., Bryce, J., Cleason, M.; The WHO-World Bank Child Health and Poverty Working Group. (2004). Child health: Reaching the poor. American Journal of Public Health, 94, 726–736.

Walzer, M. (2011). On humanitarianism: Is helping others charity, or duty, or both? Foreign Affairs, 90(4). Retrieved from http://www.foreignaffairs.com /articles/67931/michael-walzer/on-humanitarianism

World Bank. (2013). Defining civil society. Retrieved from http://web.world- bank.org/WBSITE/EXTERNAL/TOPICS/CSO/0,,contentMDK:2010149 9~menuPK:244752~pagePK:220503~piPK:220476~theSitePK:228717,00. html

World Bank. (2014). Poverty overview. Retrieved from http://www.worldbank .org/en/topic/poverty/overview

World Health Organization. (n.d.). Nursing and midwifery at WHO. Retrieved from http://www.who.int/hrh/nursing_midwifery/en/

World Health Organization. (2008). Primary health care: Now more than ever. Retrieved from http://www/who.int/2008/whr08_en.pdf

World Health Organization. (2009a). Global health risks: Mortality and burden of disease attributable to selected major risks. Retrieved from http://www .who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full .pdf

World Health Organization. (2009b). Women and health: Today’s evidence, tomorrow’s agenda. Retrieved from http://whqlibdoc.who.int/publications /2009/9789241563857_eng.pdf

M08_MARY9591_06_SE_C08.indd 211 06/09/14 6:39 PM

212 Unit 2 influences on Population health

World Health Organization. (2010). World health statistics 2010. Retrieved from http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf

World Health Organization. (2013a). Global status report on road safety 2013: Supporting a decade of action. Retrieved from http://www.who.int /violence_injury_prevention/road_safety_status/2013/report/en/index.html

World Health Organization. (2013b). Global tuberculosis report 2013. Retrieved from http://apps.who.int/iris/bitstream/10665/91355/1/9789241564656_ eng.pdf?ua=1

World Health Organization. (2013c). Polio eradication & end game strate- gic plan, 2013-2018. Retrieved from http://www.polioeradication.org /Portals/0/Document/Resources/StrategyWork/PEESP_ES_EN_A4.pdf

World Health Organization. (2013d). The top 10 causes of death. Retrieved from http://www.who.int/mediacentre/factsheets/fs310/en/

World Health Organization. (2013e). World health statistics 2013. Retrieved from http://www.who.int/gho/publications/world_health_statistics /2013/en/

World Health Organization. (2014a). About WHO. Retrieved from http://www .who.int/about/en/

World Health Organization. (2014b). Global health governance. Retrieved from http://www.who.int/trade/glossary/story038/en/

World Health Organization. (2014c). Globalization. Retrieved from http:// www.who.int/trade/glossary/story043/en/

World Health Organization. (2014d). Immunization coverage. Retrieved from http://www.who.int/mediacentre/factsheets/fs378/en/

World Health Organization. (2014e). International Health Regulations. Retrieved from http://www.who.int/topics/international_health_regulations/en/

World Health Organization. (2014f). Poliomyelitis. Retrieved from http://www .who.int/mediacentre/factsheets/fs114/en/

World Health Organization. (2014g). Sector-wide approaches (SWAPs). Re- trieved from http://www.who.int/trade/glossary/story081/en/

World Health Organization. (2014h). Smallpox. Retrieved from http://www .who.int/mediacentre/factsheets/smallpox/en/

World Health Organization. (2014i). World Health Assembly. Retrieved from http://www.who.int/mediacentre/events/governance/wha/en/

World Health Organization & UNICEF. (2013). Progress on drinking water and sanitation, 2013 update. Retrieved from http://www.wssinfo.org/fileadmin /user_upload/resources/JMPreport2013.pdf

World Trade Organization. (2014). Intellectual property: Protection and enforcement. Retrieved from http://www.wto.org/english/thewto_e /whatis_e/tif_e/agrm7_e.htm

M08_MARY9591_06_SE_C08.indd 212 06/09/14 6:39 PM

Population Health Nursing Strategies

C h

a p

te rs 9 — Political Strategies

10 — Community Empowerment Strategies

11 — Health Promotion and Education Strategies

12 — Case Management Strategies

13 — Home Visits as a Population Health Nursing Strategy

3 unit

M09_MARY9591_06_SE_C09.indd 213 06/09/14 6:40 PM

chaPter

Political Strategies9

Key Terms

allocative policies

bill

campaigning

coalitions

community organizing

electioneering

executive orders

governance

health impact assessment (HIA)

health policy

interest group

judicial decisions

laws

legislative proposals

lobbying

networking

pocket veto

policy agenda

political advocacy

politics

procedural policies

public policies

redistributive policies

regulation

regulatory policies

sin taxes

stakeholders

substantive policies

Learning Outcomes

After reading this chapter, you should be able to:

1. Analyze potential population health nursing roles in policy development.

2. Discuss four avenues for public policy development.

3. Describe at least four aspects of the policy development process.

4. Apply criteria for health policy evaluation.

M09_MARY9591_06_SE_C09.indd 214 06/09/14 6:40 PM

Creating the Children’s Bureau

An early history of the U.S. Children’s Bureau credits the development of this federal agency to “a hardy band of practical dreamers who, beginning about 1903, studied the past and present circumstances of children in order to chart a course for the future” (Oettinger, 1962, p. 1). Chief among those practical dreamers were Lillian Wald and Florence Kelley. It was actually Lillian Wald who conceived of the idea of a federal agency to address the needs of the nation’s children over tea with her friend and colleague Florence Kelly, a social worker who lived and worked at the settlement.

Two letters received simultaneously addressed the needs of children, one asking for help and one offering to help in any way to reduce the numbers of children dying. They sparked a comment by Ms. Wald, “I wish there were some agency that would tell us what can be done about these problems” (Oettinger, 1962, p. 2). An article in the newspaper that same day described the activities of the Secretary of Agriculture related to weevil infestations in southern cotton crops, which led to the idea of a federal agency to address the needs of children. As expressed by Ms. Wald, “If the government can have a department to take such an interest in what is happening to the Nation’s cotton crop, why can’t it have a bureau to look after the Nation’s crop of children?” (Bradbury & Eliot, 1956, p. 1). Even before that time, Florence Kelley had proposed a “ Commission for Children” during a series of lectures at major universities and colleges.

Dr. Edward Devine, a member of Florence Kelley’s diverse personal network informed President Theodore Roosevelt of the idea, and Ms. Wald was invited to the White House to discuss it with him. The next 9 years saw the introduction of 11 bills in the U.S. house or senate, nationwide campaigning by Ms. Wald, Mrs. Kelley, and other individuals and organizations including the National Child Labor Committee in which Florence Kelley was actively involved (Bradbury & Eliot, 1956, p. 2). During this period, Mrs. Kelley published several books, including Some Ethical Gains Through Legislation, in which she presented evidence of the need for federal intervention to support the health and welfare of children (Bradbury & Eliot, 1956). In 1912, their efforts culminated in the passage of the enabling legislation and its signature by then President William Howard Taft (Social Security Administration, n.d.). Both Lillian Wald and Florence Kelley were also involved in numerous other political advocacy activities related to women’s and children’s health, the laboring poor, rural nursing services, and women’s suffrage (Florence Kelley, 2011; Jewish Women’s Archive, 2010; Lewis, 2011).

A d

vo ca

cy T

h en

A d

vo ca

cy N

ow The Campaign for APRN Consensus In 2008, an alliance of professional nursing organizations, educational organizations, certifying bodies, and the National Council of State Boards of Nursing (NCSBN) collaborated to draft the “Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education,” more popularly known as the “Consensus Model.” The model is designed to provide for nationwide standardization in the education, licensure, and practice of advanced practice registered nurses (APRNs) in the roles of nurse practitioner, clinical nurse specialist, nurse anesthetist, and nurse midwife. The intent of the model is to assure safety and quality in the services provided by advanced practice nurses across the nation as well as to promote public access to APRN care and facilitate mobility among APRNs (American Association of Colleges of Nursing [AACN], 2008).

Among the model’s several provisions is a mandate for independent practice by APRNs without physician oversight. Because nursing practice is regulated at the state level, however, implementation of the model will require modification of state nurse practice acts on a state-by-state

215

M09_MARY9591_06_SE_C09.indd 215 08/09/14 4:07 PM

Policy decisions affect every aspect of our lives, in-cluding our access to health care and the way in which health care is provided. Policy arises from a demand for action, or inaction, in relation to a particular issue. Unfortunately, policy development often ex- cludes those most knowledgeable about the area of concern. Population health nurses need an awareness of the political context in which their practice occurs and must possess the skills and abilities to influence health policy development to achieve their goal of improving the health of the public. The need for policy development skills is one of the key nursing competencies recognized in the recent Institute of Medicine report, “The Future of Nursing: Leading Change, Advanc- ing Health” (IOM, 2011b). Skills required to influence policy formation include social astuteness, interpersonal influence, networking ability, and sincerity (Chaffee, Mason, & Leavitt, 2012). Social astuteness involves the ability to understand one- self and others in the context of social situations. Interpersonal influence requires the ability to adapt to situations and to be a pleasant and productive person to work with. Networking involves the capacity to develop and bring into play diverse connections with others and to take advantage of opportuni- ties as they present. Finally, sincerity demands personal integ- rity, authenticity, and honesty. To develop these skills, health policy content needs to be integrated into all levels of nursing education and nursing students need to develop the habit of examining the policy implications of everything they study in nursing (IOM, 2011b).

Policy and Politics Policy is established by organizations and political units in both public and private sectors and reflects the values, beliefs, and attitudes of policy makers.

Policy was defined in Chapter 8 as a set of principles de- termining direction for action and allocation of resources to achieve identified goals.

As noted earlier, policy development takes place in both public and private sectors. Public policies are the ways in which public officials deal with public problems or govern- ment directives intended to influence the actions of others in areas that affect the public good (Chaffee et al., 2012), whereas private policies are enacted to deal with problems in private- sector organizations. Public policies include laws or statutes, regulations, executive orders, court rulings, and state develop- ment plans. Public policy is derived from governance, which is defined as the ways in which needs are articulated, power is exercised, and resources are used to meet those needs (Slokum- Bradley & Bradley, 2010). Public policies arise from several in- terdependent sectors beyond those directly related to health, including housing, national security, education, welfare ser- vices, and so on.

Public or private policy is created through the policy development process. Policy development was defined in Chapter 1 . Politics, on the other hand, is the mechanisms by which scarce resources are allocated among members of the population (Chaffee, 2012), or the way in which conflicts aris- ing from multiple sets of values or interests are addressed.

Relationships Between Public Policy and Health As noted above, policy in a variety of arenas can influence the health status of the population. Health policy involves courses of action designed to achieve health-related goals (World Health Organization [WHO], 2014, para. 1), has a direct impact on health in the population. The overall goal of health policy is to promote the highest possible level of health in the population at a reasonable cost.

Many policies arising out of other social sectors have health implications that frequently go unrecognized until major prob- lems arise. Awareness of this interaction between other social and economic policy initiatives and health consequences has

basis. To that end, professional organizations have mobilized their members to educate state and territorial legislators about the model and the need for changes in nurse practice acts. The National Council of State Boards of Nursing has created a toolkit to facilitate legislative advocacy in pursuit of model implementation. The toolkit is designed to assist nurses in promoting relevant legislation in their own states and contains resources for nurse advocates (NCSBN, 2011) as well as a handbook that can be shared with legislators (NCSBN, n.d.). For further information about the toolkit, see the resources provided in the External Resources section of the student resources site.

As of April, 2014, the NCSBN reported that eight states had fully implemented the consensus model (NCSBN, 2014). What is being done in your state to implement the model? What can you do to promote the legislative changes needed to implement the model in your state?

216

M09_MARY9591_06_SE_C09.indd 216 08/09/14 4:07 PM

chaPter 9 Political Strategies 217

prompted a call for health impact assessments for all major pol- icy proposals, in much the same way that major building or de- velopment proposals trigger environmental impact assessments (EIAs) (Centers for Disease Control and Prevention [CDC], 2014). A recent Institute of Medicine report (IOM, 2011a) rec- ommended that state and federal governments adopt a “health in all policies” approach, which would involve consideration of the potential positive and negative health effects of all policies through health impact assessments. A health impact assess- ment (HIA), or health impact analysis is “a systematic process that uses an array of data sources and analytic methods, and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population” (National Research Council, 2011, p. 5). The intent of HIA is to assist policy makers in evaluating the potential health effects of a plan, policy, or program before it is implemented to minimize the potential for adverse health out- comes (CDC, 2014). Elements of HIA include the following:

• Screening and identification of projects and policies for which an HIA would be appropriate

• Identifying which specific potential health impacts should be examined

• Assessing the risks and benefits of the policy or project for those who will be affected

• Developing recommendations for changes to proposals to promote positive health effects and mitigate negative ones

• Reporting the results of the assessment to policy makers • Evaluating the effects of the HIA on the policy decision

(CDC, 2014).

Potential health effects of policies in other social sectors in- clude the following examples. A study of the plan for commu- nity development in a San Francisco community was deemed to have potentially negative effects related to traffic congestion, creation of hazardous design features that might increase the incidence of injuries, and result in decreased emergency access, all of which have health implications. In addition, there were expectations of increases in noise and air pollutants during construction (San Francisco Planning Department, 2010).

A health impact assessment conducted in Columbia, Missouri, examined the probable health consequences of ex- panding the public transit system. Four specific health out- comes were addressed: (a) physical activity; (b) exposure to the outdoors; (c)  access to health care, employment, education, and healthy food; and (d) creation of a livable, sustainable com- munity. The assessment found that expansion of public tran- sit would have favorable effects in all four areas (HIA Partner Team, 2012).

The focus of a health impact assessment in Saint Paul, Minnesota (Malekafzali & Bergstrom, 2011) was a proposal to construct a light rail transit line through the city’s central cor- ridor. Residents of the corridor comprised 60,000 of the low- est-income, most diverse people in the city. In addition to evaluating the potential health effects of the proposal, the HIA

was intended to empower residents to make decisions that af- fected their health. The assessment addressed the probable ef- fects of the proposal on 50 indicators directly and indirectly related to health (e.g., healthy and affordable housing, economic growth). The assessment identified several negative effects of the proposal, including displacement of local small businesses in the corridor, loss of jobs for residents with low educational attain- ment, increased gentrification and higher housing costs in the area that would displace many current low-income residents, and increased potential for unsafe pedestrian infrastructure in the area that could limit physical activity. Recommendations arising from the assessment included a city commitment to the creation of sustainable low-income housing, promoting com- mercial parking, and employment assistance.

A final example of a health impact assessment of economic policy revolves around the potential health effects of approving casino construction and gambling in an urban area. Some of the positive health consequences anticipated included increased employment, income, and health insurance coverage for ca- sino employees, and increased state tax revenues that could be used for health-related initiatives. Negative consequences included sleep deprivation and increased second-hand smoke exposure for patrons and employees, increased traffic result- ing in diminished air quality and driving under the influence of intoxicants, thus contributing to both motor vehicle crashes and pedestrian injuries, and increases in the transient popu- lation and gambling addictions possibly leading to increased crime. Finally, there were anticipated costs related to accident and addiction treatment, greater public safety costs (e.g., po- lice presence), and a need for expansion of health care services to address the needs of tourists (Purtle, 2010). As we can see from these examples, numerous economic and social policies have health-related implications that need to be considered in policy development. We will consider health impact assessment in greater detail later in this chapter when we discuss the assess- ment of a policy situation in the context of the determinants of health in the population health nursing model.

Types of Policies As noted earlier, health policies may be either public or private, depending on their source and focus. Policies may also be cat- egorized as substantive or procedural. Substantive policies are those that dictate action to be taken. For example, a policy (in this case legislation) mandating helmet use by bicycle riders is a substantive policy, as is a policy funding health care services for the indigent. Procedural policies are those that determine how the action will occur. In the case of the helmet law, procedural policies would determine how the law would be implemented. In the health services funding policy, procedural policies would address who is eligible for services, how services are to be ob- tained, how providers will be reimbursed for services, and so on.

Policies can also be categorized as allocative or regulatory (Chaffee et al., 2012). Allocative policies distribute goods and services among members of the population. The Medicaid and

M09_MARY9591_06_SE_C09.indd 217 06/09/14 6:40 PM

218 unit 3 Population health nursing Strategies

Medicare programs are examples of allocative policies that determine who may receive care reimbursed by these funding sources. Similarly, Congressional funding decisions that pro- mote specific research agendas over others (e.g., development of a vaccine for avian influenza) provide direction for alloca- tion of federal research funds. When policies take goods and services away from some members of the population and give them to others, they are considered redistributive policies. For example, taxing the income of some citizens to fund services for others is a redistributive policy. Regulatory policies restrict or constrain behavior in some way. For example, nurse practice acts are regulatory policies that restrict the practice of nursing to people who meet identified criteria for licensure. Some poli- cies are self-regulatory, as in the case of professional codes of ethics or standards for accreditation of schools of nursing.

Avenues for Public Policy Development Health policy formation may take one of four major forms in the public sector: legislation and health programs created by legislation, rules and regulations for implementing legislation, administrative decisions, and judicial decisions. Development of state health plans is another avenue for health-related pol- icy formation at the state level that may incorporate several of these approaches.

Legislation Laws, or statutes, are public policy decisions generated by the legislative branch of government at the federal, state, or local level. Laws are created in a social system to express the collec- tive values, interests, and beliefs of the society that generates them. Law is a mechanism for enforcing social norms within a given society. As a society develops, so do its beliefs, values,

Evidence-Based Practice

Policy Development Like all health care practice, health-related policy formation should be based on the evidence of effective interventions that is derived from sound research and consideration of the situational factors related to specific target populations. Nurses and other researchers need to make sure that policy makers are apprised of research findings that have a bearing on health-related policy development (Young, 2009). Some authors suggest an eight-step RAPID Outcome Mapping Approach (ROMA) to direct involve- ment of researchers in policy development. The eight steps of the approach are as follows:

1. Develop a clear policy objective to define the expected outcome of policy development.

2. Map the policy context in terms of factors influencing the policy process.

3. Identify key stakeholders in the policy area. 4. Identify desired behavior changes in stakeholders to

promote support of the policy initiative. 5. Develop a strategy to promote those changes. 6. Analyze the internal capacity to make change. 7. Establish an action plan for the policy change. 8. Develop a monitoring and learning system to track progress

in policy implementation (Young, 2009).

For population-based policy initiatives, the evidence base for effective intervention may come from a variety of sources. One useful source of evidence for population-based intervention strategies is the Guide to Community Preventive Services developed by the Community Preventive Services Task Force. The task force is an independent decision-making body, similar to the U.S. Preventive Services Task Force for individual-level interventions, convened by the U.S. Department of Health and Human Services. The task force evaluates the evidence base for population level interventions to address major pub- lic health problems and makes recommendations on the use of specific interventions, based on their effectiveness, economic efficiency, and feasibility. These recommendations can form the basis for evidence-based public health policy formation. Topics addressed in the Guide as of 2014 included adoles- cent health; alcohol; asthma; birth defects; cancer; diabetes; health communication; HIV/AIDS, STIs, and pregnancy; mental health; motor vehicle accidents; nutrition; obesity; oral health; physical activity; social environment; tobacco; vaccines; vio- lence; and the worksite (Community Preventive Services Task Force, 2014). Specific guidelines will be addressed in relevant chapters later in this book.

Federal legislation is only one way in which the political context influences health and health care services. (Multitel/Shutterstock)

M09_MARY9591_06_SE_C09.indd 218 06/09/14 6:40 PM

chaPter 9 Political Strategies 219

and interests. Some laws enacted in earlier periods of a soci- ety’s evolution eventually become obsolete. Sometimes laws are created or revised to address new problems that surface as so- ciety changes. Modifications or changes in laws are legislative attempts to correct discrepancies that may have arisen between past and current social practices. Although this description of the function of legislation is highly simplified, the point is that laws reflect societal needs and values and are subject to revi- sion. The 2011 IOM report, “For the Public’s Health: Revitaliz- ing Law and Policy to Meet New Challenges,” noted that much of state and federal law related to public health is outdated (IOM, 2011a). The authors of the report recommended mod- ernizing public health law to assure that “appropriate powers are in place to enable public health agencies to address contem- porary challenges to population health” (p. S-3). Other recom- mendations made in the report include the following:

• States should enact legislation and allocate funds to assure that public health agencies have the capability of providing the essential public health services discussed in Chapter 1 .

• States should mandate accreditation of state and local health departments to assure quality provision of services.

• The federal government should set minimum requirements for public health policy.

• Public health agencies should have access to legal counsel to prevent preemption of state and local prerogatives by higher levels of government.

• The federal government should facilitate local and state en- forcement of federal and state health and safety standards, and governmental levels should share resources whenever possible.

• State and local governments should create health councils that assure stakeholder input into policy development and that conduct health impact assessments prior to and after implementation of all major legislation, regulations, and policies.

• The Department of Health and Human Services should cre- ate a group of experts to develop methods to assess evidence of the health effects of public policies and develop eviden- tiary standards to support translation of research findings into policy and practice (IOM, 2011a).

Figure 9-1• depicts the typical progress of a bill through the legislative process. The process is similar at federal and state levels, and the discussion here addresses both. The names of specific legislative bodies and committees will vary from one jurisdiction to another, however. A similar but more circum- scribed process is used in the development of ordinances and policies by local government bodies (e.g., city council or county board of supervisors). Local communities may vary somewhat in the extent of and avenues for public input into policy deci- sions. The asterisks in Figure 9-1• indicate points in the state or federal process at which population health nurses might in- fluence legislation.

Legislative proposals are statements of beliefs or interests that have been brought to the attention of a legislator. These interests may come to the legislator’s attention through his or

her constituents, personal experiences, or involvement on a legislative subcommittee dealing with specific issues. Popula- tion health nurses and nursing and other health-related orga- nizations can influence the legislative process at this point by making lawmakers aware of the need to develop policy or to modify existing policies (Ridenour & Santa Anna, 2012). After due consideration, constituents’ beliefs or interests are drafted in a bill, which is a formally worded statement of a desired legislative policy. There are two kinds of legislation: authori- zation and appropriation. Authorization legislation establishes laws or programs; appropriation legislation, on the other hand, provides funding for the implementation of laws and programs for the next fiscal year (American Association of Colleges of Nursing [AACN], 2010).

Once a bill has been drafted, the sponsoring legislator sub- mits it for identification, meaning that the bill will carry the legislator’s name as sponsor. It is not unusual for a proposed bill to have multiple sponsors. Many state and national nursing and other health-related organizations (e.g., AACN, the Amer- ican Nurses Association [ANA] or the American Public Health Association [APHA]) maintain a legislative focus that allows them to keep members informed of pending legislation with health implications. They also typically provide their members with information on how to access drafts of legislation for re- view and how to contact legislators and specific committees. Membership in such organizations is an important avenue for keeping up-to-date on legislative initiatives that may affect the health of the population. For further information about the toolkits, see the resources provided in the External Resources section of the student resources site.

The bill is assigned a number, listed by the clerk of the ap- propriate legislative body, and sent to a general committee for review. The committee may revise the language of the bill or amend it. In the normal course of events, the bill would then be sent on to the House or Senate floor for its “first reading.” After its first reading, the bill might be referred to the appro- priate committee for hearings. Some bills are sent to multiple committees. Several congressional committees included in Table 9-1• deal with most health-related legislation at the federal level. Most of the committees presented in the table deal with authorization legislation. The House and Senate Appropriations Committees are responsible for allocating the funds for the various federal programs, and the Budget Committees develop broad budgetary directions for the legis- lature, respectively (Hendrickson, Ceccarelli, & Cohen, 2012). In addition to the committees listed in Table 9-1, members of the House of Representatives and Senate serve on several joint committees, the two most relevant of which are the Joint Economic Committee and the Joint Committee on Taxation (U.S. Senate, n.d.). A similar committee structure exists at the state level.

Once bills are referred to a committee, it is not unusual for them to be sent to a subcommittee, which does the most thorough review of the proposed legislation. Functions of subcommit- tees include hearings, markup, and reporting. Subcommittees may hold public hearings on the issue addressed by the bill.

M09_MARY9591_06_SE_C09.indd 219 06/09/14 6:40 PM

220 unit 3 Population health nursing Strategies

FIgure 9-1 A Typical Legislative Process *Points at which population health nurses can best influence the process.

Idea or concept presented to legislator*

SENATE HOUSE /ASSEMBLY

Bill drafted, numbered, and listed

Sent to Revision and Amendment Committee

General Assembly*

Joint Committee on Passed Bills presents

bill to Chief Executive

Vote

Third reading and �oor debate

Second reading

Conference Committee

Sent to Subcommittee*

First reading

Chief Executive signs*

LAW

Chief Executive vetoes

Bill returns to legislature

Both houses override veto*

After 10 days with no signature

M09_MARY9591_06_SE_C09.indd 220 06/09/14 6:40 PM

chaPter 9 Political Strategies 221

TABLE 9-1 Congressional Committees with Health-Related Responsibilities Senate Committees

Health-Related Responsibility

House of Representatives Committees

Health-Related Responsibility

Agriculture, Nutrition, and Forestry

• Food stamp program • Human nutrition • School nutrition programs

Agriculture • Human nutrition and home economics

• WIC and Food Stamps • Rural development • Bioterrorism • Animal diseases • Inspection of animal products

Appropriations Allocation of funds Appropriations Allocation of funds of funds Armed Services • National defense issues

• Military benefits Armed Services • Common defense

• National security • Military benefits • Military research • Counter-drug programs

Banking, Housing, and Urban Affairs

• Nursing home construction • Public and private housing • Urban development and mass

transit Budget Annual budget planning Budget Budget resolutions and process Commerce, Science, and Transportation

• Science, engineering, and technology research, development, and policy

• Highway safety

Education and Workforce • Child labor • Early childhood education • Child abuse and adoption • School food programs • Higher education and workforce

training • Education and labor • Worker’s compensation

Energy and Natural Resources

• Emergency preparedness • Nuclear waste • Energy development

Energy and Commerce • Biomedical research • Health and health facilities • Public health and quarantine • Consumer protection and product

safety • Motor vehicle safety

Environment and Public Works

• Air pollution and environmental policy

• Solid waste disposal and recycling Finance • Social Security Act health programs

• Health programs financed by special tax or trust funds

• National social security

Financial Services • Public and assisted housing

Foreign Relations • Foreign assistance • International treaties and foreign

policy

Foreign Affairs • Foreign assistance • HIV/AIDS in foreign countries • International law enforcement

(including drug control) Health, Education, Labor, and Pensions

• USDHHS • Education • Labor and employment law • Retirement plans and railroad

pensions Homeland Security and Governmental Affairs

• Census and statistics • Government agency performance • Effects of legislation • National security • Civil Service

Homeland Security • National security • Science and technology

preparedness • Transportation security

Judiciary • Immigration and naturalization • Civil liberties • Federal penitentiaries

Judiciary • Federal penitentiaries

Natural Resources • Water and power • Indian Affairs

M09_MARY9591_06_SE_C09.indd 221 06/09/14 6:40 PM

222 unit 3 Population health nursing Strategies

TABLE 9-1 (Continued)

Senate Committees

Health-Related Responsibility

House of Representatives Committees

Health-Related Responsibility

Science, space and Technology • Environmental and energy research • National Science Foundation

Transportation and Infrastructure • Clean water and waste water management

• Flood damage reduction • Disaster preparedness and response

Veteran’s Affairs Veteran’s hospitals, services Veteran’s Affairs Veteran’s hospitals, services Indian Affairs Indian health and special services Ways and Means • Customs

• Tax exempt foundations • National Social Security • Social Security Act health programs

and those funded by specific taxes • Health services payment • Health insurance tax credit and

deductions Special Committee on Aging

Advise on issues related to aging

Sources: U.S. House of Representatives. (n.d.). House committees. Retrieved from http://www.house.gov/committees/; U.S. Senate. (n.d.). Committees. Retrieved from http://www.senate.gov/pagelayout/committees/d_three_sections_with_teasers/committees_home.htm

“Markup” refers to modifications made in the proposal. Finally, the subcommittee makes a report regarding the intent of the bill, any amendments made in the committee, ramifications in terms of changes to current laws, the costs of implementation, and any dissenting views on the bill ( Ridenour & Santa Anna, 2012). Population health nurses can influence the legislative process during subcommittee review by contacting lawmak- ers and making their views known on legislation pending before them. Such contacts may be made by individual nurses or by lobbyists employed by nursing and other health-related interest groups. Lobbying is discussed in more detail later in the chapter.

Committee members considering a particular piece of leg- islation can either review and modify a bill or decide not to report the bill out of committee, thus effectively killing it. Legis- lation can also bypass assignment to a standing committee and be assigned to a specially created ad hoc committee or advance directly to a second reading on the floor of the particular leg- islative chamber. The bill may then proceed to a third reading, be referred back to committee, or be sent to another committee for review and revision before advancing to the third and final reading. Following the third reading, the proposed legislation is placed on the calendar for floor debate and, finally, voted on. At this point in the legislative process, population health nurses can contact their own representatives and try to persuade them to support nursing’s position on a particular bill.

If the legislation is passed in the chamber of Congress or the state legislature where it originated, it is sent to the other chamber for approval. In many cases, when a bill has advanced to this point, it is passed by the second chamber without fur- ther modification. The bill can, however, be sent to another committee for review and modification. Once a bill has passed the second chamber, it is returned to the house or chamber

where it originated for final approval. At the state level, a bill must be signed by the leaders of both houses of the legislature as well as the secretary of state before it is forwarded for the governor’s signature. After the bill is signed by the governor, it is renumbered according to the appropriate lawbook code number and filed with the secretary of state, and becomes law. A similar process occurs at the federal level after a bill is signed by the president.

In most states and in Congress, if the two chambers of the legislature cannot agree on a similar version of a given bill, a special committee composed of members of both chambers is formed. The purpose of this joint conference committee is to develop a compromise bill. It is highly unusual for a joint committee recommendation not to be passed. If, however, the committee cannot reach agreement, the bill dies. Once the compromise bill has passed both houses of the legislature, it is sent to the executive branch of the government (governor or president) for final approval.

The chief executive (governor or president) can either sign the bill or hamper its progress by not signing it or vetoing it. If the chief executive does not sign the bill, it automatically becomes law after 10 days, unless the legislative session ends in the interim. In that case, the bill dies (Ridenour & Santa Anna, 2012). Holding a bill unsigned until the end of the legislative session is called a pocket veto. Lobbying may also be used at this point to influence the chief executive’s disposition of a particular bill. If the executive vetoes a bill, it is returned to the legislature. The legislature is then required to meet a constitu- tionally prescribed majority vote (usually a two thirds major- ity) to override the veto and enact the bill into law. Any bill that does not complete the legislative process during the legislative session in which it is introduced is dead, and it must be reintro- duced in a subsequent session if it is ever to become law.

M09_MARY9591_06_SE_C09.indd 222 06/09/14 6:40 PM

chaPter 9 Political Strategies 223

Regulation Policy decisions enacted as legislation are usually implemented by regulatory agencies charged with implementing specific types of legislation. For example, federal policies related to environ- mental issues are implemented by the Environmental Protection Agency (EPA); state health-related policies are usually imple- mented by a state board of health or a comparable agency.

These agencies develop regulations that determine how leg- islation will be implemented. A regulation is a rule or order having the force of law that deals with procedures to be fol- lowed in implementing a piece of legislation (Alliance for Health Reform, 2010). Regulations are intended to promote individual accountability for actions and to protect the public health and welfare. Regulations specify how policies are real- ized in actual behavior.

Regulatory agencies exert a great deal of control over health-related activities by both professionals and the general public. State agencies such as boards of nursing, for example, regulate who may practice nursing and how nursing licensure is granted. These same agencies might also be responsible for determining which health care providers can write prescrip- tions for medication in those states where such practices are authorized for personnel other than physicians.

When a piece of legislation authorizing an activity such as prescription writing is passed, the legislature usually designates an existing agency or creates a new agency to implement the legislation. This agency develops the regulations that govern implementation of the law. In the case of prescription-writing privileges, the regulatory agency would determine who can write prescriptions and what additional qualifications might be required of those persons. For example, in California, nurses who are certified by the state as nurse practitioners may write prescriptions, but only if they have completed an approved course in pharmacology. Other regulations specify who is eli- gible for certification as a nurse practitioner in the state.

Another example of regulations that implement legislation is the procedures for handling hazardous substances in the workplace, which were developed by the Occupational Safety and Health Administration (OSHA). The enabling legislation mandated protection of employees from exposure to hazard- ous substances, but regulations developed by OSHA specify how certain substances should be handled. For example, cer- tain types of ventilatory equipment are required in manufac- turing processes using hazardous aerosols to minimize the risk of exposure to employees.

Regulations instituted by various agencies may dramatically influence the actual impact of a law. For example, when pre- scription writing by nurse practitioners was first instituted in Tennessee, one proposal was to restrict the privilege to nurse practitioners prepared at the master’s level. As this require- ment would have excluded many nurse practitioners in rural counties where physicians were scarce, it would have under- mined the intent of the enabling legislation—to provide greater access to health care for underserved populations.

Population health nurses can have input into regula- tions that affect their professional practice as well as into the

legislation that shapes public health policy. When a regulatory agency is in the process of formulating regulations, the pub- lic is informed that the process is being initiated. Generally, the agency formulates some preliminary regulations that are published for public review and comment. At the federal level, proposed regulations are published in the Federal Register as a Notice of Proposed Rulemaking (NPRM); similar registers exist in each state. Interested parties are then allowed to comment on the proposed regulations and suggest changes (Alliance for Health Reform, 2010).

When regulations deal with particularly sensitive areas, the regulatory body involved may hold public hearings to so- licit input from interested parties. Population health nurses may either comment on proposed regulations in written com- munications to the regulatory agency or provide testimony at public hearings (Ridenour & Santa Anna, 2012). Nursing input should be provided early in the development process. It should also be supported by data and identify how nursing’s position on proposed regulations supports the intent of the legislation. The regulatory agency may use the input to refine the regula- tions, but is not required to do so. Regulations are published in the appropriate state or federal publication and promulgated among individuals affected by them. Once regulations are pub- lished and go into effect, they have the force of law.

Administrative and Judicial Decisions Health policy development can also occur by means of admin- istrative or judicial decisions. Administrative decisions are those made by an individual or agency that affect the imple- mentation of health care policies or programs. For example, a state board of nursing or other similar agency would develop the processes by which one becomes licensed in that state. One specific type of administrative decision is an executive order. Executive orders are legally binding orders that an executive officer (president or governor) gives governmental agencies and individuals on how they are to implement legislation. Ex- ecutive orders do not have to be approved by the legislative branch and are occasionally used to contradict or add to the intent of legislation through interpretation. The legislature can override an executive order with more explicit legislation. Former President Clinton, used executive orders to achieve a number of health policy changes that were not originally in- cluded in legislation, such as instituting programs to promote Medicaid enrollment for eligible children. Judicial decisions are decisions within the court system regarding how laws are to be interpreted. As an example, a federal court ruled that the individual mandate for health insurance coverage included in the Patient Protection and Affordable Care Act violated constitutional provisions of freedom of choice and exceeded Congressional authority to regulate interstate commerce, but overturned a prior ruling that the entire Act was unconsti- tutional (Lowes, 2011). Subsequently, in response to further legislative challenges, the U.S. Supreme Court modified the individual mandate as a tax on most people who do not have health insurance coverage as of 2014 (National Federation of Small Business, 2012).

M09_MARY9591_06_SE_C09.indd 223 06/09/14 6:40 PM

224 unit 3 Population health nursing Strategies

State Health Plans Another avenue for health policy development that may involve legislation as well as regulation is the development of state health plans. State health plans are comprehensive policy statements that provide direction for efforts to improve the health of the state’s population. They are analogous to the Healthy People documents, but at a state, rather than federal level. State health plans may vary in their depth and scope. The Wisconsin plan, for example, includes specific objectives in 23 focus areas to be achieved over the course of the next decade. The plan also encompasses a set of ten “pillar” objectives critical to the overall plan’s success (Wisconsin Department of Health Services, 2010). These pillar objectives are presented in the Highlights box below.

State health plans for Vermont and California, on the other hand, are more circumscribed and deal primarily with the

creation of state health care systems in a move to single-payer systems. Vermont’s plan created a board to develop a payment system that incorporates the concept of the medical home and to design a health budgeting system for the state. Additional mandates include development of a single-payer plan to provide a minimum package of health care benefits established by the board, but yet to be approved by the legislature and to address the costs, revenue, and savings anticipated from the proposed reforms (State of Vermont, 2011).

California’s plan, approved by the state Senate in 2010, also addresses the creation of a single-payer health plan and creates a California Health System that pools all state and federal money currently spent on health care with a to-be-determined payroll tax to provide health insurance coverage for basic health services for all state residents. Residents will have the option of purchasing additional private insurance coverage for uncovered services (California Senate OKs single-payer health plan, 2010).

Nursing and Policy Development Florence Nightingale and other early population health nurses were adept at using the political process to promote the health of the population. We saw at the beginning of this chapter that Lillian Wald engaged in political activism to spur creation of the Children’s Bureau. She and other early nursing leaders were alert to the political culture of the times, using that knowledge to gain important changes in societal conditions. For example, Clara Barton and Florence Nightingale minimized their active support for women’s suffrage issues in order to address what they considered more critical social issues. Others, such as Margaret Sanger and Lavinia Dock, were more confrontational in their political activism, but all achieved significant social changes. These early leaders in population health nursing realized that the political process was a means of achieving their goal of improved health for all and that, because of its focus on the health of population groups population health nursing is, by definition, political in nature.

In addition to the political activities to improve the public’s health and the plight of the poor, early nursing political activity focused on nursing education and its standardization and the creation of professional nursing organizations. Subsequently, however, many nurses became uncomfortable with the idea of political involvement, with the possible exception of exercis- ing the right to vote. Politics had an unfavorable aura that was seen as incompatible with nursing’s altruistic philosophy. With the advent of the women’s movement in the 1960s, nurses once again began to recognize the need to influence health care policy decisions (Lewenson, 2012).

Among several reasons for nursing involvement in policy development is the level of power that nurses have in the health care arena. That power arises from several sources, the first of which is the sheer number of nurses in the country. When nurses speak with a united voice on policy issues, policy makers listen. Nurses also possess expert power by virtue of their health care expertise and legitimate power conferred by licensure as health care providers. In addition, nurses can

Pillar Objectives of the Wisconsin State Health Plan • Develop and enforce policies and procedures for tracking

health determinants for populations experiencing health disparities.

• Fund initiatives to eliminate health disparities to a level equal to the Midwest state average.

• Develop and implement policies to improve social cohesion and support by reducing racism and discrimination; creating healthy home, workplace, and community environments; and promoting diversity and social connectedness.

• Develop and implement programs that reduce poverty.

• Develop and implement educational policies that support healthy outcomes.

• Improve the system of primary care, behavioral screening and intervention, mental health services, oral health, alcohol and drug use treatment, chronic disease management, and reproductive and sexual health and enable secure and appropriate information exchange to support effective health decision making.

• Improve the health and resilience of youth and families through a variety of educational and health care services and interventions.

• Implement community designs that promote physical activity, healthy diets, and social interaction, while reducing air and water pollution and heat retention.

• Create the capacity to conduct health impact assessments related to proposed policies and to compare and disseminate information on the effectiveness of alternative population health policies and practice.

• Increase per capita public health funding at least to average levels in surrounding states.

Data from: Wisconsin Department of Health Services. (2010). Healthiest Wisconsin 2020: Everyone living better, longer. Retrieved from http://www.dhs.wisconsin.gov/ hw2020/report2020.htm

Highlights

M09_MARY9591_06_SE_C09.indd 224 06/09/14 6:40 PM

chaPter 9 Political Strategies 225

exercise the referent power inherent in the respect and trust accorded to them by the general public. Finally, like other citi- zens, nurses can exercise reward power by voting for policy makers who support nursing’s stance on health-related policy issues. In order to exercise their power, nurses need to under- stand the legislative and policy processes, know and become known to key players in policy formation, and communicate with policy makers. A Political Astuteness Inventory is included in the Assessment Guidelines section of the student resources for this book. The inventory can be used to assess the political activity and savvy of nurses.

Spheres of Nursing Influence in Policy Development Political writers in nursing have identified four spheres in which nurses influence policy development (Chaffee et al., 2012). The first sphere of influence is the community sphere, in which nurses influence health-related policy through community activism. In this sphere, the nurse may become involved in civic organizations, planning boards, or other agencies and groups that develop policy that affects health directly or indirectly. The second sphere is in the workplace, where policies influence both health care delivery (e.g., policies related to fees for basic preventive services such as immunizations) and health determinants (e.g., policies banning smoking in the workplace). The third sphere is the governmental policy arena, in which nurses advocate for public policies that support health. Note that public policies often “bleed” into the private sector. For example, recent Medicare policies regarding reimbursement for “never events” (preventable adverse health outcomes) influence care for all clients in an institution, not just those whose care is paid for by Medicare. The final sphere of nursing influence in policy making is within professional organizations. Policy making in this sphere influences the regulation and education of the profession itself and provides impetus for public policy formation in the government sphere.

Principles of Policy Development Effective policy making is based on several core principles. These principles include the following:

• Effective policy making is designed to achieve clearly de- fined future-oriented outcomes.

• The policy-making process considers a wide array of factors influencing the policy situation.

• The policy-making process is flexible and innovative, seek- ing creative solutions to identified problems.

• Effective policy making is evidence-based, and the best available evidence is accessible to key stakeholders.

• The policy-making process is inclusive, and considers the needs of all those directly or indirectly affected by the policy.

• Effective policy making takes a holistic view, examining the potential effects on multiple segments of society.

• Effective policy making takes account of lessons learned from previous policy initiatives.

• Effective policy making considers how policy will be communicated to the public and other stakeholders.

• Effective policy making incorporates processes for evaluating the effects of the policy.

• Existing policies are reviewed for their adequacy in address- ing the problems they were designed to address (Office of the First Minister and Deputy First Minister, n.d.).

The Policy Development Process Population health nurses can influence health-related poli- cies at all levels. To do so, however, they must be conversant with the political process and its use. The ability of population health nurses to influence policy development is affected by their skill in assessing the policy situation, agenda setting, plan- ning and implementing health care policy, and evaluating the effects of health policy development and the resulting health policies.

The policy development process is a series of steps analo- gous to the nursing process and begins with identification of a problem that can be resolved through policy formation. This entails an assessment of the nature of the problem, who is af- fected, and the factors contributing to the problem. The second step in the process is getting the policy issue on the agenda of policy makers, followed by development of a policy option de- signed to address the problem and based on scientific data and consideration of other relevant factors, such as public opinion, economic factors, and so on. Implementation of the policy usu- ally requires involvement of interest groups and stakeholders. Stakeholders are persons interested in or affected by a specific issue, policy, or program. Following implementation of the policy, perhaps on a trial basis, its outcomes, costs, benefits, risks, and progress toward problem resolution are evaluated and modified as needed (Berkowitz, 2012). We will discuss each of these steps in policy development in more detail in the application of the population health nursing model to the pol- icy context later in this chapter. Elements of the policy devel- opment process are summarized in the Highlights box below.

The Policy Development Process • Problem identification and assessment

• Agenda setting

• Formulation of proposed policy to address the problem

• Involvement of interest groups and stakeholders

• Policy implementation

• Evaluation of effects, benefits, costs, risks, and progress toward problem resolution

• Policy modification, as needed

Highlights

M09_MARY9591_06_SE_C09.indd 225 06/09/14 6:40 PM

226 unit 3 Population health nursing Strategies

Population Health Nursing Roles and Policy Development Population health nurses may engage in one or more of four roles in their efforts to influence policy development in areas that affect health. These roles include those of citizen, activist, politician, and researcher. In their role as citizens, nurses engage in traditional political activities such as staying informed; vot- ing; speaking out on local issues; participating in public forums; becoming acquainted with local, state, and federal officials; and participating in politically active nursing organizations. In the activist role, nurses contact public officials, register others to vote, contribute to and work for political campaigns, and en- gage in other activities to educate and influence policy mak- ers. In their role as politicians, some nurses become policy makers themselves through elected or appointed office. In the researcher role, population health nurses may conduct research to create the foundation of evidence on which effective health policy should be based. Beyond conducting the actual research studies, however, nurse researchers need to make a concerted effort to acquaint policy makers with research findings and as- sist them to incorporate research evidence, with other consider- ations (e.g., economic implications, societal values, and so on), into policy decisions (Young, 2009). The IOM (2011b) “Future of Nursing” report notes in particular, that doctorally prepared nurses need to link their research to policy formation and

develop skills in policy development as part of their doctoral education. Nursing activities in each of the four roles for policy involvement are summarized in Table 9-2•. Actions related to the citizen, activist, and politician roles will be discussed in more detail in the section on strategies for implementing policy.

Applying the Population Health Nursing Model to Policy Development The elements of the population health nursing model can assist population health nurses to assess the context surrounding a policy issue and in formulating, implementing, and evaluating health-related policy. In the remainder of this chapter, we will explore the application of the model to policy development in general and then examine the Affordable Care Act as a critical example of health policy affecting the population’s health.

ASSESSiNg THE POLiCy SiTuATiON. Assessment of a policy situation involves two basic aspects: assessing the need for policy formulation and assessing factors that are influencing the policy situation and resolution of the underlying problem. Some health-related problems or issues cannot be resolved through policy formation, and population health nurses need to be able to identify those problems that are amenable to resolution through policy. For example, the incidence of traumatic brain injury in motorcycle riders might be reduced

TABLE 9-2 Population Health Nursing Roles and Activities in Policy Development

Role Related Nursing Activities

Citizen • Voting • Staying informed • Speaking out on policy issues • Participating in public forums • Becoming acquainted with elected officials • Joining politically active professional nursing organizations

Activist • Contacting public officials • Registering members of the public to vote • Contributing to political campaigns • Working for political campaigns • Lobbying decision makers with relevant data • Forming or joining relevant coalitions • Writing letters to the editor • Inviting legislators to the workplace • Organizing media events to publicize issues • Providing testimony on health-related issues • Locating and soliciting grant funding

Politician • Running for public office • Seeking appointment to a regulatory body • Seeking appointment to a governing board of a public or private entity • Using nursing experience as a frontline policy maker

Researcher • Identifying health policy issues through research • Ensuring the inclusiveness of viewpoints in policy formation • Assuring the quality, integrity, and objectivity of data on which policy decisions are based • Recognizing and communicating uncertainty and risk (e.g., acknowledging when research evidence is equivocal) • Assuring transparency and openness regarding the bases for policy decisions • Reviewing policy decisions to assure that they reflect up-to-date knowledge

M09_MARY9591_06_SE_C09.indd 226 06/09/14 6:40 PM

chaPter 9 Political Strategies 227

by legislation mandating helmet use or development of motorcycle lanes on major highways. Other issues, such as food or housing costs, are not as amenable to policy intervention. Determining a need for policy, even when policy might help resolve a problem, is also dependent on the extent and severity of a problem. Policy makers will not be interested in problems or issues that affect only a limited number of people or that have minimal consequences. For example, legislatures would be unlikely to legislate mandatory school absence for cases of the common cold, but do mandate school absence for serious conditions that are highly communicable, such as measles or chickenpox.

The second aspect of assessing the policy situation involves examination of the factors that affect the policy issue and its

resolution (Leavitt, Mason, & Whelan, 2012). Such an assess- ment can occur in the context of the determinants of health component of the population health nursing model as de- scribed below.

Biological determinants. An assessment of biophysical factors influencing a policy situation would include a determination of who is affected by the health problem. For example, what age groups are most often affected by accidental injuries? What age-related factors contribute to the problem? For example, diminished strength, mobility, and sensory acuity are factors that lead to injury in the elderly. Are there gender differences in injury incidence? Does the existence of other health conditions, such as epilepsy or arthritis, contribute to injury? In this example, it is unlikely that factors related to genetic inheritance will affect injury incidence, but would be an influencing factor in problems related to diabetes mellitus or cardiovascular disease.

Psychological determinants. The population health nurse exploring factors that contribute to a particular health problem would also examine the contribution of psychological determinants. Do depression or anger contribute to accidental injury? Risk taking and perceptions of invulnerability common among adolescents are certainly contributors to accidental injury in this age group.

Environmental determinants. A variety of environmental elements are widely known to contribute to accidental injuries, from safety hazards in the home to driving conditions. The population health nurse would examine the effect of specific environmental conditions on injury incidence in the population affected by a proposed policy. Data in this area and that related to other categories of determinants might come from published research, epidemiologic studies, or personal observations by the nurse and other health care providers and interested parties.

Sociocultural determinants. A variety of sociocultural de- terminants influence policy situations. These may include the economic effects of the problem or issue or economic con- siderations in its resolution. For example, policy makers may favor a particular policy option that is less costly than other approaches to problem resolution. Educational, cultural, and le- gal factors may also influence policy development. For instance, educational levels among the population to be affected by the proposed policy may help or hinder its implementation or be part of the problem the policy is designed to address. Similarly, a proposed policy that conflicts with existing legislation may pose difficulties. Two other important sociocultural determi- nants that influence policy development are the values and ethi- cal considerations operating in the situation and the influence of persons or groups with vested interests in the issue.

Values and ethical considerations. Conflicts among values are often noted in policy situations. For example, legislation designed to promote motorcycle or bicycle helmet use is often resisted on

global Perspectives

Cho and Kashka (2004) described the political efforts of Mo Im Kim to establish a national population health nurse practitioner program in Korea. The intent of the program was to combine the skills of population health nurses with those of nurse practitio- ners to meet the health care needs of rural Koreans. Dr. Kim began by instituting a 6-month population health nurse prac- titioner program at Yon Sei University. The program addressed health policy formation, implementation and evaluation of com- munity health programs, program management, and community development strategies as well as skills in physical assessment, prevention and detection of disease, and disease management. Dr. Kim and her associates made use of a number of political opportunities, including a government coup, to promote the con- cept of the CHNP to meet population health needs. Some of her strategies included capitalizing on the reform goals of the new regime, informing officials of the work of the CHNPs and invit- ing them to nursing seminars where firsthand stories of practice were shared, lobbying legislators and government officials, and publishing a collection of CHNP cases. Dr. Kim herself also held a congressional office. Dr. Kim used research data regarding the public popularity of the CHNP program to sway legislators and defuse resistance from vested interests such as physicians and obtained external assistance from the Asian Foundation and WHO. She also engaged in specific initiatives to educate govern- ment officials, such as arranging for the chair of the Congres- sional Health Policy Committee to visit the United States and observe population health nursing roles.

1. How might Dr. Kim’s political strategies be adapted for use in another country or culture?

2. Would Dr. Kim’s strategies be likely to be successful in the United States? Why or why not?

Developing a National Population Health Nurse Practitioner Program in Korea

M09_MARY9591_06_SE_C09.indd 227 06/09/14 6:40 PM

228 unit 3 Population health nursing Strategies

grounds that such mandates violate the strongly held U.S. value for individual liberty. For example, the slogan on the helmet issues page of an online bikers’ rights organization is “let those who ride decide” (Bikersrights.com, 2013). At the same time, the values of protecting the health of individual riders and protecting both individuals and society from catastrophic economic burdens are also at play. In this instance, policy makers have to make a determination of which values should receive higher priority. Similarly, federal child labor laws prohibiting child labor under a certain age do not apply to children of any age working on their family-owned farms, presumably on the basis of the value that children should help with chores at home and that parents, not government, should control their behavior (OSHA, n.d.).

Another example of the influence of values and ethics in policy development lies in the issue of “sin taxes.” Sin taxes are taxes levied on products that are deemed harmful to health, such as tobacco and alcohol (Green, 2010). The argument for sin taxes is that people who engage in unhealthful behavior (e.g., smoking) are choosing to jeopardize their health, and they, rather than society, should be responsible for the con- sequences. In initiating sin taxes, governments are usually re- sponding to two values: improvement of the public’s health by deterring unhealthy behavior and generation of revenue that can be used to offset the societal costs of such behaviors. For example, a $0.50 per pack tax on cigarettes in California has resulted in more than $4 billion in revenue designated for child health and education programs. Similarly, a 3% tax on beer sales in Arkansas generates more than $14 million per year used for preschool programming. The public perspective on sin taxes is usually split between approval of the revenues generated and complaints of discrimination by those who pay the additional taxes, and powerful lobbies are active on both sides. Again the conflicting values are societal good and indi- vidual autonomy and responsibility (Green, 2010).

Vested interests. An interest group is a group of people and/ or organizations that have a common interest in the outcome of a specific policy initiative (Warner, 2012). Using our injury example, motorcycle groups that campaign against helmet laws are one example of interest groups and their influence on health care policy. On the other hand, emergency health care providers might be an interest group that would support helmet laws.

Tobacco industry organizations are possibly the classic ex- ample of interest groups that actively campaign against ini- tiatives designed to prevent smoking and protect individual and public health. The tobacco industry has consistently cam- paigned against legislation designed to prohibit smoking. For example, industry claims of up to 20% decline in revenue and loss of patronage for bars that initiate smoking bans were used to argue against smoke-free bars. Research indicates, however, that there has been no decrease in alcohol sales revenue in such establishments following institution of smoking bans (Loomis, Shafer, & van Hasselt, 2013).

Similarly, the RJ Reynolds company capitalized on the ex- clusion of cigars from restrictions on cigarette advertising, but

creating cigarettes marketed as “little cigars” with lower tax rates. Flavored little cigars are specifically targeted for a youth market. In 2012, 16.7% of high school boys smoked cigars, and a third of them smoked little cigars (CDC, 2013). In addition, to- bacco manufacturers are now employing “front organizations” to present messages that do not appear to support the industry’s self-interest but support their policy positions. A front group is a an organization that portrays itself as representing one agenda (e.g., responsible alcohol use) when it actually serves the inter- ests of another group (e.g., alcohol distillers) that remains in the background (Front groups, 2013). Front groups frequently claim to represent the voice of the people. A “citizens for free choice” group might be such a front organization.

A recent U.S. Supreme Court ruling permits corporations to make unlimited contributions to election advocacy campaigns, permitting them to influence voters in favor of candidates that support their policy positions (Wiist, 2011). Due to the relative funding available to large corporations and public health inter- est groups, such contributions can undermine public health policy advocacy. Population health nurses working in the policy arena need to identify special interest groups and work to form coalitions with those that support nursing’s policy po- sitions and to counteract the efforts of those working against those positions.

Behavioral determinants. Behavioral determinants may also influence policy situations. Behavioral determinants, such as consumption behaviors, for example, may contribute to the problem to be addressed by a proposed policy. For instance, increased alcohol and drug use is a significant contributor to accidental injuries of all types, and policies may be advanced to attempt to control or minimize use as a means of reducing the incidence of injuries. Similarly, dietary behaviors and sedentary lifestyles contribute to the problems of obesity and consequent chronic disease. In this instance, policies to promote physical activity opportunities in communities may help to address obesity risk and other consequences. Health-related behaviors may also be the focus of policy formation. For example, economic policy and health insurance coverage may influence access to and use of screening services such as mammography.

Health system determinants. Finally, factors related to the health care system may influence both the need for and direction of policy formation. For example, the nursing shortage, in part the result of lack of qualified faculty to educate nurses led to the development of educational funding programs for nursing faculty. Similarly, the dearth of primary care physicians has contributed to expansion of the scope of practice of APRNs, in particular, nurse practitioners. Such shortages have also influenced changes in some nurse practice acts to permit APRNs to function without physician oversight and were part of the impetus for the development of the APRN Regulatory Model discussed earlier in this chapter. Other health system determinants, such as reimbursement mechanisms, availability of certain types of care, and access to care issues, also create

M09_MARY9591_06_SE_C09.indd 228 06/09/14 6:40 PM

chaPter 9 Political Strategies 229

a need for policy development or revision and influence the direction of policy initiatives.

AgENDA SETTiNg. The next step in policy development is setting the policy agenda. A policy agenda is the list of priority issues that become the focus for action by policy makers. Agenda setting is a process of getting a particular problem or policy issue incorporated in the agenda of issues to be addressed by policy makers (The Policy Circle, n.d.).

Priority among specific policy goals is promoted when there is widespread perception that the current status of a problem or issue is unacceptable, there is a high degree of cohesion among groups supporting the policy issue, and national political lead- ers champion the issue. Other conditions that bring issues to the forefront of a policy agenda include the use of credible evi- dence to educate policy makers, development of clear and fea- sible policy alternatives that are likely to address the issue, and the use of national events to promote public awareness of the issue. When a particular issue is given priority on the policy agenda, policy makers exhibit concern for the issue, govern- ment enacts policies to address it, and funding is allocated to support the policies enacted.

For a particular issue to become a focus for action, policy makers often need to be made aware of the issue through issue analysis. Population health nurses may engage in issue analysis resulting in a formal policy issue paper. The elements of a pol- icy analysis are included in Table 9-3•. Some of the elements of policy analysis have been addressed in the discussion of the determinants of health affecting the policy situation presented above. Tips for assessing a policy situation are included in the Focused Assessment on the next page.

Effective policy analysis requires collection, interpretation, and use of data, which may be of two types: primary data and secondary data. Primary data is information that the nurse or affiliated groups collect. Secondary data is information from existing data sources. In an issue such as teenage pregnancy, adolescent pregnancy statistics collected by the local health department would be secondary data, whereas findings of a survey on why teens are sexually active collected by a teen pregnancy coalition would be primary data. Data have a variety of uses beyond validating a problem. For example, data can be used to convince others of the need for action, as a basis for developing policy goals and objectives, and to mark progress toward problem resolution.

PLANNiNg HEALTH CARE POLiCy. Planning health care policy involves a number of activities in which population health nurses can be involved. These activities include developing and evaluating alternative policy solutions for identified problems, delineating the policy, and planning strategies to garner support for the selected alternative.

Evaluating policy alternatives. There may be multiple policy alternatives to resolving a particular health problem, and policy makers must evaluate potential alternatives in terms of what is feasible given the constraints operating in the situation (Leavitt et al., 2012). The first step in evaluating alternatives is determining the criteria that will be used for evaluation. Some of the criteria that may be used include the relative cost of one alternative over another, the ease of implementing a particular alternative, the acceptability of the policy to those who will be affected, and so on. One particular area that should always be considered is the

TABLE 9-3 Elements of an issue Analysis

Element Explanation

Problem identification and analysis Description of the problem or issue, including information regarding causes and effects Description of factors affecting the problem (could be organized in terms of the determinants of health); a description of past history of attempts at problem resolution

Background Description of the history of the issue and prior attempts at problem resolution Political setting Identification of the entities with jurisdiction over the problem Stakeholders Description of parties with an interest in the outcome of the issue (e.g., those affected by the problem,

implementers of possible solutions, special interest groups, specific policy makers with an interest in the area)

Values assessment Identification of underlying values shaping stakeholders’ perspectives Power analysis Determination of power bases of stakeholders (both supporters and resisters of problem resolution) Resources Identification of the resources (financial and human) needed to address the issue Alternatives Potential solutions to the problem Evaluation criteria Development of criteria for judging the appropriateness of alternative solutions in light of desired out-

comes; typical criteria might include cost, equity, quality, feasibility, and resource needs Alternative analysis and scoring Analysis of the extent to which any given alternative meets established criteria for evaluation; may em-

ploy a scoring mechanism that ranks each alternative based on weighted criteria Policy recommendation Recommendation to select one or more alternatives based on the analysis

Data from: Leavitt, J. K., Mason, D. J., & Whelan, M.E. (2012). Political analysis and strategies. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy and politics in nursing and health care (6th ed., pp. 65–76). St. Louis, MO: Saunders.

M09_MARY9591_06_SE_C09.indd 229 06/09/14 6:40 PM

230 unit 3 Population health nursing Strategies

political feasibility of the policy alternative. Political feasibility reflects the anticipated ease or difficulty of getting the proposed policy accepted by policy makers. Three sets of factors influence the political feasibility of a particular policy issue: issue-related factors, process factors, and institutional factors.

Issue-related factors include the comprehensiveness, com- plexity, and costliness of the proposed policy. Comprehensive policies that lead to massive change and those that are complex in their implementation are more difficult to achieve than those that result in modest or incremental change and are simple to implement. Similarly, less costly alternatives usually receive greater support from policy makers than more costly ones. For example, moving to a national health system in the United States would be a sweeping change in the health care delivery system and would be extremely complex in its implementation. Incremental policies that cover smaller subpopulations (e.g., Medicare for the elderly) have historically been easier to enact.

Process factors relate to the situational context rather than the policy itself. Examples of process factors include the impor- tance of the issue to the general public and to policy makers and the timing of the proposal in relation to other issues and factors, such as an election year or major focus on other events and issues (e.g., national security). Institutional factors reflect the political context and include such things as a landslide political victory or control of both houses of government by a single party.

Delineating the policy. Once policy alternatives have been evaluated, an appropriate alternative or group of alternatives is selected and the policy itself is developed in detail. The program

or plan should be made as clear and simple as possible. One of the reasons for the failure of the Health Security Act, proposed by former President Clinton, was its complexity and the inability of the general public, as well as legislators, to understand it. Many of these issues were more successfully addressed in the Patient Protection and Affordable Care Act, which is discussed in more detail later in this chapter.

An important consideration in outlining the details of the selected policy option is the identification of needed resources and their potential availability. What will be required to imple- ment the planned policy? Is there a need for specially trained personnel? For equipment? Where will these resources be ob- tained, and how will they be financed? Where will funding for policy implementation be derived?

POLiCy imPLEmENTATiON STRATEgiES. When the proposed policy has been outlined, strategies are developed to promote its adoption by policy makers. These may include developing a message, forming coalitions, mobilizing grassroots constituencies, and developing a specific action plan. The action plan should include long- and short-term goals, activity timeframes and areas of responsibility, strategies for developing community support, and identified target audiences and agents of change.

The message or issue should be framed in terms that are meaningful to stakeholders and target audiences (Leavitt, Mason, & Whelan, 2012). Different messages may be needed depending on the target. For example, messages designed for the general public might be different from those designed to

FOCuSED ASSESSmENT Assessing the Policy Situation

alternative? Which alternative(s) is most likely to achieve the goal or desired outcome?

• Are there strongly held values that will be supported or threatened by the proposed policy?

• Who will be affected by the policy? Who will support the policy? Who might oppose it? Why? What influence does the opposition wield? What is the power base of supporters of the proposed policy?

• Who should be involved in policy development? Implementation?

• Does the proposed policy adequately address the issue?

• Does the policy safeguard individual rights as much as possible?

• Are proposed implementation strategies fair and equitable?

• How easy or difficult will it be to implement the proposed policy?

• What will be the cost of policy implementation? What resources will be needed? How will these resources be obtained?

Effective participation in policy formation requires the ability to assess the policy situation and determine factors that are operating in the situation. Here are some considerations that should guide policy assessment.

• What is the health problem or issue to be addressed? Why has the need for policy development or change arisen? What are the data related to the problem or issue?

• What biophysical, psychological, environmental, sociocultural, behavioral, and health system factors are contributing to the problem to be addressed by the proposed policy?

• What biophysical, psychological, environmental, sociocultural, behavioral, and health system factors will influence the policy direction?

• What is the appropriate policy arena? Where does jurisdiction lie?

• What is the goal or desired outcome of policy development?

• What are the potential alternative strategies for the problem? What are the advantages and disadvantages of each

M09_MARY9591_06_SE_C09.indd 230 06/09/14 6:40 PM

chaPter 9 Political Strategies 231

enlist support from health professional organizations. Other specific strategies to promote adoption of a proposed policy by policy makers are discussed below.

Population health nurses alone cannot assure the develop- ment and implementation of effective health care policies. Al- though they may be actively involved in policy development, achieving policy approval and implementation usually requires broad-based support in many segments of society. Nurse policy makers can use a variety of strategies to create support for de- sired policy options. These include keeping informed of policy issues, communicating with policy makers, networking, coali- tion building, reciprocal action, creating media support, com- munity organizing, lobbying, and providing testimony.

Staying informed and communicating with policy makers. Unlike the rest of the strategies for creating support for policy adoption, staying informed and communicating with policy makers are ongoing strategies that are not confined to a specific issue or policy. Population health nurses need to stay current on issues and problems related to health at local, state, national, and international levels. This can be accomplished through involvement in nursing and other health-related organizations and by keeping up with literature in public and professional domains (e.g., local news media and journal literature). For population health nurses, APHA is the single most effective advocacy group for public health policy in the United States and is also influential in international policy development. National and state nursing organizations (e.g., ANA and its state affiliates and nursing specialty organizations) also advocate for some health issues, but do not address population health issues with the breadth of APHA. As we saw in Chapter 8 , the International Council of Nurses, composed of national nursing organizations, exerts a great deal of influence on international health policy, as do other international organizations.

To be seen as credible resources regarding specific issues, population health nurses need to become acquainted with policy makers at multiple levels. To do so, they should en- gage in regular contact with legislators and other policy mak- ers, promote their visibility as issue experts, and provide clear, consistent messages. Population health nurses should develop strategies and tactics for becoming known to policy makers. Strategies are general approaches to be taken; tactics are the im- plementation details of a particular strategy. Population health nurses may communicate with legislators through letters sup- porting a particular position or by presenting data related to issues of interest to legislators or nurses. For example, a pop- ulation health nurse may routinely send new information re- garding a particular topic to legislators who are supporting (or not supporting) a related piece of legislation. Similarly, nurses may make periodic visits to legislators who represent their state or district. On the local level, nurses may invite policy makers or members of their staffs to important community meetings or extend an invitation to participate in regular meetings of community-based organizations.

When attempting to influence policy makers, the APHA (2011) recommends meeting them where they are and ac- knowledging the constraints under which they operate. When- ever possible, nurses and others working for health policy changes should link health policy to major issues of interest to legislators and other policy makers. In addition, they should present issues clearly, in terms that policy makers can under- stand, and address economic considerations as appropriate.

When communication relates to a particular issue, nurses or allied groups should create a clear public image and articulate key messages that are consistent and targeted to the intended audiences. Audiences may include the general public as well as legislators and other policy makers. Communication ne- cessitates identifying the most appropriate means of reaching specific audiences. For example, members of an ethnic cultural group may be approached by means of ethnic radio and televi- sion stations or newspapers, whereas e-mail messages and tele- phone calls may be more appropriate for communicating with policy makers.

Networking, coalition building, and reciprocal action. Another group of related strategies for creating support for health policy initiatives includes networking, coalition building, and reciprocal action. Networking is a process of coming to know and becoming known to others with similar interests. Population health nurses can engage in networking by joining groups dedicated to addressing specific health-related issues or becoming involved in organizations that have a broader health focus. These groups or organizations may be local, regional, national, or international in their focus. At the local level, for example, a population health nurse might become a member of a community collaborative that addresses all kinds of com- munity issues, including those that affect health. Or the nurse may become involved in the state nurses association or APHA. Nurses can also network by attending conferences related to specific areas of interest or by contacting authors who write about these areas.

Coalitions are alliances of individuals or groups who unite to address a common interest. Coalitions have several advan- tages in promoting adoption of a desired policy alternative including the ability to pool resources and to achieve more extensive results than individuals or single agencies operating alone. Membership in coalitions may also lead to involvement in broader issues or similar issues at broader levels. Coalitions can make efficient use of resources and prevent duplication of effort. In addition, coalitions promote communication, coop- eration, and idea generation and build a broader, more stable constituency than a single organization might have. Finally, all of these characteristics of coalitions build to a final advantage, greater political clout than independent action (Rice Bowers- Lanier, 2012). It is critically important that coalitions include partnerships with groups of community residents as well as other groups and organizations working in the community.

In addition to their many advantages in supporting adop- tion of specific policy proposals, coalitions do have a few

M09_MARY9591_06_SE_C09.indd 231 06/09/14 6:40 PM

232 unit 3 Population health nursing Strategies

disadvantages. There is a need for staff time to carry out the work of the coalition that may draw staff of member agen- cies away from their usual responsibilities. There is also work needed to maintain the interactions of the coalition as well as to address the policy issue. For example, efforts must be un- dertaken to communicate among members. Another disad- vantage is the increased time needed for group decisions and the potential for a weakened stance on an issue necessitated by the need to compromise to gain agreement among mem- bers. Finally, credit for the success of coalition endeavors must be shared among all members, which may make it more dif- ficult for individual agencies to showcase their achievements to funders and other interested parties. Additional challenges posed by coalitions include getting the right participants, ar- eas of distrust among members, and the need to protect one’s own “turf” or agenda. One final difficulty is the potential for conflict among members posed by different perspectives on directions that should be taken to address policy issues or the strategies that should be employed to promote them (Rice Bowers-Lanier, 2012).

Usually a few salient issues must be addressed for effective coalition formation. Three of these issues are coalition leader- ship, structure, and funding. Generally, two types of leadership are required for effective coalitions—motivational leadership and organizational leadership—and it is unusual for one per- son to embody both. The motivational leader has a bold vision and can motivate others to pursue that vision. The organiza- tional leader deals with the day-to-day operation of the coali- tion. Issues related to coalition structure deal with governance and decision making. How should decisions be made, and by whom? Finally, there is the issue of funding. Some coalitions acquire operating funds from dues paid by members, but many have to seek outside funding through grants and other sources. The need to actively seek funds adds to the work of the coali- tion (Rice Bowers-Lanier, 2012).

Coalition formation occurs in a series of steps, the first of which is determining whether or not a coalition is an appro- priate approach to a given policy issue. If so, the next task is determining who should be invited to participate. Once par- ticipation has been solicited, the group must develop con- sensus on the goals to be achieved and the strategies used to achieve them. The coalition then engages in activities designed to achieve the designated goals and evaluates goal accomplish- ment. Throughout this process, the coalition must engage in activities that maintain its forward momentum.

Networking and coalition building may necessitate recipro- cal action. This usually involves providing support for the is- sues and projects of interest to other members of the network or coalition in return for their support on issues of interest to nursing. For example, nurses may agree to support bond issues to expand police and fire services in return for the support of these groups in issues related to housing code violations.

Creating media support. Much of the information regarding policy issues received by the general public is transmitted by the

media. To create public support for a policy initiative, popula- tion health nurses must carefully select and orchestrate media coverage.

Nurses need to help assure that policy debate is framed in the interests of the public’s health while accounting for con- textual factors that influence the policy situation. For example, a policy should not be perceived to unduly advantage one seg- ment of the population to the disadvantage of others. Policy makers should seek out media that are favorable to the partic- ular issue, and media messages should be targeted to specific audiences to create support for a given policy initiative. The burgeoning social media movement is an excellent way to edu- cate the public about health-related issues (Daniels, Glickstein, & Mason, 2012). Media messages should be designed not only to inform the public, but also to encourage them to mobilize to support the initiative. Public support is only effective when it is visible to policy makers through organized efforts such as contacting legislators, and so on.

Community organizing. Another way population health nurses create support for policy directions is community or- ganizing. Community organizing is the process of mobilizing community resources in support of planned change within the community. It is a systematic process of assessment, analysis, and planning, conducted within the context of the political process. Aspects of community organizing include locality development, social planning, and social action. Locality devel- opment involves promoting the ability of community members to help themselves. Training community members for leader- ship roles and promoting their ability to interact with policy makers would be examples of locality development. Social plan- ning involves collecting problem-related data, goal setting, and planning policies that address community problems that later inform social action. Social action involves efforts to increase the power and resources available to members of the com- munity to enable them to address problems and create change (Work  Group for Community Development and Change, 2013). Population health nurses can be actively involved and provide a leadership role in data collection activities.

Lobbying and advocacy. Lobbying and advocacy are ad- ditional means for promoting adoption of a particular policy alternative. In the political context, these terms have different legal definitions. Lobbying refers to attempts to influence pol- icy makers to take a particular action with respect to a specific piece of legislation. Lobbyists may be volunteers, but are often paid representatives of organizations, agencies, or businesses. Political advocacy, on the other hand, involves communicat- ing with policy makers regarding an issue without requesting specific action. The U.S. federal government makes important distinctions between lobbying and advocacy. If a person spends more than 20% of his or her time in lobbying efforts, he or she must register as a lobbyist with Congress, report on the focus of lobbying efforts, and report funding contributions above a certain fixed limit. Advocacy activities, on the other hand, are

M09_MARY9591_06_SE_C09.indd 232 06/09/14 6:40 PM

chaPter 9 Political Strategies 233

not regulated and are often performed by ordinary citizens (Whelan & Woody, 2012).

Government agencies may or may not be permitted to en- gage in lobbying activities, but lobbying may be restricted to specific individuals within the organization. The federal Hatch Act specifically prohibits government employees of agencies receiving federal monetary support from engaging in any parti- san political activity (Malone & Chaffee, 2012).

Presenting testimony. Policy makers sometimes hold pub- lic hearings or meetings to gather background information on an issue before attempting to draft legislative proposals or regulations. On occasion, such meetings are held by legislative subcommittees to explore the potential impact of a proposed piece of legislation. Writing and presenting testimony in a pub- lic hearing is another way population health nurses can influ- ence policy makers.

Testimony presented by population health nurses should specifically address the issue in question and be brief, factual, and well documented. Legislative representatives are not usu- ally health care providers, so testimony should avoid medical jargon and be clearly understandable. A copy of the testimony should be given to the legislative representatives and staff ei- ther immediately preceding or at the time of the hearing. Documentation of sources of data permits later verification by legislators or their staff members. Population health nurses should also be conversant with the format for hearings and the rules governing presentation of testimony. In addition, it is helpful to identify potential questions that might be asked by policy makers in order to be prepared to answer as fully as possible. If the answer to a question is not known, offer to get the relevant information (Whelan & Woody, 2012). On no ac- count, however, should data be invented.

Population health nurses can also influence policy develop- ment and implementation through more traditional political activities. These activities influence the selection of policy mak- ers and issues to be addressed and include voting, campaign- ing, obtaining political appointments, and holding office.

Voting. Voting is perhaps the easiest means of influencing health care policy formation at governmental levels. Nurses can themselves vote and motivate others to vote to support policy di- rections that enhance public health. One vote alone may not seem important, but it may be a key factor in determining the outcome on an important issue. Because lawmakers in the United States are elected, they are susceptible to the power their constituents hold through the ballot box. Thus, voting is a vital component of the political process in which all nurses can participate.

In addition to voting, nurses can educate others regarding the need to vote. Legislative networks among nurses are in- tended to keep members informed of health-related issues and the need for support or lack of support for certain policy direc- tions. Nurses can also educate the general public on legislative issues that come up for public vote. Finally, nurses can partici- pate in voter registration programs that motivate the general

public to exercise their constitutional right to influence policy formation.

Campaigning. Campaigning is a process designed to influ- ence the public to vote in a particular way on an issue or a can- didate. An issue or candidate is presented in a favorable light with the intent of influencing voters. Campaigning can be im- plemented via media presentations, in group meetings or rallies, or in face-to-face contacts with the public.

Campaigning for an issue involves presenting information related to the issue that persuades people to support nursing’s position. Campaigning for a specific candidate can help ensure the election of policy makers who support nursing’s position on important issues. Campaigning is an opportunity for nurses to become personally known to a candidate and other cam- paign workers. It is also an opportunity to become known as a reliable source of information about health and health care issues. Campaigning for a candidate also creates a debt on the part of an elected official that may result in future support for a position promoted by population health nurses.

Much of the work of political action committees (PACs) is designed to support the candidacy of specific individuals. The American Nurses Association Political Action Commit- tee (ANA-PAC) was created in response to nursing’s perceived lack of influence in the formulation of health care policy (ANA, 2014). The purpose of ANA-PAC is to promote constructive national health care legislation through the political “election- eering” process. Electioneering is the active process of endors- ing candidates who have demonstrated support for nursing’s political agenda and contributing time and money to their campaigns. ANA-PAC and similar political action committees supported by nurses seek to enhance the political influence of nurses by supporting the election of candidates who back the profession and its position on significant health-related issues.

There are some constraints on campaign involvement for certain groups of nurses. For example, nurses employed by government agencies (whether part-time or full-time, perma- nently or temporarily) are prohibited by the Hatch Act (also

Voting is a common way to affect change. (Karin Hildebrand Lau/ Shutterstock)

M09_MARY9591_06_SE_C09.indd 233 06/09/14 6:40 PM

234 unit 3 Population health nursing Strategies

known as the Act to Prevent Pernicious Political Activities) from soliciting campaign contributions (even anonymously by telephone) or engaging in campaign activities while on duty, in uniform, or using an agency vehicle. They are also prohib- ited from running for office in a partisan election. The provi- sions of the Hatch Act cover all federal employees, employees of the District of Columbia, employees of state or local agencies funded by the federal government, and Commissioned Officers in the U.S. Public Health Service (Malone & Chaffee, 2012).

Holding political appointments and elected offices. A final means of creating support for policy directions promoted by population health nurses is to become a policy maker oneself. This may involve being appointed to a specific position or run- ning for elective office. In either case, the population health nurse must first become politically active in some of the other ways described in this chapter to be sufficiently well known to be elected or appointed to a policy-making position (Hall-Long, 2012; Leavitt & Chaffee, 2012).

One may also work in the background in policy making by becoming a legislative staff person or a lobbyist for an orga- nized group. Again, such positions require familiarity with the political process and well-developed interpersonal relation- ships with legislators and other policy makers. Strategies to influence policy development and implementation are summa- rized in Table 9-4•. EvALuATiNg HEALTH POLiCy DEvELOPmENT. Population health nurses should be involved in evaluating the policy development process as well as polices developed. In evaluating the process itself, the nurse would consider the extent to which all stakeholders, including those affected by a given policy, have been involved in policy development. In addition,

the nurse would assess the adequacy of strategic management of the policy development process, gaining insights into what worked and what did not for application in future policy development efforts.

Population health nurses should also evaluate the adequacy of health policies developed. Criteria for evaluating health poli- cies include their adequacy in meeting the health needs of the public, safeguards for the rights of individuals, equitable allo- cation of resources, their capacity for implementation, and the effects of the policy on the target population.

Health policies must be developed that effectively address the health needs of the affected population and identification of needs must derive from population-based data. For example, a local government policy allowing homeless persons to sleep in city-owned buildings addresses only one small part of the problem of homelessness. In this case, a more comprehensive policy that addresses both short-term and long-term solutions to the problems of homelessness is needed.

Safeguarding individual rights is another criterion for sound health care policy development. As an example, a policy that would require homeless individuals to surrender personal be- longings to meet communal needs when admitted to a shelter would violate their property rights. There are circumstances, however, in which the good of society supersedes individual rights. For example, homeless persons may be prohibited from smoking in a shelter to prevent exposing others to smoke or to prevent a fire. Whenever possible, health policies should be written so that they do not violate the rights of individuals af- fected by them.

Health care policies should also promote equitable distribu- tion of health care resources. This means that policies should not discriminate against certain subgroups within the popula- tion. For example, open housing policies in homeless shelters

TABLE 9-4 Strategies for Promoting Policy Adoption

Strategy Description of Strategy

Staying informed Keeping current on health-related issues at local, state, national, and international levels Communicating with policy makers Becoming known to policy makers

Establishing credibility as a source of information Networking Becoming aware of and known to groups and individuals with similar policy-related interests Coalition building Creating a temporary alliance among individuals or groups to work toward common goals Reciprocal action Supporting the policy efforts of others in return for support of issues of interest to nursing Creating media support Selecting appropriate media and designing targeted media messages for specific audiences Community organizing Mobilizing community resources in favor of planned change or a proposed policy Lobbying Engaging in personal communications with policy makers in an attempt to elicit a specific ac-

tion with respect to a specific policy Presenting testimony Providing information on an issue to policy makers at a public hearing Voting Exercising one’s personal right to vote

Encouraging others to vote Participating in voter registration drives

Campaigning Providing endorsements or monetary support for specific policy proposals or candidates with the intent of influencing voters’ responses

Holding a political appointment or elected office Assuming a position as a policy maker by virtue of election or appointment to a specific office

M09_MARY9591_06_SE_C09.indd 234 06/09/14 6:40 PM

chaPter 9 Political Strategies 235

may inadvertently discriminate against women and children who may be subjected to force to make them give way to adult men who desire shelter. Sex-segregated shelters that ensure ac- cess for both males and females provide for a more equitable allocation of resources.

For a specific health policy to be effective in promoting health or preventing illness, it must be capable of being implemented or enforced. For example, a local government might adopt a policy encouraging houses of worship to provide overnight shelter for homeless individuals. But unless the houses of wor- ship are willing to cooperate, the policy cannot be implemented.

Population health nurses planning to influence health care policy formation should assess proposed policies or modifica- tions of existing policies in light of these five criteria. Policies that do not meet the criteria should be redesigned, if possible, before they are presented to policy makers. If a proposed pol- icy continues not to meet one or more criteria, its supporters should be prepared to justify the need for the policy. For exam- ple, nurses should be prepared to convince policy makers that a smoking ban in shelters for the homeless is warranted despite the violation of the individual’s personal freedom of choice.

Population health nurses may also be actively involved in as- sessing the effects of health care policies on meeting the needs of the particular target group. Population health nurses could assist in collecting data related to the outcomes of programs put into operation. For example, data might be gathered on the incidence of health problems among the homeless to evalu- ate the effects of policies designed to foster health promotion, illness prevention, or treatment services in this population. In addition, information could be collected regarding the num- ber of persons who continue to be homeless despite assistance from established programs.

The Patient Protection and Affordable Care Act—PL 111–148 The most sweeping piece of U.S. health-related legislation in several years culminated in the signing of the Patient Protection and Affordable Care Act in March 2010. In spite of political and legal challenges, broad segments of American society are currently engaged in implementing its provisions. A general overview of these provisions was provided in Chapter 7 . For further information about the Affordable Care Act, see the re- sources provided in the External Resources section of the student resources site. Here we will briefly review some of the aspects of the development of this significant piece of legislation.

Efforts to provide health insurance coverage for the American people began as far back as 1912 when Theodore Roosevelt’s Progressive Party included social insurance, in- cluding health insurance, in the election platform. As recently as 1993, the Clinton Administration developed a proposal for health care reform, the Health Security Act, which failed in Congress (Kaiser Family Foundation, 2011). What then was dif- ferent in 2010 that permitted the passage of the Affordable Care Act (ACA)?

One factor influencing the success of the legislative initiative was the long-standing complaints from business and industry about the rising cost of health insurance premiums for employ- ees. At the same time, there were concerns about increasing fed- eral costs for Medicare and Medicaid programs. In addition, a greater percentage of the American people—nearly 50 million— were without health insurance coverage than ever before. These factors led to the impetus for major legislation to reform the health care delivery system (APHA, 2012b; Sparer, 2011).

Any possible legislation, however, faced three major ob- stacles: significant self-interest on the part of many organiza- tions, disagreement about the appropriate role of the federal government in health care, and the need to circumvent a Sen- ate filibuster designed to kill the legislation. Factors operating in favor of the legislative proposal included a mandate in the 53% of the popular vote that elected President Barack Obama, coupled with a Democratic majority in the U.S. Senate. In ad- dition, the Obama administration designated health care re- form a governmental priority and linked it to recovery from a serious economic recession. Rather than develop a proposal from the executive branch that was forwarded to Congress for action, Obama charged the Senate with developing a workable plan for reform and emphasized willingness to compromise, limiting the opposition from interest groups (Sparer, 2011).

In addition, the Obama administration highlighted the need to base reform on the current system rather than creating an entirely new system of care, again defusing some opposition from vested interests. Changes are incremental rather than overwhelming in nature, and some provisions left out of the initial bill were reincorporated in the reconciliation process between House and Senate versions of the legislation (Kaiser Family Foundation, 2011).

Several elements of the Affordable Care Act have far reach- ing implications for population health status. These include a significant reduction in the number of uninsured, an emphasis on health promotion and prevention, and provisions for im- proving chronic disease management, as well as elimination of discriminatory insurance practices (APHA, 2012a; Centers for Medicare and Medicaid Services [CMS], 2013b). In addition, the law is expected to result in considerable savings over the long term. In fact, CMS has reported $8.3 million in savings on prescription drug costs as of 2013. In addition, sufficient savings have been realized to hold Medicare Part B premiums at the prior year’s level and to reduce both Part A and Part B deductibles (CMS, 2013a).

One of the most salient aspects of ACA for population health practice is the creation of the National Prevention, Health Promotion, and Public Health Council. This federal agency is charged with developing a National Prevention Strategy that incorporates evidence-based health promotion practices. In 2011, the “National Prevention Strategy: America’s Plan for Better Health and Wellness” was released. The strategy de- lineates four strategic directions: (a) promoting healthy and safe communities, (b) enhancing clinical and community prevention services, (c) eliminating health disparities, and

M09_MARY9591_06_SE_C09.indd 235 06/09/14 6:40 PM

236 unit 3 Population health nursing Strategies

Effective population health nurses use the political process to attain their primary objective, enhancing the health of the pop- ulations with which they work. Political activity by population health nurses may occur at the institutional or societal level and often involves efforts to influence legislation related to health issues. The political process begins with identification of health issues or problems that can be resolved through policy forma- tion. Agenda setting and delineation of the actual policy are fol- lowed by development of strategies designed to get the desired policy adopted and implemented. These strategies may include

staying informed on policy issues, communicating with policy makers, networking, coalition building, reciprocal action, cre- ating media support, and community organizing. Additional strategies include lobbying, presenting testimony, voting, cam- paigning, and holding political appointments or elected offices. Policy development ends with an evaluation of the policy de- velopment process as well as the effectiveness of the policy in addressing the identified health issue. The Patient Protection and Affordable Care Act is a prime example of the use of the political process to enhance the health of the population.

CHAPTER RECAP

In focus groups conducted to determine local health needs, resi- dents of a low-income, culturally diverse neighborhood repeat- edly voiced concerns about intimidation of tenants by landlords. Because of housing shortages, many tenants were (justifiably) worried that reporting inadequacies to landlords would result in evictions. With limited low-income housing available, people were not willing to take the risk of making complaints about needed repairs or noisy neighbors.

Cultural differences, the tenants’ lack of facility with English, and the fact that most owners of rental units were absentee land- lords complicated the situation. More than half of the residents in the community were members of ethnic cultural groups, in- cluding many relatively recent refugees from Southeast Asia and the Middle East. Long-time area residents were primarily older persons on fixed incomes who also could not afford to antago- nize landlords.

There was a fledgling landlord/tenant association in the neighborhood, but few of the absentee landlords were active par- ticipants. There was also a neighborhood collaborative that had successfully mounted some initiatives to improve conditions for residents, including decreasing drug dealing in selected areas of the neighborhood and putting up antitobacco billboards. The collaborative had developed relatively close relationships with city council members and county supervisors in the wider com- munity, although recently several political positions had been

filled by newly elected officials. One or two long-time residents were particularly influential with local politicians. The nearby university law school provided landlord/tenant mediation ser- vices to individuals in the community. Other agencies and as- sociations active in the neighborhood included local schools, the community center, Boys and Girls Club, the community health center, the local health department office, the university school of nursing, a Lao-Hmong Association, the Vietnamese Federation, and several programs geared toward children and the elderly. 1. What steps might the local population health nurses take to

address the problem of intimidation by landlords? 2. What community groups might be appropriate coalition

partners in resolving this problem? Why? 3. What approaches might be taken in terms of policy develop-

ment to deal with intimidation? 4. Are there particular government agencies that should be-

come involved? If so, what are they and how would you pro- mote their involvement?

5. How might local residents become actively involved in re- solving the issue?

6. What cultural considerations have relevance for this situa- tion and its resolution?

influencing Housing PolicyCASE STuDy

(d) empowering people. The strategy also addresses seven tar- geted priority issues including (a) tobacco-free living, (b) drug abuse and excessive alcohol use, (c) healthy eating, (d) active living, (e) injury and violence-free living, (f) reproductive and sexual health, and (g) mental and emotional well-being (National Prevention, Health Promotion, and Public Health

Council, 2013). ACA also includes a number of other provi- sions that focus on health promotion and prevention including insurance coverage for preventive services, requirements for community health needs assessments, and funding for health promotion and prevention initiatives (APHA, 2012a).

M09_MARY9591_06_SE_C09.indd 236 06/09/14 6:40 PM

chaPter 9 Political Strategies 237

Alliance for Health Reform. (2010). Implementing health reform: Federal rules and state roles. Retrieved from http://www.allhealth.org/publications/State_ health_issues/Implementing_Health_Reform_-_Federal_Rules_and_State_ Roles_100.pdf

American Association of Colleges of Nursing. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification, and education. Re- trieved from http://www.aacn.nche.edu/education-resources/APRNReport .pdf

American Association of Colleges of Nursing. (2010). From patient advocacy to political activism: AACN’s guide to understanding healthcare policy and politics. Washington, DC: Author.

American Nurses Association. (2014). ANA-PAC: What is ANA-PAC? Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAPolitical- Power/ANAPAC.aspx

American Public Health Association. (2011). Transportation and health toolkit. Retrieved from http://www.apha.org/advocacy/priorities/issues/transporta- tion/Toolkit.htm

American Public Health Association. (2012a). Affordable Care Act overview: Selected provisions. Retrieved from http://www.apha.org/NR /rdonlyres/26831F24-882A-4FF7-A0A9-6F49DFBF6D3F/0/ACAOverview_ Aug2012.pdf

American Public Health Association. (2012b). Why do we need the Affordable Care Act?. Retrieved from http://www.apha.org/NR/rdonlyres/19BEA341- A7C3-4920-B2BC-65BDC846B803/0/WhyWeNeedtheACA_Aug2012.pdf

Berkowitz, B. (2012). The policy process. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 49–58). St. Louis, MO: Elsevier Saunders.

Bikersrights.com. (2013). Helmet issues: Use your head. Retrieved from http:// www.bikersrights.com/helmets.html

Bradbury, D. E., & Eliot, M. M. (1956). Four decades of action for children: A short history of the Children’s Bureau. Retrieved from http://www.ssa.gov /history/pdf/child1.pdf

California Senate OKs single-payer health plan. (2010, January 29). Retrieved from http://articles.sfgate.com/2010-01-29/bay-area /17840931_1_health-care-single-payer-state-plan

Centers for Disease Control and Prevention. (2013). Emerging tobacco products gaining popularity among youth. Retrieved from http://www.cdc.gov/ media /releases/2013/p1114-emerging-tobacco-products.html

Centers for Disease Control and Prevention. (2014). Health impact assessment. Retrieved from http://www.cdc.gov/healthyplaces/hia.htm

Centers for Medicare and Medicaid Services. (2013a). CMS announces major savings for Medicare beneficiaries. Retrieved from http://www.cms.gov /Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases- Items/2013-10-28.html

Centers for Medicare and Medicaid Services. (2013b). CMS strategy: The road forward 2013–2017. Retrieved from http://www.cms.gov/About-CMS /Agency-Information/CMS-Strategy/Downloads/CMS-Strategy.pdf

Chaffee, M. W. (2012). Science, policy, and politics. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 307–317). St. Louis, MO: Elsevier Saunders.

Chaffee, M. W., Mason, D. J., & Leavitt, J. K. (2012). A framework for action in policy and politics. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 1–11). St. Louis, MO: Elsevier Saunders.

Cho, H. S. M., & Kashka, M. S. (2004). The evolution of the community health nurse practitioner in Korea. Public Health Nursing, 21, 287–294.

Community Preventive Services Task Force. (2014). What is the community guide? Retrieved from http://www.thecommunityguide.org/index.html

Daniels, J., Glickstein, B., & Mason, D. J. (2012). Using the power of media to influence health policy and politics. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 88–104). St. Louis, MO: Elsevier Saunders.

Florence Kel ley . (2011) . Retr ie ved f rom http : / /w w w.nndb.com /people/460/000204845/

Front groups. (2013). Retrieved from http://www.sourcewatch.org/index.php /Front_groups

Green, R. (2010). The ethics of sin taxes. Public Health Nursing, 28, 68–77. doi:10.1111/j.1525-1446.2010.00907.x

Hall-Long, B. (2012). Taking action: Nurse, educator, and legislator: My journey to the Delaware General Assembly. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 579–582). St. Louis, MO: Elsevier Saunders.

Hendrickson, K. C., Ceccarelli, C., & Cohen, S. S. (2012). How government works: What you need to know to influence the process. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 480–493). St. Louis, MO: Elsevier Saunders.

HIA Partner Team. (2012). Expanding public transit in Columbia, Missouri: A health impact assessment. Retrieved from http://www.health impactproject.org/resources/document/Columbia-MO-Transit-HIA- Executive- Summary-FINAL-1.pdf

Institute of Medicine. (2011a). For the public’s health: Revitalizing law and policy to meet new challenges. Washington, DC: National Academies Press.

Institute of Medicine. (2011b). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.

Jewish Women’s Archive. (2010). Lillian Wald, 1867–1940. Retrieved from http://jwa.org/historymakers/wald

Kaiser Family Foundation. (2011). Timeline: History of health reform efforts in the U.S. Retrieved from http://kff.org/health-reform/timeline /history-of-health-reform-efforts-in-the-united-states/

Leavitt, J. K., & Chaffee, M. W. (2012). Political appointments. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 533–539). St. Louis, MO: Elsevier Saunders.

Leavitt, J. K., Mason, D. J., & Whelan, E.-M. (2012). Political analysis and strate- gies. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy and politics in nursing and health care (6th ed., pp. 65–76). St. Louis, MO: Saunders.

Leavitt, J. K., Mason, D. J., & Whelan, E.-M. (2012). Political analysis and strate- gies. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 65–76). St. Louis, MO: Elsevier Saunders.

Lewenson, S. B. (2012). A historical perspective on policy, politics, and nurs- ing. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy and politics in nursing and health care (6th ed., pp. 12–18). St. Louis, MO: Elsevier Saunders.

Lewis, J. J. (2011). Florence Kelley. Retrieved from http://womenshistory.about .com/od/workgeneral/p/florence_kelley.htm?p=1

Loomis, B. R., Shafer, P. R., & van Hasselt, M. (2013). The economic impact of smoke-free laws on restaurants and bars in 9 states. Preventing Chronic Disease,10, 120327. doi: http://dx.doi.org/10.5888/pcd10.120327. Retrieved from http://www.cdc.gov/pcd/issues/2013/12_0327.htm

Lowes, R. (2011). US Appeals court in Atlanta strikes down individual mandate. Retrieved from http://www.medscape.com/viewarticle/747987?sssdmh= dm1.709979&src=nl_newsalert

REFERENCES

M09_MARY9591_06_SE_C09.indd 237 06/09/14 6:40 PM

238 unit 3 Population health nursing Strategies

Malekafzali, S., & Bergstrom, D. (2011). Healthy corridor for all: A community health impact assessment of transit-oriented development policy in Saint Paul, Minnesota.Retrieved from http://www.healthimpactproject.org/news /project/body/Healthy-Corridor-summary-FINAL.pdf

Malone, T. A., & Chaffee, M. W. (2012). Political activity: Different rules for government-employed nurses. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 590–593). St. Louis, MO: Elsevier Saunders.

National Council of State Boards of Nursing. (n.d.). Campaign for APRN consensus: Model for uniform national advanced practice registered nurse (APRN) regulation: A handbook for legislators. Chicago, IL: Author. Retrieved from https://www.ncsbn.org/2010_APRN_Handbookfor Legislators_web.pdf

National Council of State Boards of Nursing. (2011). APRN consensus model toolkit. Retrieved from https://www.ncsbn.org/2276.htm

National Council of State Boards of Nursing. (2014). APRNs in the U.S. Retrieved from https://www.ncsbn.org/2567.htm

National Federation of Small Business. (2012). PPACA: The individual mandate tax. Retrieved from http://www.nfib.com/cribsheets/individual-mandate/

National Prevention, Health Promotion, and Public Health Council. (2013). 2013annual status report. Retrieved from http://www.surgeongeneral.gov /initiatives/prevention/2013-npc-status-report.pdf

National Research Council. (2011). Improving Health in the United States: The role of health impact assessment. Retrieved from http://www.nap.edu/ catalog.php?record_id=13229

Occupational Safety and Health Administration. (n.d.). Youth in agriculture. Retrieved from https://www.osha.gov/SLTC/youth/agriculture/other.html

Oettinger, K. B. (1962). It’s your Children’s Bureau. Retrieved from http://www .ssa.gov/history/childb2.html

Office of the First Minister and Deputy First Minister. (n.d.). A practical guide to policy making in Northern Ireland. Retrieved from http://www.ofmdfmni .gov.uk/practical-guide-policy-making.pdf

Policy. (2011). In Merriam-Webster’s online dictionary. Retrieved from http:// www.merriam-webster.com/dictionary/policy

The Policy Circle. (n.d.). The process: Policy development. Retrieved from http:// www.policyproject.com/policycircle/content.cfm?a0=4

Purtle, J. (2010). Gambling on the health of the public: A rapid health impact assessment for an urban casino. Retrieved from http://www.health impactproject.org/resources/document/sugarhouse-casino.pdf

Rice Bowers-Lanier, R. (2012). Coalitions: A powerful political strategy. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 626–632). St. Louis, MO: Elsevier Saunders.

Ridenour, N., & Santa Anna, Y. (2012). An overview of legislation and regula- tion. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 494–505). St. Louis, MO: Elsevier Saunders.

San Francisco Planning Department. (2010). Initial study: Glen Park community plan. Retrieved from http://www.hiaguide.org/sites/default/files/SF.pdf

Slokum-Bradley, N., & Bradley, A. (2010). Is the EU’s governance “good”? An assessment of EU governance in its partnership with ACP states. Third World Quarterly, 31(1), 31–49. doi:10.1080/01436590903557314

Social Security Administration. (n.d.). History: The Children’s Bureau. Re- trieved from http://www.ssa.gov/history/childb1.html

Sparer, M. (2011). U.S. health care reform and the future of dentistry. American Journal of Public Health, 101, 1841–1844. doi:10.2105/AJPH.2011.300358

State of Vermont. (2011). Brief summary of Act 48: Vermont health reform law of 2011I. Retrieved from http://hcr.vermont.gov/sites/hcr/files/ACT%20 48%20one%20page%20summary%20June%2014.doc

U.S. House of Representatives. (n.d.). House committees. Retrieved from http:// www.house.gov/committees/

U.S. Senate. (n.d.). Committees. Retrieved from http://www.senate.gov/page- layout/committees/d_three_sections_with_teasers/committees_home.htm

Warner, J. R. (2012). Interest groups in health care policy and politics. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 594–601). St. Louis, MO: Elsevier Saunders.

Whelan, E.-M., & Woody, M. P. (2012). Lobbying policy makers: Individual and collective strategies. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 519–526). St. Louis, MO: Elsevier Saunders.

Wiist, W. H. (2011). Citizens United, public health, and democracy: The Supreme Court ruling, its implications, and proposed action. American Journal of Public Health, 101, 1172–1179. doi:10: 2105/AJPH.2010.300043

Wisconsin Department of Health Services. (2010). Healthiest Wisconsin 2020: Everyone living better, longer. Retrieved from http://www.dhs.wisconsin .gov/hw2020/report2020.htm

Work Group for Community Development and Change. (2013). Community tool box: Section 8: Some lessons learned on community organization and change. Retrieved from http://ctb.ku.edu/en//tablecontents/sub_section_ tools_1386.htm

World Health Organization. (2014). Health policy. Retrieved from http://www .who.int/topics/health_policy/en/

Young, J. (2009, September). Helping researchers become policy entrepreneurs. Overseas Development Institute Briefing Paper, 53. Retrieved from http:// www.odi.org.uk/resources/download/1127.pdf

M09_MARY9591_06_SE_C09.indd 238 06/09/14 6:40 PM

chaPter

10 Community Empowerment Strategies

community building

community capacity

community competence

community development

empowerment

participatory evaluation

powerlessness

Key Terms

Learning outcomes

After reading this chapter, you should be able to:

1. Discuss the relationship of community empowerment to other similar concepts.

2. Identify levels of community empowerment.

3. Apply selected models for community empowerment.

4. Describe the process of community empowerment.

5. Apply criteria to evaluate community empowerment.

6. Analyze the role of population health nurses in community empowerment.

M10_MARY9591_06_SE_C10.indd 239 06/09/14 6:40 PM

240

A d

vo ca

cy T

h en Harriet Tubman

Harriet Tubman epitomized the concept of a nurse empowering others. Born into slavery, Harriet Tubman suffered lasting consequences of a blow delivered by an overseer when, as a young girl, she thwarted his efforts to capture a runaway slave (Sahlman, 2011). After escaping to the North herself, she made multiple trips back to the South to lead an estimated 300 slaves, including members of her own family, to freedom, earning the title “the Moses of her people” (Maschi, n.d.; New York History Net, n.d.). These activities required her to employ a number of creative strategies including traveling in disguise and using hymns to spread the word that she would be in the area to guide willing slaves to freedom (Driggs, 1980). She collaborated with members of the underground railroad, and became an accomplished speaker at antislavery and women’s rights meetings, gaining the support of such well-known figures as suffragette Susan B. Anthony, Secretary of State William H. Seward, and authors Ralph Waldo Emerson and Louisa May Alcott (Lewis, n.d.).

During the Civil War, Tubman worked as a nurse and teacher, meeting the needs of escaped slaves fighting with the U.S. Army and the Gullah people of the South Carolina Sea Islands, left behind by their White owners (Lewis, n.d.). In addition, she organized a network of scouts and coordinated the Union attack on Southern supply lines on the Combahee River (Conrad, n.d.). In addition to disrupt- ing supply lines, the expedition freed several hundred slaves from plantations along the river (Conrad, n.d.). During her scouting missions, she continued to try to persuade slaves to leave their masters and join the Union Army. After the war, Tubman, herself illiterate, worked to establish schools for freed slaves in South Carolina and later to establish a home for indigent elderly former slaves.

A d

vo ca

cy N

ow Self-Empowerment of Indian Women Self-employed women in the state of Gujarat, India, found themselves living in poverty with no em- ployment security and no coverage under the national social security system. More than 1 million of these women organized a self-help trade union, the Self-Employed Women’s Association (SEWA) to improve their living and working conditions. Starting their own bank, the women provided ac- cess to credit and kept the proceeds of their labor without being exploited by lenders charging high interest rates. In addition, vegetable producers and sellers started their own shops and eliminated exploitation by middlemen. Other initiatives undertaken by the group include child care and col- lective health insurance coverage. In 2008, SEWA campaigned for legislation for social security coverage for informal self-employed workers, including insurance, pension, and maternity benefits. In response, the Indian government established a commission to develop related laws and policies for informal workers (World Health Organization, 2008, 2009).

Throughout this book, we emphasize the advocacy role of the population health nurse. Population health nurses act on behalf of individuals, families, and population groups that, for whatever reason, cannot act for themselves. The ultimate outcome of advocacy by population health nurses, however, is the ability of the cli- ent to act independently. Community empowerment, as dis- cussed in this chapter, is designed to accomplish that outcome,

to enable communities to identify community health problems, and take steps to resolve them independently of or in concert with health care professionals and others. Just as successful nursing education programs prepare graduates to function ef- fectively on their own in the practice milieu, so too does effec- tive population health nursing, as community empowerment, prepare communities to deal with their own health problems and issues.

M10_MARY9591_06_SE_C10.indd 240 06/09/14 6:40 PM

chaPter 10 community empowerment Strategies 241

Although some authors trace the beginnings of community organization and empowerment to the settlement house activi- ties of the late 1800s (Minkler & Wallerstein, 2012), the nurses of the Henry Street Settlement did not engage in community organization or empowerment activities as we know them to- day. Those nurses certainly functioned as advocates for the health and social welfare needs of the immigrant populations they served, but they did not work to enable those populations to act on their own behalf. On the contrary, they tried to work within the existing power structure to benefit these popula- tions, rather than attempting to redistribute power in their favor. Today, however, community development and particu- larly community empowerment are key strategies to address health disparities throughout the world (Tsey et al., 2010). In fact, community empowerment, as exemplified in community participation in health care decisions, is one of the five prin- ciples of primary health care promoted by the World Health Organization (WHO) ( Aston, Meagher-Stewart, Edwards, & Young, 2009). Community development may improve health directly by addressing specific health issues or indirectly through empowering communities to take action to address health issues.

Empowerment and Related Concepts Community empowerment, the topic of this chapter, is closely related to a number of similar concepts. Empowerment is “a social action process that promotes participation of people and communities toward goals of increased individual and commu- nity control, improved quality of life and social justice” (World Health Organization [WHO], 2009, Empowerment focuses on assisting the community to develop its own capacity to resolve problems rather than relying on outside assistance (Burkett, 2013). At a very basic level, empowerment involves transferring power from official bodies, authorities, or experts to members of the community. In some instances, this may involve commu- nity ownership of resources as well as capitalization on existing community assets (Cooke, 2013).

Powerlessness is the antithesis of empowerment. Powerlessness is the belief that one’s actions cannot determine the achievement of outcomes sought and is widely considered a significant contributor to health and social inequities through- out the world. As noted by some authors, “If powerlessness is the underlying factor among all adverse social conditions . . ., then empowerment takes precedence over other theoreti- cal frameworks used to eliminate health disparities” (Wiggins et al., 2009, p. 12).

Community empowerment arises from activities related to community development, community organizing, community mobilization, and community building. Empowerment, in turn, leads to increased community capacity and competence. The re- lationships among these concepts are depicted in Figure 10-1•. Some authors have noted that community development as a

concept has been co-opted by governments and other organiza- tions in top-down efforts to further their own agendas rather than empowering communities to control power and resources themselves (Craig & Mayo, 2013). Community development has been linked to capacity building and has been defined as “a set of practices and methods that focus on harnessing the in- nate abilities and potential that exist in all human communities to become active agents in their own development and to or- ganize themselves to address key issues and concerns that they share” (International Association for Community Develop- ment, 2014, para 2). Community development involves build- ing people’s skills and their ability to resolve common problems (Improvement and Development Agency, 2012).

The concept of community organization was presented in Chapter 9 and reflects the process of mobilizing resources to resolve community-identified problems. Community mo- bilization, a similar term, was defined as a community health

Community empowerment requires participation by diverse segments of the community. (Bikeriderlondon/Shutterstock)

Figure 10-1 Community empowerment and related Concepts

Community empowerment

Community capacity

Community competence

Community building

Community mobilization

Community organization

Community development

M10_MARY9591_06_SE_C10.indd 241 06/09/14 6:41 PM

242 Unit 3 Population health nursing Strategies

nursing role in Chapter 1 , and involves assisting popula- tions to identify areas of concern and to develop and imple- ment strategies to address them. Both of these processes tend to be more problem specific than community empowerment, which is designed to develop overall community abilities to deal with a variety of problems. Community building is an- other similar, but more general, process that leads to com- munity empowerment. Community building is defined as “continuous, self-renewing efforts that are led by residents, fo- cused on collective action, aimed at relationship building and problem solving and build a stronger community” (Neighbor Works® America, 2014, para. 2). Community building ef- forts frequently lead to increases in community social capital as described in Chapter 1 .

Other terms often associated with empowerment include public participation and community engagement. Public par- ticipation involves providing information and soliciting input from community members in decision-making processes, but with no real power over the final decision. Engagement in- volves community members in collaborative decision-making processes, but again does not result in ultimate power lying in the hands of the community (Bailey, 2010). These terms do not reflect true empowerment, and so are not included in the dia- gram in Figure 10-1.

Community empowerment results in increased commu- nity competence and capacity, as depicted in Figure 10-1. Community competence is defined as a community’s ability to engage in problem identification and resolution. Community capacity is the abilities and resources of the community that enable it to carry out tasks and functions to achieve identified goals.

Levels of Empowerment Empowerment may occur at several levels, including individ- ual community members, organizations within the commu- nity, and the community at large. Individual empowerment

is a process of increasing one’s power to take action to im- prove one’s own life. Empowered individuals gain new skills and power to influence others and to affect the outcomes of decision making (Bailey, 2010). For example, an individual community member may develop the knowledge and skills to bring housing code violations in their rental unit to the attention of the housing authority. Organizational empow- erment involves increasing the power of community organi- zations to control decisions related to the health and welfare of the community. Using the former example, members of a Community Collaborative may develop the skills to present findings about widespread housing-code violations to the lo- cal housing authority. In this process, the balance of power may change among organizations involved in partnerships (Bailey, 2010). For example, in a university-community part- nership, the university may initially exercise a great deal of power, particularly with respect to allocation of grant fund- ing received. As the community develops greater competence and capacity, more of this power is transferred to the hands of community members, who are enabled to write independent funding grants.

Population health nurses may be involved in individual, or- ganizational, and community empowerment. For example, a nurse may assist an abused woman to obtain job training and to request a restraining order against her abuser, empowering her to leave the abusive situation. Organizational empower- ment might involve advocacy for beneficiaries of a particular health program to have more control in the management of the program. At the community level, a population health nurse might assist residents of a low-income neighborhood to collect information on gang-related criminal activity and present a pe- tition to the City Council requesting a greater police presence in the neighborhood.

Global Perspectives

International capacity building has been described as the efforts of people in one country to help those in another to achieve their objectives. Examine the news media to identify examples of in- ternational capacity building or empowerment related to health issues. Who is providing the assistance? Who is receiving it? Based on the examples you have found, does capacity building always flow from the “haves” to the “have nots”? In what ways could underdeveloped nations contribute to international capac- ity building? As one example, what could the United States learn from countries with low neonatal death rates that could decrease U.S. neonatal mortality?

International Capacity Building

effective group work requires communication and collaboration. (Wong Sze Fei/Fotolia)

M10_MARY9591_06_SE_C10.indd 242 06/09/14 6:41 PM

chaPter 10 community empowerment Strategies 243

Community empowerment may also occur at horizon- tal and vertical levels (de Wit & Berner, 2009). Horizontal empowerment is internal to the community and is reflected in the community’s ability to solve problems by mobilizing its own resources. For example, a population health nurse might help neighborhood residents to form a neighborhood watch group to help control gang activity. Vertical empower- ment involves efforts to change power structures outside the community and to leverage outside power and resources to address community concerns and may involve organizing marginalized groups to make demands on the larger society. Vertical empowerment is reflected in community members petitioning the City Council for better police coverage. Some authors point out that developing horizontal empowerment structures may be difficult in low-income populations who may not have the time, energy, or resources needed for grass- roots organizing initiatives. They also note that vertical em- powerment for these populations may have the unintended effect of increasing community dependence on outside assis- tance and decreasing community control in decision making and action.

Finally, community empowerment may be conceived as oc- curring along a continuum from personal empowerment to the development of small mutual support groups, to the develop- ment of community organizations, to the creation of coalitions and partnerships, to community-based social and political ac- tion related to community concerns. At the level of personal empowerment, a population health nurse might help a home- less man with a substance abuse problem find work and enroll in a recovery program. At the next level, the nurse might as- sist a group of homeless individuals to form a support group that permits them to share knowledge of resources. Helping to create an organization composed of homeless individuals and families and members of the social services community to ad- dress the health care needs of the homeless population would be an example of the third level of empowerment. Finally, at the fourth and fifth levels, the population health nurse might assist the community organization to link with legal advocates and others to promote legislation to protect the civil rights of home- less individuals.

Models for Community Empowerment Community empowerment can be conceptualized in a number of ways, and various models for viewing community empower- ment have been put forth. Bailey (2010) developed the concept of decision-making spaces occurring at three levels: closed, in- vited, and claimed or created spaces. In closed spaces, decisions are made behind closed doors without input from community members. In invited spaces, community members may be in- vited by authorities to provide input and work collaboratively to resolve community-identified problems. These spaces re- flect the community participation and engagement approaches

described earlier. At the third level, community members claim, create, or demand opportunities for input or to make decisions for themselves.

Laverack (2007) used the concept of a ladder with three sets of rungs to depict the process of community empow- erment in health promotion program development that can be applied to empowerment of populations in general. The foot of the ladder rests on a foundation of community readiness to work with outside agents to resolve community problems. Ascending the ladder moves the community or population from participation in decision making to taking action for themselves. The first rung addresses community involvement and includes community participation in the identification of existing community needs and providing input for programs to address those needs. The next set of rungs encompasses the creation of community competence and includes fostering community engagement, community organizing, community development, and building commu- nity capacity. Community engagement, in Laverack’s model, involves collaborative identification of solutions to problems and creation of partnerships to mobilize resources, influence systems, and change relationships. Community organization involves the development of structures within the commu- nity designed to achieve shared goals. Again, development of a Crime Watch program might be an example of community organization. In community development, outside assistance is received to improve the lives of members of the commu- nity or population. Often, this assistance occurs in the form of distribution of resources and opportunities. For example, a skills training program might be initiated to educate women in the community for employment opportunities. The final rung related to community competence involves building community capacity and includes the identification or devel- opment of community assets needed to resolve community- identified problems.

The third set of rungs on the ladder moving toward com- munity or population action addresses community control. The first rung at this level incorporates community action, which involves community ownership of specific issues and their resolution. The final rung is that of community empower- ment, in which members of the community or larger popula- tion group have achieved control over decisions and resources that affect their lives and engage in social and political action to exercise that control (Laverack, 2007).

Another model for approaching community empower- ment is the Asset-based Community Development, or ABCD, model (Leech & Potts, 2010). This model builds on exist- ing community strengths or assets and provides an inherent challenge to power hierarchies by putting the community in charge. An asset-based orientation also addresses frequent assumptions by community members that government agen- cies have and control the resources needed to address identi- fied community problems. Such assumptions fail to recognize the existence of agency deficits that impede problem resolu- tion and lead to dismissal of available community resources

M10_MARY9591_06_SE_C10.indd 243 06/09/14 6:41 PM

244 Unit 3 Population health nursing Strategies

that might be brought to bear in the solution of community problems.

Steps in the ABCD model include recognition and iden- tification of community strengths and building on those strengths and existing social capital to address problems (Leech & Potts, 2010). Identification of strengths might occur through the process of asset mapping in which the resources, skills, and capacities of individual community members are determined. For example, some members of the community might possess child care skills that could assist in the devel- opment of needed child care services for employed women. Community organizations may also possess resources and ca- pabilities that can be used to solve community problems. For example, unused space in a church might be converted into a teen center with activities to discourage gang membership or drug and alcohol use.

Asset-based community development has several additional advantages beyond identifying assets that might be employed to resolve community problems. Working from a strengths orientation can increase collective beliefs in community com- petency and increase community perceptions of self-efficacy. In addition, just the process of asset mapping may increase public discussion and awareness of community issues and pro- mote cooperation among members of the population. Finally, an asset-based approach portrays community members, com- munity organizations, and government agencies as cooperative elements of the same community that represent mutual assets and avoids perceptions of the community as a “special needy population dependent on . . . an outside supplier of resources” (Leech & Potts, 2010, p. 82).

The natural helper model employs a particular type of community asset to address specific types of health-related problems. This model focuses on the use of natural help- ers within the community to promote community empow- erment. Natural helpers are “individuals who are naturally sought out for advice, assistance, and emotional support by community members.” These natural helpers “possess the knowledge and tools that help foster health within their community” (Scott, 2009, p. 285). Several other types of in- formal helpers may exist as assets in a community. Among these are family, friends, and neighbors, role-related help- ers, people with similar problems, and volunteers. The role of friends, family, and neighbors as informal helpers is well understood. Role-related helpers are people who, because of their role in the community, can provide help in certain cir- cumstances. For example, educated shopkeepers could assist clients to make healthy food choices or could be sources of information and referral in other health-related areas. Peo- ple who have similar kinds of problems can form self-help and support groups and share group resources, knowledge, and skills. Volunteers are people who are willing to contrib- ute their time and energy to specific initiatives or program efforts. Natural and informal helpers are not the same as community health workers (CHWs), who are members of

a community with some training hired by community agen- cies to work directly with their fellow residents. We will dis- cuss the use of community members as health workers later in this chapter.

Population Health Nursing and Community Empowerment The process of community empowerment is very similar to the nursing process. In this chapter, we will address some of the as- pects of that process, focusing on the population health nurse’s role in community empowerment and assessment, planning, implementation strategies, and evaluation of empowerment initiatives.

The Population Health Nurse’s Role in Fostering Empowerment Population health nurses and other health care professionals who desire to foster empowerment among individuals, orga- nizations, communities, and population groups first need to foster perceptions of themselves as partners with community members and as an asset possessed by the community or popu- lation. This requires health professionals to recognize and shift power relationships with community members to move away from “professionally dominated decision making” to decision making by group members (Aston et al., 2009, p. 25). Leech and Potts (2010) were quite explicit in noting that failure by population health nurses and other professionals to self-iden- tify as community assets supports a power hierarchy, in which the professional is seen as an expert and an employee of an in- stitution or agency rather than as an active and equal member of the community.

Laverack (2005) described three primary roles of population health nurses and others in fostering empowerment. The first role involves becoming a more effective communicator who engages in listening, assists others to talk, gives advice, and ob- tains feedback. Some of the tasks involved in this role include providing information, increasing community members’ un- derstanding of the underlying causes of their lack of power, and combining media channels to foster communication. Such media channels might include one-on-one discussions with community members, use of printed materials, and use of pop- ulation-specific and mass media.

The second major role of the empowering health care professional is increasing the critical self-awareness of mem- bers of the community. This may involve mapping positions of power, ranking complex issues, and developing decision- making skills. Mapping positions of power includes develop- ing an understanding of how community members can build a power base from their existing positions of strength, identi- fying areas under their control, and identifying strategies for increasing their power (Laverack, 2005). For example, labor

M10_MARY9591_06_SE_C10.indd 244 06/09/14 6:41 PM

chaPter 10 community empowerment Strategies 245

unions learned early on that they had the ability to influence business and industry through their power to stop production. This knowledge gives them power even when they choose not to exercise it through a strike. Just the possibility of a strike confers power and influence.

Fostering an empowering provider–client relationship is the third major role of the empowering health care professional. Such relationships can be fostered with individual clients as well as between professionals and communities or population groups. Activities involved in fostering empowering relation- ships include clearly defining and communicating the role of the professional to the client, promoting individual and group clients to political leaders, fostering support for community leaders and community organizations, serving as a liaison in the creation of new partnerships with other organizations and the private sector, facilitating change through skills train- ing of community members, and facilitating the involvement of marginalized groups within the community or population (Laverack, 2005).

Empowering professionals may also engage in three other activities designed to empower communities. These include di- rection, facilitation, and collaboration, each of which occurs in a particular time period (Laverack, 2007). Initially, the health care professional may provide community members with direc- tion in what needs to be done and how it may be accomplished. As the community or population becomes more competent, the population health nurse may shift into a facilitative role, asking questions and assisting community members to deter- mine what they want to do and how they want to do it. Finally, the empowering professional may engage in collaboration with community members to bring about social and political changes, gradually relinquishing control of activities to com- munity agents.

Assessing Community Strengths and Needs Community assessment, in the context of community em- powerment, has two general purposes. The first is to provide information for change—facts about the current situation, contributing factors, and assets that may be brought to bear to facilitate change. The second purpose is to provide infor- mation for empowerment. As the old adage states, “knowl- edge is power,” and communities need knowledge in order to assess the situation and take action (Hancock & Minkler, 2012). The same elements of community assessment data can contribute to the achievement of both purposes. Com- munity assessment may also result in several other indi- rect effects for community empowerment, including the creation of social cohesion among community members, encouragement of self-help within the community, persua- sion for change, and identification and development of local leadership.

The actual assessment of the community can be framed in terms of the determinants of health from the population health

nursing model, examining factors in each of the six categories of determinants that reflect community assets or contribute to community needs. The specifics of such an assessment are ad- dressed in detail in Chapter 15 . Some of the areas that might be examined in a community empowerment assessment in- clude 16 elements of community strength and six dimensions of culture (Bartle, 2013). These elements of strength and di- mensions of culture are described in Table 10-1 •.

Population health nurses can help members of the com- munity to conduct an assessment as a first step in community empowerment. For example, the nurse can assist community members to identify relevant categories and sources of data needed and to develop effective data collection strategies. In addition, the nurse can help community members analyze as- sessment data and identify factors that impede and facilitate community empowerment. Clark et al. (2003) provided an example of a population health nurse facilitating resident in- volvement in a community assessment. In this process, the population health nurse assisted community members to con- duct focus groups among multiple segments of the community to identify community needs and assets. The findings of the as- sessment were shared with the wider community and became the impetus for a variety of community-initiated efforts to im- prove living conditions in the community.

Planning and Implementing Empowerment Strategies Community empowerment is most effective when it em- ploys a planned and systematic process based on fundamental principles. In this portion of the chapter, we will discuss the principles of effective community empowerment, goals of com- munity empowerment, issue selection, the process of group de- velopment as a foundation for community empowerment, and strategies that can be employed by population health nurses to facilitate community empowerment.

Town hall meetings can foster community empowerment. (Rawpixel/Shutterstock)

M10_MARY9591_06_SE_C10.indd 245 06/09/14 6:41 PM

246 Unit 3 Population health nursing Strategies

PRINCIPLES of CoMMuNITy EMPoWERMENT. Effective community empowerment is based on several general principles that are summarized in the box on the next page.

DoMAINS of CoMMuNITy EMPoWERMENT. Four key domains or goals of empowerment have been identified. These domains include the following:

• Community activation: Promoting community members’ participation in community problem solving.

• Competence development: Developing community mem- bers’ expertise in problem solving.

• Program management skill development: Fostering program management and team-building skills among community

members; promoting skill in planning, implementation, and evaluation methods; and promoting use of evidence-based solutions and strategies.

• Creation of a supportive environment: Developing lobbying and political advocacy skills and linking community groups to resources (Kasmel & Tanggaard, 2011).

ISSuE SELECTIoN. It may be helpful, and more meaningful for community members, to initiate community empowerment activities in the context of a specific health problem or issue. Hopefully, community empowerment engendered in the context of this particular issue will carry over to promote community action with respect to other issues. There may be

TABLE 10-1 Elements of Strength and Dimensions of Culture in Community Empowerment Assessment

Element of Strength Description

Altruism The extent to which community members are willing to sacrifice personal goals to achieve group goals Common values The extent to which values are shared among group members Communal services The extent of group members’ access to needed services and facilities Communication The degree of willingness and ability to communicate effectively Confidence The degree of shared confidence in the group’s ability to solve problems

Context • Political • Administrative • Approach

The existence of an environment that supports empowerment • Attitudes and values of political leaders • Attitudes and values of adminstrative agents • An approach in which needs are provided weakens groups, whereas an approach that enables people to provide

for their own needs strengthens the group

Information Access to and abilities to process and analyze information; level of knowledge; and the degree of wisdom among key individuals

Intervention focus Extent of focus on increasing or decreasing dependency and levels of internal sustainability without external assistance Leadership The power of community leaders to influence and move the community in desired directions Networking The extent of existing links to useful resources Organization Perceptions of group members of their role in supporting the activities of the whole Political power The extent of participation and influence in decision making Skills The extent of abilities to get things done, including technical and management skills of group members Trust The degree of trust among group members Unity The degree of shared sense of belonging among group members Wealth The extent of community control over actual and potential resources, as well as their production and distribution Dimension of Culture Description

Technological dimension Ideas and behaviors that allow community members to invent, use, and teach others about tools, including ele- ments such as language, material resources, and community infrastructure (e.g., roads, sewers, etc.). Changes in this dimension result in changes in each of the other five dimensions

Economic dimension • Ideas and behaviors that give value to cash • Ways and means of producing and allocating goods and services • Distribution of wealth, how and by whom

Political dimension

Ways of allocating power and influence • Types of leaders in community • Extent of member participation and ways of promoting participation in decision making • Mechanisms and changes in the distribution of power and influence

Institutional dimension Ways in which people interact and are expected to interact Values dimension The community structure of ideas about good/bad, beautiful/ugly, and right/wrong

Worldview dimension The population’s world view, ideas about the nature of the universe and their place in it, cause and effect, and con- ceptions of time, matter, and behavior

Data from: Bartle, P. (2008). The human factor and community empowerment. Review of Human Factor Studies Special Edition, 14(1), 99–122; Bartle, P. (2013). Community Empowerment Collective Society. Retrieved from http://cec.vcn.bc.ca/cmp/collect.htm

M10_MARY9591_06_SE_C10.indd 246 06/09/14 6:41 PM

chaPter 10 community empowerment Strategies 247

any number of issues that can be used to foster community empowerment, but there are some criteria that might lead members of a community to select one issue over others.

The issue should be one that can be clearly articulated and explained by community members to give them confidence in presenting their case to policy makers. The issue should also be one that will serve to unite community members and fos- ter their participation in its resolution. In addition, the issue should promote the visibility and credibility of the community or representative groups as entities who should be involved in decision making. Other criteria include the degree of consis- tency of the issue with the long-range goals of the community and have the potential to promote growth and capacity build- ing in the community. To this end, the issue should provide opportunities for leadership development among community members. Other considerations include the effect of work re- lated to the issue of community or organizational resources and assets and the potential of the issue for creating either new allies or enemies for the community. In addition, the issue should focus on an area for direct action and have significant potential for a positive outcome. The criteria for selection of an issue to promote community empowerment are reflected in the Focused Assessment presented below.

GRouP DEvELoPMENT. Engaging in community empow- erment activities may necessitate the formation of effective groups or organizations within the community to spearhead empowerment initiatives. Group development occurs in a series of stages: orientation, accommodation, negotiation, operation, and dissolution, sometimes also labeled as forming, norming, storming, performing, and termination or ending (Stein, n.d.). These stages parallel the components of the nursing process, as indicated in Table 10-2•. Specific tasks must be accomplished during each stage of group development for the group to function effectively.

Principles of Community Empowerment • Holders of power must want the community to be more

self-reliant and must be willing to cede power to community members.

• A trained facilitator is needed to guide the community in its efforts to be more self-reliant.

• Assistance should be offered in the form of a collaborative partnership rather than charity and should be designed to promote increased self-reliance and capacity in the community.

• Empowerment starts where community members are and does not try to force change on the community.

• Struggle and adversity strengthen social organizations and communities when they are overcome through community activity.

• Hands-on participation in decision making and problem resolution increases problem-solving capabilities. Decisions need to be made by community members, not for them by others, however well-intentioned.

• The community should supply a substantial portion of the resources needed for problem resolution or project implemenation to promote long-term sustainability.

• Community empowerment activities should be designed from the beginning to achieve the ultimate goal of community control of and responsibility for decision making and actions taken.

Data from: Bartle, P. (2013). Community empowerment collective society. Retrieved from http://cec.vcn.bc.ca/cmp/collect.htm

Highlights

foCuSED ASSESSMENT Selecting an Issue for Community Empowerment

• How will the issue affect community or organizational resources?

• Does the issue have potential for creating new community allies? New enemies?

• Does the issue focus on direct action?

• Will the issue result in victory?

Data from: Minkler, M., & Wallerstein, N. (2012). Improving health through community organization and community building. In M. Minkler (Ed.), Community organizing and community building for health and welfare (3rd ed., pp. 37–58). New Brunswick, NJ: Rutgers University Press; Staples, L. (2012). Selecting and cutting the issue. In M. Minkler (Ed.), Community organizing and community building for health and welfare (3rd ed., pp. 187–214). New Brunswick, NJ: Rutgers University Press.

• Is the issue simply and easily explained by community members?

• Will the issue unite community members and involve them in problem resolution?

• Does the issue provide greater visibility and credibility for the community or for the organizing group within the community?

• Is the issue consistent with the long-range goals of the community or organization?

• Does the issue have potential for promoting growth of the group?

• Will the issue provide educational or training experiences for community leaders?

M10_MARY9591_06_SE_C10.indd 247 06/09/14 6:41 PM

248 Unit 3 Population health nursing Strategies

TABLE 10-2 Tasks of Group Development by Stage and Related Nursing Process Component

Nursing Process Component Stage of Group Development Group Development Tasks

Assessment and diagnosis Orientation (forming) 1. Selection of group members 2. Training for group participation 3. Identification of goals and purposes

Planning Accommodation (norming)

1. Establishment of modes of decision making 2. Development of mechanisms for conflict resolution 3. Development of communication network 4. Development of climate conducive to group collaboration

Negotiation (norming) 1. Negotiation of member roles 2. Development of methods of task assignment

Implementation Operation (performing) 1. Assignment of specific tasks to accomplish group goals 2. Performance of actions to accomplish goals

Evaluation Dissolution (leaving)

1. Planning of evaluative mechanisms 2. Assignment of member roles and tasks in evaluation 3. Data collection 4. Analysis of evaluative findings 5. Possible group dissolution

Orientation. The orientation stage of group development, sometimes referred to as the “forming stage,” is when group members come to know each other and assess their ability to function as a group. Tasks of this stage include selection of group members, training them for group participation, and identification of group goals and purposes. Also during this stage, the group assesses community empowerment needs and community assets.

Accommodation. The accommodation (or “norming”) stage of group development focuses on the development of group

dynamics, the ways in which the group will carry out its group- related functions. This does not relate to activities the group will undertake to resolve any identified community issues, but to the ways in which the group itself will operate. Tasks in this stage include developing an atmosphere conducive to group collaboration and establishing modes of group decision making, conflict resolution, and communication.

Group action requires group decisions, and decisions must be made after careful consideration by group members. To facilitate decision making, group members should agree on the method by which decisions will be made. Because most people are not famil- iar with group processes or the deliberate need to select a decision- making strategy, the population health nurse may need to guide the group in this task. Decisions can be made in one of six ways: by default, by the leader, by a subgroup, by majority vote, by con- sensus, or by unanimous consent. For the purposes of community empowerment, majority vote, consensus, and unanimous consent are the most appropriate methods of group decision making.

Establishing modes of group conflict resolution is the sec- ond task in the accommodation stage of group development. Breakdowns in the decision-making process are one source of conflict within the group. Other potential sources of conflict are unclear expectations, poor communication, differing values or attitudes, and competition for scarce resources. Lack of clear ju- risdiction among group members and conflicts of interest may also be sources of conflict within the group. Additional sources of conflict are interdependence when needs are not met and the exis- tence of prior unresolved conflict between members or subgroups.

Conflict is a normal component of group effort and is to be expected. In fact, many group behavior theorists include a conflict or “storming” stage in describing the development of groups over time. If the group has developed mechanisms for conflict resolution before conflicts arise, conflict can often be a positive rather than divisive experience for the group.

empowered communities are able to deal with local problems. (Monkey Business Images/Shutterstock)

M10_MARY9591_06_SE_C10.indd 248 06/09/14 6:41 PM

chaPter 10 community empowerment Strategies 249

Recognition of conflict as a normal phenomenon is essential if the group is to plan ahead for conflict resolution. Again, many groups do not anticipate conflict, and when conflict occurs they are unprepared to deal with it. Strategies for resolving conflict constructively involve creating a climate conducive to discus- sion, identifying and eliminating sources of conflict, capitalizing on areas of agreement, and rationally considering alternative so- lutions to conflict. The population health nurse can explore these approaches to conflict resolution with members of the group and assist members to select the most appropriate approach.

Creating a climate in which disagreement is acceptable can minimize or resolve conflict. Conflict resolution requires that all parties be fully able to express their perspectives through open communication. Open communication cannot take place when there is pressure to conform and there is the lack of ac- ceptance of different opinions. Lack of communication ham- pers conflict resolution as well as contributing to conflict. As a group leader, the population health nurse may need to en- courage group members to express thoughts and opinions that may not be congruent with those of other members. Through the use of interpersonal skills, the nurse can ensure that com- munications within the group are not accusatory, but deal with issues rather than personalities.

Recognizing the existence of conflict and identifying its sources and possible solutions are strategies for constructive use of conflict. A conflict that is ignored in the hope that it will resolve itself is likely to become worse. The population health nurse can encourage other group members to acknowledge that a conflict exists and help them explore the reasons for con- flict. Again, the nurse should be alert to covert signs of conflict and bring them to the attention of the rest of the group. For ex- ample, a nurse working with a group trying to determine bud- get allocations among health care programs within the county may notice that representatives of programs for the elderly are maintaining a stony silence during the discussion. The nurse may comment on the fact that they have not participated in the discussion and ask why. In the ensuing discussion, it may be learned that these group members feel that too much money is being allocated to maternal–child health programs and that the elderly are being shortchanged. Once this conflict has been exposed, the group can begin work to resolve it.

Another strategy for resolving conflict involves identify- ing small areas of trust and agreement between group mem- bers that can be expanded. For example, although two group members may disagree on the “appropriate” approach to a problem, they can capitalize on their shared concern for cli- ents’ welfare. Finally, rational consideration of alternative solu- tions to a particular conflict using the group’s decision-making and problem-solving processes can result in conflict becoming a valuable learning experience in group problem solving. The population health nurse can assist the group to explore a va- riety of alternative solutions to a conflict and to select an ap- proach that is agreeable to all members.

Developing group communication strategies is another task in planning group operation. The importance of an

effective communication network cannot be overemphasized. The group must develop a common language that facilitates communication, and members should refrain from using jar- gon familiar only to members of their own discipline. When it is necessary to use terminology unfamiliar to others, efforts should be made to translate it into the common language. The nurse in this situation can either play the part of the transla- tor or ask other members for clarification. For example, some members of a group may use acronyms unfamiliar to others, such as CMS. The nurse should then explain to the group that this stands for the Centers for Medicare and Medicaid Services. If the nurse does not recognize the acronym, he or she can ask for an explanation of its meaning.

The group should also agree on the forms that communi- cation will take. For example, communications may be verbal, written, or a combination of both, depending on the situa- tion. Perhaps the group will decide that communication with sponsoring institutions should take the form of formal written memoranda, whereas communications between group mem- bers should be more informal verbal messages.

Consideration should also be given to the fact that com- munication takes place outside of regular group sessions. The content of these informal encounters between group members should not undermine group function or provide a forum for airing grievances or denigrating other members. The popula- tion health nurse who encounters unproductive communica- tion outside of group meetings can bring relevant issues to the attention of the entire group, so open discussion can take place and conflict can be avoided or resolved.

Establishing a climate in which group members feel re- spected and in which differences are accepted contributes to an effective communication network. This means that all group members should be encouraged to participate and should re- ceive positive reinforcement for their contribution whether or not others agree with it. In the beginning of the group’s opera- tion, the nurse group leader may need to ask reluctant group members for their ideas and opinions. As their participation is received positively, they will begin to volunteer remarks.

Negotiation. Tasks of the negotiation stage of group development include role negotiation and methods of task assignment. Professional roles often overlap, and role negotiation is crucial to effective group function. In addition, social change professionals working in a community empowerment context need to be careful not to usurp roles that should be performed by community members. The goal of community organizing and empowerment is to develop leadership within the community, not to provide that leadership. When two or more group members possess similar skills, the group must decide who will be responsible for exercising those skills. These decisions may be made as a general rule of thumb, so that one member always has responsibility for certain activities, or may change with the needs of the situation.

One particular group role that must be negotiated is the role of the leader. This position incorporates functions related to group administration, liaison with outside groups, teaching,

M10_MARY9591_06_SE_C10.indd 249 06/09/14 6:41 PM

250 Unit 3 Population health nursing Strategies

and coordination of group effort. Additional group leadership roles may include providing information for group decision making, clarifying issues, refocusing the group’s attention, and playing “devil’s advocate” to promote exploration of alterna- tive ideas. The leadership role may be assigned to one member, may shift with the situation, or may reside with the group as a whole. In the last instance, no one member acts as the leader and leadership functions are performed by the group as a unit. Ideally, as community empowerment progresses, group leader- ship is assumed by members of the community rather than by helping professionals.

Operation and dissolution. The operation stage of group development is analogous to the implementation stage of the nursing process. It is during this stage that the group assigns and

performs specific roles and tasks to achieve group-designated goals and objectives.

The dissolution stage of group development focuses on eval- uation of the group’s accomplishments and decisions regarding the continuation or dissolution of the group. Depending on the focus of group empowerment initiatives, the group may shift its focus to address other community issues after achieving its original purpose. Or it may dissolve to reform with other par- ticipants to address additional issues. Tasks of the dissolution stage of group development include planning evaluative mech- anisms related to both the process and outcomes of community empowerment, assignment of member roles in evaluation, data collection and analysis, and dissemination of findings. Evalua- tion of community empowerment activities will be discussed in more detail later in this chapter.

Evidence-Based Practice

Supporting Community Empowerment In 2008, the Department for Communities and Local Govern- ment (Pratchett et al., 2009) commissioned a systematic review of the evidence base supporting community empowerment. The review focused on three aspects of the effects of empowerment initiatives: effects on individual participants, effects on com- munities, and effects on decision making. Individual effects included development of personal skills in influencing local ser- vices. Community effects examined such things as improved lev- els of political efficacy, social capital, and social cohesiveness. Finally, decision-making effects included the ability of individu- als and communities to influence decision making.

The review identified six mechanisms for promoting commu- nity empowerment: asset transfer, citizen governance, electronic participation, participatory budgeting, petitions, and redress. As- set transfer referred to a mechanism for promoting community management or ownership of community assets and social en- terprises. This particular strategy was found to be effective in achieving public control over decision making and assets, but required ongoing support to prevent setting communities up for failure and overburdening volunteer staff.

Citizen governance strategies involved incorporation of com- munity residents on decision-making boards and forums that make public policy decisions. The success of this strategy de- pends on the openness of policy makers to attend to citizen in- put. Electronic participation through e-forums and petitions was an effective means of empowerment for segments of the popula- tion who took part in them, but were limited in their ability to effect empowerment at the wider community level.

Participatory budgeting involves citizen participation in the development of budgets and allocation of resources. This strategy is capable of achieving wide levels of empowerment, but requires

willingness to engage in transformational political change. Peti- tions serve to raise policy makers’ awareness of community con- cerns. When petitions are attended to and community members can see specific effects, they can be empowering; when they are ignored, they may become disempowering.

Finally, redress is a mechanism for community members to voice complaints that are investigated and responded to. Because complaints are usually unrelated to formal decision-making pro- cesses, they are unlikely to result in widespread community em- powerment. Each of the strategies was found to result in some level of empowerment, primarily at the level of the individual citizen. Only the citizen governance and participatory budgeting strategies were consistently associated with a community em- powerment effect (Pratchett et al., 2009).

Although there are a number of reports on the results of com- munity empowerment initiatives in resolving community prob- lems, less research has been done on their effectiveness in actually empowering communities and increasing their abilities to be self-determining and self-reliant. This lack limits the evi- dence base for strategies that work or do not work in promoting community empowerment.

1. What community empowerment strategies, if any, have been initiated in your community?

2. To what extent has the effectiveness of those strategies in promoting empowerment been evaluated?

3. How might you go about evaluating those strategies in terms of their effects on community empowerment, thereby contributing to the evidence base for the effectiveness of community empowerment in helping communities address health disparities?

M10_MARY9591_06_SE_C10.indd 250 06/09/14 6:41 PM

chaPter 10 community empowerment Strategies 251

STRATEGIES foR PRoMoTING CoMMuNITy EMPoWERMENT. Implementation of community empower- ment activities encompasses the basic principles of implementing any community program. These principles will be discussed in detail in Chapter 15 . Here, we will briefly address some general strategies to foster empowerment.

Members of the community should be involved in all as- pects of community empowerment initiatives from identifica- tion of the problem or issue to be addressed, to development of objectives or expected outcomes to be achieved, to devel- opment of strategic approaches to achieve those outcomes, to management of everyday implementation of the campaign, and to evaluation of its effectiveness. Table 10-3• indicates some of the skills required of community members in each of these areas of involvement. Population health nurses and other empowering professionals may be instrumental in assisting community members to develop these skills.

Studies of population health nurses in their role of com- munity empowerment have identified the need to work with rather than for community members (Aston et al., 2009). This requires a shift in perspective for both community mem- bers and nurses from seeing the nurse as an expert to viewing him or her as a community resource and partner. Interviews with population health nurses elicited four major strategies for empowering communities employed by the nurses. These included building trusting relationships, building commu- nity members’ confidence and skill, engaging in empowering

educational strategies, and connecting individuals and groups to broader social networks (Aston et al., 2009).

Activities involved in building relationships included active listening, belief in the capacity of community members to guide their own destiny, a focus on strengths, and creation of a safe environment that fosters community participation in decision making. The strategy of building confidence and skills involved promoting active participation in decision making by marginal- ized populations and actively soliciting their input and partici- pation. Other activities related to this strategy included starting from and building on community members’ strengths, giving positive feedback and affirmation, and engaging in a constant shifting of roles for the nurse and pulling back as community members became more competent (Aston et al., 2009).

Use of empowering educational strategies involved roles as consultants and as process-focused educators. As consul- tants, the nurses shared information with community mem- bers. In the role of process-focused educators, they asked questions to stimulate thought, provided information, and discussed possible next steps in the resolution of community problems. Finally, the nurses connected community members, both individuals and groups, with broader social networks. Activities related to this strategy included building partner- ships among groups, establishing self-help groups, connecting to other agencies, and advocating for community needs. Other activities included linking agencies together and working col- laboratively with multiple sectors of the community to assist community members to achieve desired outcomes (Aston et al., 2009).

The nurses also identified constraints to their practice in empowering communities. These included a lack of funding for empowerment efforts, lack of visibility, and lack of under- standing of the nurses’ role in empowerment by politicians, the general public, and public health nurse managers. Other constraints included competing demands for limited time and conflicting responsibilities for mandated programs such as im- munizations, increased paperwork drawing them away from active participation in communities, and a limited presence at planning tables (Aston et al., 2009). Population health nurses may need to actively advocate for their role in community em- powerment, study the effects of that role, and discover ways to combine that role with other mandated responsibilities.

Evaluating Community Empowerment Evaluation of community empowerment is another area that should involve community members as participants in all phases, from conceptualizing the evaluation, to data collection and analysis, to dissemination and use of evaluative findings. Community participation in evaluation helps to continue to build community competence while assessing the outcomes of prior activities. Participatory evaluation is a process in which “the stakeholders themselves are responsible for collecting and analyzing the information and for generating recommen- dations for change” (World Bank, 2011, para. 2). As early as

TABLE 10-3 Skills Required for Stages of Involvement in Community Empowerment Initiatives

Activity Stage Requisite Skills

Problem identification

• Literature review • Analysis of epidemiologic data • Identification of community needs • Appraisal of program design

Objective development

• Development of objectives for problem resolution

• Development of empowerment objectives

Strategy development to empower individuals, groups, and communities

• Materials development • Knowledge of relevant models and

theories • Interpersonal communication • Workshop/meeting facilitation • Effective group and public presentation

Management by the community

• Fund-raising • Budgeting • Resource procurement • Human resource management • Managing consultant input

Evaluation

• Designing evaluation methodology • Developing evaluation questions • Analyzing evaluation data • Interpreting and presenting findings

M10_MARY9591_06_SE_C10.indd 251 06/09/14 6:41 PM

252 Unit 3 Population health nursing Strategies

1997, the United Nations Development Programme (UNDP) recommended participatory evaluation for the assessment of the effectiveness of international programming. In their pro- gram evaluation handbook, they noted that “project stake- holders and beneficiaries are the key actors of the evaluation process and not the mere objects of the evaluation” (1997, p. 1).

Participatory evaluation has several benefits. Some of these advantages are presented in the Highlights box below.

Considerations in participatory evaluation, a form of partic- ipatory action research, include questions of who participates in the evaluation and to what degree, who determines the is- sues to be addressed, how to engage participation by commu- nity members, and the power dynamics between researchers and community members. Obviously, it would be unwieldy for the entire community to participate in the design and conduct of an evaluation of empowerment initiatives, so community leaders and empowering professionals should determine what segments of the community should be involved and what that involvement should constitute. Broad input from community members beyond those actually involved in conducting the evaluation should be solicited, however, in determining what issues or questions should be addressed.

Engaging the participation of community members in par- ticipatory evaluation may be difficult for a number of reasons. In their work with youth, Checkoway and Richards-Schuster

(n.d.) identified a number of barriers to participation that are applicable to other members of the community as well. First, people may not have time to be involved in the time-consum- ing process of evaluation, and they may be frustrated by lack of expertise in evaluation methods. Health care professionals and others may view community residents as passive recipients of services rather than as active participants in the develop- ment and evaluation of services and the policies that support them. In addition, both community members and profession- als may view evaluation as an area that requires special exper- tise. Finally, local authorities may not want to share the power embodied in evaluation with community members. This last barrier may also be reflected in different perspectives of power and control between community members and researchers as- sisting with the evaluation. Population health nurses can assist in eliminating these barriers to participation by planning eval- uation activities to fit community members’ schedules, foster- ing varying levels of participation, and educating community members in the process of evaluation. In addition, they can advocate with authority figures for community involvement in evaluation.

Steps in participatory or empowering evaluation are simi- lar to those in any evaluation process except that commu- nity participation is integral in each step. The basic steps are: (a) framing the scope and focus of the evaluation, (b) develop- ing an organizational structure to support evaluation activities, (c) determining the evaluation questions to be asked, (d) gath- ering information to address the questions asked, (e) analyzing the information and making some sense of it, (f) sharing infor- mation with others, and (g) taking action based on evaluation findings (Checkoway & Richards-Schuster, n.d.; Rabinowitz, 2013). Each of these steps will be explored in more detail in Chapter 15 . For further information about participatory ac- tion research as it relates to community empowerment, see the resources provided in the External Resources section of the student resources site.

In the context of community empowerment, both the out- comes of a specific initiative and the extent of community empowerment achieved should be evaluated. For example, the evaluation might focus on the health outcomes achieved through community activity (e.g., the decrease in accident fa- talities resulting from community advocacy for traffic-calming interventions such as speed bumps in residential areas) and the level of community empowerment reached.

The extent of empowerment achieved can be evaluated in terms of each of the four domains of empowerment. These domains and related evaluation questions are presented in Table 10-4•.

A final measure of the effectiveness of community em- powerment efforts would be the extent to which community members are included in policy making. The ultimate goal of effective community organizing and empowerment should be the inclusion of community members in every aspect of pol- icy making. Studies of community empowerment initiatives have demonstrated increases in preventive behaviors among

Advantages of Participatory Evaluation • It provides a perspective on the needs of project beneficiaries

and the effectiveness of interventions.

• It facilitates information gathering from salient stakeholders.

• It highlights what did and did not work from the perspective of community members.

• It can help to explain why something did or did not work.

• It empowers community members and provides a voice for those who may frequently be unheard.

• It teaches skills useful in other endeavors.

• It fosters self-efficacy and self-confidence in community members.

• It provides an example of ways in which community members can take control of their lives.

• It encourages community ownership of activities and initiatives.

• It can foster creativity in thinking and problem resolution.

• It facilitates collaborative activity.

• It fits into a larger participatory effort and fosters overall community empowerment.

Data from: Rabinowitz, P. (2013). Participatory evaluation. Retrieved from http:// ctb.ku.edu/en/table-of-contents/evaluate/evaluation/participatory- evaluation/main

Highlights

M10_MARY9591_06_SE_C10.indd 252 06/09/14 6:41 PM

chaPter 10 community empowerment Strategies 253

community members and better intersectoral coordination of health promotion efforts (Sanchez et al., 2009), changes in attitudes and skills at individual levels, improvement in cross- cultural relationships, and awareness of a need for involve- ment in social leadership at broader levels (Tsey et al., 2010). In addition, some studies have shown changes in the attitudes

and behaviors of governmental organizations and agencies. As noted by one group, “just as citizens honed their civic skills and vociferously pressed their views, government developed a cul- ture of responding to and learning from, rather than rejecting, many grassroots initiatives” (Putnam & Feldstein, as quoted in New Laboratories of Democracy, 2009, p. 3).

TABLE 10-4 Domains of Community Empowerment and Potential Evaluation Questions

Domain Potential Evaluation Questions

Community activation

• To what extent have community members increased their participation in small groups and organizations designed to take action on community problems?

• To what extent have new community participants been engaged in problem resolution? • To what extent have new community networks or or groups been established? • To what extent is the community able to engage in critical assessment of causes of inequities and

powerlessness?

Community competence development

• To what extent is the community able to identify community problems and possible solutions? • How effective is the community in disseminating information to improve community members’ understanding

of issues and potential solutions?

Program management skill development

• To what extent has local community leadership been developed? • To what extent are local leaders able to foster community participation, facilitate problem resolution, resolve

conflict, and so on? • To what extent are effective communication strategies used within the community? • To what extent are community members able to identify and evaluate evidence-based solutions to problems?

Supportive environment development

• To what extent has the community developed organizational structures that facilitate participation in decision making, effectively mobilize and allocate resources, and so on?

• To what extent is the community able to mobilize both internal and external resources? • To what extent are community members able to effectively lobby and advocate for political support or needed

resources? • To what extent are community assets and existing resources brought to bear to solve identified problems? • To what extent have internal links between individuals or organizations within the community been developed

or strengthened? • To what extent have links to external organizations been created or strengthened? • To what extent have power relationships with outside entities been equalized? • To what extent has the community been able to exercise control of decisions and resource allocations affecting

the welfare of its members?

Empowerment is a strategy used by population health nurses and others to promote self-advocacy among individuals, or- ganizations, communities, and populations. The ultimate goal of empowerment is to allow people to assume control over the decisions that affect their health and well-being. Empow- erment begins where community members are, moves them toward the goal of political and social action on their own behalf, and involves the development of discreet skills as well

as feelings of self-confidence and self-efficacy. Empowerment activities can occur within the context of the nursing process moving from enhancing community assessment capabilities to planning, implementing, and evaluating empowerment ac- tivities. Empowerment initiatives often begin with a focus on a discrete issue or problem, but the lessons learned can lead to greater community involvement in wider social and political action.

CHAPTER RECAP

M10_MARY9591_06_SE_C10.indd 253 06/09/14 6:41 PM

254 Unit 3 Population health nursing Strategies

You have been given a referral to visit Mrs. Esparza, who lost her baby after a premature delivery. The address you have been given is located in a poor neighborhood that houses a large number of migrant workers. When you arrive at the home, you discover that it is a two-bedroom apartment occupied by three couples and their five children. Both Mrs. Esparza and her husband are present when you arrive, and both are obviously grieving the loss of their third child. In talking with them, you discover that Mrs. Esparza did not receive any prenatal care and was admitted to the delivery unit of the local hospital after going to the emergency room when she experienced heavy contractions in the 29th week of her preg- nancy. Mr. Esparza becomes angry when you ask about prenatal care, shouting that they tried to get an appointment at the health department’s prenatal clinic but were told there was a 2-month wait for new appointments. At that time Mrs. Esparza was in the fifth month of her pregnancy. In tears, he informs you that they did not have the money to see a private doctor. Even though most of the migrant workers are in the United States legally, they are not eligible for any financial assistance. Your state does not pro- vide Medicaid pregnancy coverage for nonresident women. Mrs. Esparza reminds her husband that they are not alone in their suffering. When you inquire further into her comment, she tells you that seven other women in the apartment complex have lost

babies at some point in their pregnancies in the last 2 years. You comfort the family as best you can, make arrangements for Mrs. Esparza to receive a postpartum examination at the health de- partment, and refer the three families to the immunization clinic because all of the children in the home are behind on their im- munizations. You explain that both postpartum services and im- munizations are free to those who do not have money to pay for them, even for nonresidents.

When you return to the office, fellow population health nurses describe similar visits to families in the area. In checking county vital statistics, you note that the census track where the Esparzas live and two adjacent areas that house large migrant populations have a fetal death rate three times that of the rest of the county. 1. How would you begin to empower the migrant worker com-

munity to address the issue of lack of access to prenatal care? 2. What assets might you look for within the migrant commu-

nity to address the issue? 3. What allies might you find in the nonmigrant community to

assist you? 4. How can you motivate participation by community mem-

bers in the initiative?

CASE STuDy Indigent Health Care

Aston, M., Meagher-Stewart, D., Edwards, N., & Young, L. M. (2009). Pub- lic health nurses’ primary care practice: Strategies for fostering citi- zen participation. Journal of Community Health Nursing, 26, 24–34. doi:10.1080/07370010802605762

Bailey, N. (2010). Understanding community empowerment in urban regen- eration and planning in England: Putting policy and practice in context. Planning, Practice and Research, 25, 317–332. doi:10.1080/02697459.2010. 503425

Bartle, P. (2008). The human factor and community empowerment. Review of Human Factor Studies Special Edition, 14(1), 99–122.

Bartle, P. (2013). Community Empowerment Collective Society. Retrieved from http://cec.vcn.bc.ca/cmp/collect.htm

Burkett, I. (2013, Spring). Community to community empowerment: The story of the AusCongo Network. Practice Insights, 2, 6–8.

Checkoway, B., & Richards-Schuster, K. (n.d.). Participatory evaluation with young people. Retrieved from http://www.ssw.umich.edu/public/current- Projects/youthAndCommunity/pubs/youthbook.pdf

Clark, M. J., Cary, S., Diemert, G., Ceballos, R., Sifuentes, M., Atteberry, I., …, Trieu, S. (2003). Involving communities in community assessment. Public Health Nursing, 20, 456–463.

Conrad, E. (n.d.). General Tubman. Retrieved from http://harriettubman.com /tubman2.html

Cooke, I. (2013, Spring). Community ownership: A catalyst for community-led regeneration. Practice Insights, 2, 4–5.

Craig, G., & Mayo, M. (2013, Spring). Reflections on two decades of “commu- nity empowerment.” Practice Insights, 2, 16–17.

de Wit, J., & Berner, E. (2009). Progressive patronage? Municipalities, NGOs, CBOs and the limits to slum dwellers’ empowerment. Development and Change, 40, 927–947. doi:10.1111/j.1467-7660.2009.01589.x

Driggs, M. B. (1980). They called her Moses: Harriet Tubman. Retrieved from http://harriettubman.com/callhermoses.html

Hancock, T., & Minkler, M. (2012). Community health assessment or healthy community assessment: Whose community? Whose health? Whose assess- ment? In M. Minkler (Ed.), Community organizing and community building for health and welfare (3rd ed., pp. 153–170). New Brunswick, NJ: Rutgers University Press.

Improvement and Development Agency. (2012). Useful definitions. Retrieved from http://www.idea.gov.uk/idk/core/page.do?pageId=16639526

International Association for Community Development. (2014). About us. Retrieved from http://www.iacdglobal.org/about

REfERENCES

M10_MARY9591_06_SE_C10.indd 254 06/09/14 6:41 PM

chaPter 10 community empowerment Strategies 255

Kasmel, A., & Tanggaard, P. (2011). Conceptualizing organizational domains of community empowerment through empowerment evaluations in Estonian communities. Societies, 1, 3–29. doi: 10.3390/soc10100093

Laverack, G. (2005). Public health: Power, empowerment, and professional practice. New York: Palgrave Macmillan.

Laverack, G. (2007). Health promotion practice: Building empowered communi- ties. New York, NY: Open University Press.

Leech, T. G. J., & Potts, E., Jr. (2010). Community empowerment through an ac- ademic product: Implications for the social-justice oriented scholar. Journal of African American Studies, 14, 75–86. doi:10.1007/s12111-009-9108-3

Lewis, J. J. (n.d.). Harriet Tubman: From slavery to freedom. Retrieved from http://womenshistory.about.com/od/harriettubman/a/tubman_slavery.htm

Maschi, B. (n.d.). Harriett Tubman: Runaway slave, underground railroad conductor. Retrieved from http://www.americancivilwar.com/women/ harriet_tubman.html

Minkler, M., & Wallerstein, N. (2012). Improving health through community organization and community building. In M. Minkler (Ed.), Community organizing and community building for health and welfare (3rd ed., pp. 37–58). New Brunswick, NJ: Rutgers University Press.

Neighbor Works® America. (2014). Neighbor works community building program. Retrieved from http://www.nw.org/Network/neighborworksprogs /leadership/default.asp

New laboratories of democracy: How local government is reinventing civic engagement. Part 1: Structure and form. (2009). National Civic Review, 98(2), 3–8. doi:10.1002/ncr.245

New York History Net. (n.d.). The life of Harriet Tubman. Retrieved from http:// www.nyhistory.com/harriettubman/life.htm

Pratchett, L., Durose, C., Lowndes, V., Smith, G., Stoker, G., & Wales, C. (2009). Empowering communities to influence local decision making: A systematic review of the evidence. Benefits, 17, 297–299.

Rabinowitz, P. (2013). Participatory evaluation. Retrieved from http://ctb .ku.edu/en/table-of-contents/evaluate/evaluation/participatory-evaluation /main

Sahlman, R. (2011). Harriet Tubman. Retrieved from http://incwell.com /Biographies/Tubman.html

Sanchez, L., Perez, D., Cruz, G., Castro, M., Kour, G., Shkedy, Z., …, Van der Stuyft, P. (2009). Tropical Medicine & International Health, 14, 1356–1364. doi:10.1111/j.1365-3156.2009.02379.x

Scott, T. N. (2009). Utilization of the natural helper model in health promotion targeting African American men. Journal of Holistic Nursing, 27, 282–292. doi:10.1177/0898010109339929

Staples, L. (2012). Selecting and cutting the issue. In M. Minkler (Ed.), Community organizing and community building for health and welfare (3rd ed., pp. 187–214). New Brunswick, NJ: Rutgers University Press.

Stein, J. (n.d.). Using the stages of team development. Retrieved from http:// hrweb.mit.edu/learning-development/learning-topics/teams/articles /stages-development

Tsey, K., Whiteside, M., Haswell-Elkins, M., Bainbridge, R., Cadet-James, Y., & Wilson, A. (2010). Empowerment and indigenous Australian health: A synthesis of findings from Family Wellbeing formative research. Health and Social Care in the Community, 18, 169–179. doi:10.1111/j.1365- 2524.2009.00885.x

United Nations Development Programme. (1997). Who are the question- makers? A participatory evaluation handbook. Part II: Participatory evaluation. Retrieved from http://www.undp.org/evaluation/documents/who.htm

Wiggins, N., Johnson, D., Avila, M., Farquhar, S. A., Michael, Y. L., Rios, T., & Lopez, A. (2009). Using popular education for community em- powerment: Perspectives of community health workers in the Poder es Salud/Power for Health program. Critical Public Health, 19(1), 11–22. doi:10.1080/09581590802375855

World Bank. (2011). Participatory methods. Retrieved from http://web .worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTPOVERTY/EXTISPMA /0,,contentMDK:20190347~menuPK:412148~pagePK:148956~piPK: 216618~theSitePK:384329,00.html

World Health Organization. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Retrieved from http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf

World Health Organization. (2009). Health Promotion Track 1: Community empowerment. 7th global conference on health promotion. Retrieved from http://www.who.int/healthpromotion/conferences/7gchp/track1/en/index .html

World Health Organization. (2012). Prevention and treatment of HIV and other sexually transmitted infections for sex workers in low- and middle-income countries: Recommendations for a public health approach. Retrieved from http://apps.who.int/iris/bitstream/10665/77745/1/9789241504744_eng .pdf?ua=1

M10_MARY9591_06_SE_C10.indd 255 06/09/14 6:41 PM

chaPter

community health workers (CHWs)

health care provider control expectations

health education

learning domain

literacy

locus of control

media advocacy

social media

Key Terms

Learning Outcomes

After reading this chapter, you should be able to:

1. Define health promotion.

2. Distinguish health promotion from health education.

3. Apply selected models for health promotion practice.

4. Analyze the implications of language and health literacy for health promotion.

5. Identify four strategies for health promotion.

6. Describe the health education process.

7. Discuss the use of social marketing, branding, and tailoring in promoting health.

8. Design and implement a health education program for a selected population.

9. Describe criteria for evaluating health-related websites on the Internet.

Health Promotion and Education Strategies11

M11_MARY9591_06_SE_C11.indd 256 06/09/14 6:41 PM

257257

Tobacco Control Advocate, John F. Banzhaf III

Advocacy for tobacco control began more than 40 years ago with the filing of a complaint action with the Federal Communications Commission (FCC) by John F. Banzhaf III, a Columbia University law student. Banzhaf first alerted a television station that had broadcast the cigarette commercial that triggered his memories of what he had learned about the “fairness doctrine” and informed them that the FCC policy required broadcasters to provide free airtime for opposing views on con- troversial public issues. The station refused and Banzhaf lodged his complaint with the FCC. The FCC, in turn, notified the station that the few news stories covering the ills of tobacco use aired by the station did not offset the breadth of its cigarette advertising and required the station to provide considerable time for opposing information. Although the station appealed the ruling, the appeal was overturned in 1968 (Banzhaf, et al. v. Federal Communications Commission, et al., n.d.; Professor John F. Banzhaf, III, n.d.).

As a result, millions of dollars of free airtime was provided from 1967 to 1970, leading to a significant drop in tobacco consumption. In 1970, all radio and television cigarette advertising was banned in the United States (Office on Smoking and Health, 2012).

Banzhaf became director of Action on Smoking and Health (ASH), a nonprofit antismoking organization that uses legal action to advocate for a smoke-free world. Currently ASH is actively involved with the Framework Convention Alliance, a coalition of more than 400 organizations from over 100 countries that was instrumental in the development of the World Health Organization Framework Convention on Tobacco Control, the first-ever treaty related to a global public health issue (ASH, n.d.).

A d

vo ca

cy T

h en

A d

vo ca

cy N

ow Culturally Sensitive Prenatal Care Advocacy is not always undertaken by professionals for the good of clients. Arnold, Aragon, Shephard, and Van Sell (2011) described advocacy for culturally sensitive prenatal education un- dertaken by members of the Cherokee Nation and the March of Dimes. A 2006 survey by the Cherokee Nation in Oklahoma indicated that less than 10% of the prenatal literature provided to pregnant American Indian/Alaska Native (AI/AN) women was culturally appropriate. Utilization of prenatal care in this population is low and infant mortality and preterm birthrates are high. March of Dimes staff and volunteer faculty established an AI/AN Women’s Committee representing ten tribes to address these issues.

The women conducted focus groups in their communities and eventually decided to write a prenatal education booklet in the way a mother would educate her daughter about pregnancy. The booklet, entitled The Coming of the Blessing, incorporated beliefs and life values common across tribes and took more than a year to produce. It incorporated the use of color, positive voice, inclu- sion of family and community support, photographs, communication of health risks (e.g., alcohol use), and seeking support from family and friends, all of which are reflected in traditional tribal cultures. Factual information was provided by health care professionals and then “translated” into a cultural voice by women in the advisory committee using the concept of the medicine wheel to discuss the childbearing cycle from preconception through three trimesters of pregnancy to deliv- ery. The booklet has been used on reservations throughout the country and has become a major program initiative for the March of Dimes, which continues to advise the agency on AI/AN women’s health issues.

M11_MARY9591_06_SE_C11.indd 257 06/09/14 6:41 PM

258 Unit 3 Population health nursing Strategies

Six distinct approaches have been taken to public health over time (Awofeso, 2004). The first approach involved health protection by means of social struc-tures and lasted from ancient times until the 1830s. These social structures included rules of behavior, usually en- forced by means of religious, political, or cultural sanctions. “Miasma control” was the second approach to fostering the health of the public. Miasmas were harmful mists or vapors in the air. This era of public health, from the 1840s through the 1870s, was exemplified by the sanitary movement and gained impetus from Chadwick’s 1842 Inquiry into the Sanitary Conditions of the Labouring Population of Great Britain. From approximately 1880 to 1940, public health practice focused on contagion control based on the germ theory. During the 1940s to 1960s, emphasis was placed on preventive medicine, which expanded the germ theory to consider other disease vectors and nutritive factors in illness. Public health activity in this era was focused on populations at high risk for specific conditions. The 1970s and 1980s saw the rise of the primary health care movement, based on the Declaration of Alma-Ata, and recognized the effects of social factors on health. Finally, from 1990 to the present, the focus has been on the “new pub- lic health,” which emphasizes health promotion based on the ability of members of the population to make informed health decisions. This new focus retains many of the features of prior eras, including regulation of some aspects of health via legisla- tion, sanitation, immunization, a focus on risk modification, and recognition of the effects of social conditions on health. The eras and foci of public health practice over time are sum- marized in Table 11-1•. The emphasis on health promotion in the new public health focus highlights the importance of this role for population health nurses.

TABLE 11-1 Eras of Public Health Practice and Related Foci

Era Time Period Focus

Health protection Ancient times–1830s Regulation of behavior reinforced by religious, political, or cultural sanctions

Miasma control 1840s–1870s Sanitation Contagion control 1880s–1930s Immunization,

disinfection Preventive medicine 1940s–1960s Risk factor

modification Primary health care 1970s–1980s Modification of social

and other factors that influence health

Health promotion 1990s–present Development of capacity for informed health decisions

Defining Health Promotion A basic definition of health promotion was provided in Chapter 1 . Health promotion, as delineated by the Ottawa Charter for Health Promotion (World Health Organization [WHO], 1986), and reinforced in the Bangkok Charter for Health Promotion in a Global World (WHO, 2005), is a process that fosters people’s ability to improve their own health by in- creasing their control of its determining factors. Health promo- tion is more than educating people to change their behavior; it also involves public policy formation, development of environ- ments that support health, and promotion of community ac- tion to create conditions conducive to good health.

The Ottawa Charter emphasized health as a “resource for living” rather than an end in itself and marked an international shift from disease prevention to capacity building, improving the capability of nations and communities to provide environ- ments that support health and healthy behaviors. The Charter identified three strategies to promote global health: advocacy for conditions favorable to health, development of environ- ments that support health as well as personal information and skills to make health decisions, and mediation between groups (Tones & Green, 2010).

The foci of the Ottawa Charter were further expanded in 1997 in the Jakarta Declaration on Leading Health Promotion into the 21st Century. The Jakarta Declaration viewed health promotion as increasing healthy life expectancy by increas- ing health gains throughout populations, reducing inequities, promoting human rights, and enhancing social capital. The Declaration also established four priorities for health pro- motion in the 21st century: promoting social and individual responsibility for health, increasing investment in health de- velopment, increasing partnerships for health, and develop- ing a global infrastructure for health promotion (Tones & Green, 2010).

In the United States, health promotion efforts tend to continue to be focused on behavior modification and pre- vention of specific health conditions (termed vertical health promotion), rather than on changing broader factors that in- fluence health (horizontal health promotion) (Tones & Green, 2010). In 2003, however, the United States Department of Health and Human Services (USDHHS, 2003) launched the Steps to a Healthier US initiative, which focused on promot- ing behavior change and improving policy and environmental conditions that support healthy behavior and illness preven- tion. The Steps initiatives focused on reducing the burden of five specific conditions—asthma, cancer, diabetes, heart dis- ease and stroke, and obesity—and employed both vertical and horizontal health promotion strategies. The vertical strategies focused on behavior modification and prevention of the five conditions. The horizontal strategies addressed the policies and environmental conditions that influence health, such as insur- ance coverage for smoking cessation and incentives for schools to include physical activity in the curriculum.

M11_MARY9591_06_SE_C11.indd 258 06/09/14 6:41 PM

chaPter 11 health Promotion and education Strategies 259

The Need for Health Promotion The U.S. health care system is being overwhelmed by demands for care for myriad chronic diseases, and the system cannot continue to meet those demands. We must do something to motivate the American people to promote and protect their own health and to change the conditions in which people live to foster better health. The need for a focus on health promotion is evident in the information highlighted in the box on the next page. The data reported there led to the conclusion that health promotion is an “economic necessity” (Mathar & Jansen, 2010). It has been estimated that increasing the proportion of the population who engage in 20 health promotion and illness pre- vention services recommended by the U.S. Preventive Services

Task Force to 90% would result in health care cost savings of nearly $22 billion (Maclosek, Coffield, Flottemesch, Edwards, & Solberg, 2010). Similarly, interventions to reduce lifestyle- related risks for diabetes and hypertension have the potential to result in annual savings of $9 billion, increasing to nearly $25 billion when the possible effects on comorbid conditions are considered (Ormond, Spillman, Waldmann, Caswell, & Teresh- chenko, 2011).

Models for Health Promotion A number of models have been developed to guide health promotion practice. These include the Precaution Adoption Process model (Weinstein, Sandman, & Blalock, 2008), the Information-Motivation-Behavioral Skills (IMB) Model (Fisher, Fisher, & Shuper, 2009), the Theory of Reasoned Action and the related Theory of Planned Behavior (Eadie, 2014; Fisher, Kohut, Salisbury, & Salvadori, 2013; Southey, 2011), and the Health Belief Model (Tones & Green, 2010). Additional models include the Attitude-Social Influence- Efficacy Model (Verstraeten et al., 2014) and Pender’s Health Promotion Model (Pender, Murdaugh, & Parsons, 2010). Each of these and various other models are an attempt to explain why people do or do not engage in health-promoting activity. These explanations assist population health nurses to under- stand the motivations and factors involved in such decisions and help them to select appropriate strategies for promoting health in the population. Although it is not possible to discuss all of these models here, the reader is referred to the literature

Global Perspectives

Health promotion is an area of international concern and initia- tive spanning nearly 40 years. In 1974, The Lalonde Report in Canada shifted the focus of discussion of gains in population health from biomedical advances to consideration of the influ- ences of other non-health-sector determinants of health. This perspective was solidified in the World Health Organization’s 1978 Declaration of Alma-Ata with its focus on primary care and “health for all by 2000.” In the United States, the focus on health promotion took the form of a first set of national health promotion and disease prevention objectives promulgated in 1980 (de Salazar & Anderson, 2008).

During the 1980s, the Healthy Cities movement of the World Health Organization’s European Region, continued the focus on environments that promote health, and the first WHO International Conference on Health Promotion was held in Ottawa, Canada, in 1986. That conference issued the Ottawa Charter for Health Promotion, still the definitive international perspective on health promotion. Subsequent conferences broadened the perspec- tive on the varied social and economic determinants that affect health and that must be addressed if health is to be promoted. The 2005 conference resulted in the Bangkok Charter for Health Promotion, which forwarded the perspective that health promo- tion is critical to global development and should be a key focus of communities, societies, and corporate institutions alike (de Salazar & Anderson, 2008).

Despite the long history of health promotion efforts around the world, de Salazar and Anderson (2008), noted the limited scope and success of health promotion initiatives. Rather than dealing with the broader categories of determinants of health, such as social and economic inequities, health promotion ini- tiatives “continue to deal mostly with activities to control and prevent proximal causes of morbidity and mortality. Citizens and communities are not fully participating in the decisions that affect their lives” (p. 20).

Health Promotion Initiatives

Lack of health literacy can leave clients wandering in a confusing health care system. (CorelZavr/Fotolia)

M11_MARY9591_06_SE_C11.indd 259 06/09/14 6:41 PM

260 Unit 3 Population health nursing Strategies

cited for a description of the models. In this chapter, we will briefly explore the Precaution Adoption Process model, the Theories of Reasoned Action and Planned Behavior, the Health Belief Model, and Pender’s Health Promotion Model.

The Precaution Adoption Process Model The Precaution Adoption Process model is a stage model that describes stages in decisions to adopt or not adopt a health- related behavior (whether or not to take a specific precaution- ary action) (Weinstein et al., 2008). In stage 1, the person is unaware of the health-related issue and the need to adopt any particular health-related behavior. In stage 2, one is aware of the issue but is unengaged by it and is not considering any ac- tion. In stage 3, the person is deciding whether or not to act. He or she has considered the possibility of action but has not yet made a decision whether or not to adopt the behavior. Stage 3

may be followed by either stage 4 or stage 5. In stage 4, the person has decided not to act. Conversely, in stage 5, the per- son has decided to act but has not yet taken action. The process may stop at stage 4 for those who decide not to adopt the be- havior in question. People in stages 4 and 5 are more resistant to persuasion than those in stage 3 who have not yet made a decision. Given human tenacity, it is more difficult to influ- ence someone to change his or her mind than it is to persuade someone to act who has not yet made a decision one way or the other. Persons in stage 5 who have decided to adopt the be- havior proceed to stage 6, in which they act to engage in the behavior, and hopefully to stage 7, in which the behavior be- comes a routine part of their lifestyle. This process explaining the adoption or nonadoption of the health-related behavior of exercise is depicted in Figure 11-1•.

We can apply this model using a community-based example of installing speed bumps in residential areas. The decision to employ speed bumps to slow traffic must be adopted by the

The Need for Health Promotion • In 2010, a median of 17.3% of the U.S. population over 18

years of age was current smokers (Xu et al., 2013).

• In 2009, only 18% of the U.S. population engaged in any leisure-time walking, and only 2% engaged in bicycling (Pucher, Buehler, Merom, & Bauman, 2011), and a median of 24% of the population across all states reported no leisure-time physical activity (Xu et al., 2013).

• In 2009, less than one fourth of U.S. adults engaged in strengthening activities at least twice a week (National Center for Health Statistics, 2011).

• In 2013, the median intake of fruits among adults in the United States was 1.1 servings per day, with a median of 1.6 servings of vegetables (National Center for Chronic Disease Prevention and Health Promotion, 2013).

• In 2013, 13% of the U.S. population did not regularly use seat belts (National Highway Traffic Safety Administration, 2014).

• In 2010, a median of 15.1% of the U.S. population engaged in binge drinking, and 5% reported heavy drinking (Xu et al., 2013).

• The median prevalence of overweight across states in 2010 was 36.2%, and the median prevalence of obesity was 28.5% (Xu et al., 2013).

• In 2009, a median 40% of people across all states reported insufficient rest or sleep for at least 14 days in the prior month (Li et al., 2011).

Data from: Li et al., 2011; National Center for Chronic Disease Prevention and Health Promotion. (2013). State indicator report on fruits and vegetables, 2013. Retrieved from http://www.cdc.gov/nutrition/downloads/State-Indicator-Report- Fruits-Vegetables-2013.pdf; National Center for Health Statistics, 2011; National Highway Traffic Safety Administration. (2014). Seat belt use in 2013—Overall results. Retrieved from http://www-nrd.nhtsa.dot.gov/Pubs/811875.pdf; Pucher, Buehler, Merom, & Bauman, 2011; Xu, F., Town, M., Balluz, L. S., Bartoli, W. P., Murphy, W., Chowdury, P. P., . . . . Crawford, C.A. (2013). Surveillance for certain health behaviors among states and selected local areas—United States, 2010. Morbidity and Mortality Weekly Report, 62(SS-1), 1–247.

Highlights

Figure 11-1 Stages of Adoption of exercise Behavior

Stage 2 Unengaged

Stage 1 Unaware

Stage 3 Deciding

Stage 4 Decided not to act Stage 5

Decided to act

Stage 6 Action

Stage 7 Maintenance

M11_MARY9591_06_SE_C11.indd 260 06/09/14 6:42 PM

chaPter 11 health Promotion and education Strategies 261

City Council. In the first stage of the decision adoption process, the Council is unaware of the extent of and potential for injury and death due to drivers exceeding the speed limit in residen- tial areas. In stage 2, Council members may have become aware of the high frequency of pedestrian injuries in these areas, but are not considering taking any action to remedy the situation. At stage 3, the Council may be presented with a petition from local residents for the installation of speed bumps, but has not decided whether or not to authorize their installation. If the City Council proceeds to stage 4, they will decide not to install speed bumps possibly based on the cost of installation, which they believe would outweigh the benefits to be gained in terms of injuries and deaths prevented. If, on the other hand, they vote to install the speed bumps, but have not yet authorized the City Accounting Office to put out bids for their installa- tion, they are in stage 5 of the adoption process. At stage 6, all processes are in place, and speed bumps are being installed in identified residential areas. The City Council may then proceed to stage 7, in which construction of all new residential develop- ments within the city limits must include speed bumps.

The Theories of Reasoned Action and Planned Behavior The Theory of Reasoned Action, developed by Ajzen and Fishbein, is based on two types of beliefs: behavioral beliefs and normative beliefs. Behavioral beliefs reflect a person’s attitudes toward the expected consequences of the behavior. For example, if you expect that exercise will result in a more desirable figure, and if you value that more desirable shape, you are likely to value, and engage in, exercise. Normative be- liefs relate to subjective norms influenced by others. In the theory, the intention to act is based on one’s perceptions of others’ attitudes toward the behavior and the value placed on others’ judgments (Fisher et al., 2013). According to the related Theory of Planned behavior, action is also influenced by perceptions of one’s ability to control behavior. Behavioral beliefs, normative beliefs, and control beliefs all combine to result in behavioral intention, which is the precursor to actual behavior (Southey, 2011), as depicted in Figure 11-2•. For example, if you want to quit smoking (behavioral belief) and perceive that significant others in your life want you to quit (normative belief), but you think stopping smoking will be too difficult (control belief), you will probably not attempt to quit even though your own attitudes and those of people who matter to you support quitting.

Using the previous population-level example of the speed bumps, if City Council members expect the installation of the barriers to reduce speeds on residential streets and subse- quently reduce the frequency of pedestrian injuries and deaths, they may approve their installation. Action to install the speed bumps is even more likely if City Council members believe that failure to take action will anger voters to the point they will not be reelected. Both the perceived consequences of installing speed bumps and perceptions of voters’ attitudes will influence

their decision to take a health-promoting action on the part of the city. Their intention to act, however, may be further influ- enced by perceptions of their ability to do so. For example, they might believe that the city budget will not support the installa- tion of speed bumps.

A further extension of these two theories, the Integrative Model of Behavioral Prediction, expands the elements influ- encing intention and subsequent action to include background influences, such as individual characteristics, culture, emotion, and intervention exposure. Environmental factors and personal skills and abilities related to the desired behavior also influence performance of the behavior (Fishbein, 2009).

The Health Belief Model The Health Belief Model was developed by Becker, Rosenstock, and their colleagues several years ago and has been widely used in research and program development related to health- promoting behaviors. Elements of the model include indi- vidual perceptions of susceptibility and severity, modifying factors (demographic, sociopsychologic, and structural or en- vironmental variables), perceptions of benefits and barriers to action, and cues to action. In the model, health-promotive action is based on four basic premises or beliefs. First, one believes that one is susceptible to, or at risk for, a particular health problem. Second, one believes that the health problem can have serious consequences. Third, one believes that the problem can be prevented and fourth, that the benefits of ac- tion outweigh the costs or barriers (Tones & Green, 2010). An additional element, self-efficacy, was added to the model after 1988. Self-efficacy is the belief that one is capable of the behav- ior desired or of achieving change (Martin, Haskard-Zolnierek, & DiMatteo, 2010).

As an example, you may believe that, never having had chickenpox as a child, you are susceptible to chickenpox (perceived susceptibility). You also believe that chickenpox may cause serious consequences (perceived severity). This perception is confirmed when one of your classmates is hos- pitalized with complications of chickenpox (cue to action). In addition, you know that varicella immunization will virtually

Figure 11-2 elements of the Theories of reasoned Action and Planned Behavior

Beliefs about/ attitudes

toward behavior

Perceptions of others’s attitudes toward behavior

Intent to perform behavior

Behavior

Beliefs in one’s ability to control/ perform behavior

M11_MARY9591_06_SE_C11.indd 261 06/09/14 6:42 PM

262 Unit 3 Population health nursing Strategies

eliminate your risk of developing chickenpox (perceived ben- efit to action). Even though you know the possibility of an ad- verse reaction to the vaccine exists and you have to skip lunch to visit the student health center (perceived costs), you decide the benefits outweigh the barriers, and you get immunized.

Examining our community-level example of installing speed bumps in the light of this model, perceptions of suscep- tibility would relate to City Council members’ perceptions of the potential for injuries on residential streets. The perceived severity of the problem would reflect their knowledge of the number of deaths and serious injuries that have occurred. Per- ceived benefits might include reduced frequency of pedestrian injuries and satisfied voters. The cost of installing the speed bumps and, possibly, the loss of revenue from speeding tickets, might constitute perceived barriers to the project. Other suc- cessful strategies to minimize injuries, such as enacting helmet laws for bicyclists, might contribute to beliefs in self-efficacy among council members. Finally, the fact that the mayor’s son was nearly hit by a speeding car in front of his house may serve as a cue to action that motivates Council members to authorize the installation of speed bumps. Elements of the Health Belief Model are depicted in Figure 11-3•. Pender’s Health Promotion Model Nola Pender has developed a nursing model that directs nurs- ing intervention for health promotion. In the Health Promotion Model, behavior is influenced by individual characteristics and behavior-specific cognitions and affect (emotion) that result in a commitment to action. Commitment to action results in ac- tual behavior but may be modified by competing demands and preferences (Pender, et al., 2010). Individual characteristics in- clude personal biological, psychological, and sociocultural fac- tors that are relevant to the behavior involved. Prior behavior in this area is another individual characteristic that influences health-promoting behavior. For example, a client who was

physically active prior to pregnancy will be more likely to en- gage in exercise after delivery than one who was not.

Behavior-specific cognitions and attitudes include the per- ceived benefits of and barriers to health-promoting activity as well as one’s perceived self-efficacy. For example, the commu- nity that does not perceive itself as able to cope with the prob- lem of inadequate housing will probably not take any action to resolve the problem. Activity-related affect or feeling states related to the behavior, to oneself, or to the situation are also important in motivating health-promoting behavior. Interper- sonal and situational influences are additional factors related to cognition and affect that influence behavior. For example, if family members support weight loss, a client is more likely to stick to a diet. Conversely, low income, a situational influence, might adversely affect the client’s weight loss options.

Individual characteristics and behavior-specific cognitions and affect may lead to a commitment to health-promoting ac- tivity. Commitment includes both the intention to act and a specific plan of action. Commitment to action should lead to performance of the actual health-promoting behavior unless there is interference from competing demands and preferences. For example, the client’s intention to diet may be subverted by a family member’s serious illness and the need to eat in fast- food restaurants near the hospital.

Although Pender’s model was developed to be used to en- hance health-promoting behavior with individual clients, it can also be applied to population groups. Using the speed bump example, individual characteristics might relate to members of the City Council or of the community. For example, if members of the City Council have young children or live on busy resi- dential streets, they may be more inclined to take action than if they do not. Conversely, if the area of the city requesting speed bumps is composed largely of immigrants who rarely vote in local elections, Council members may be less likely to respond. Prior action may also have a bearing on the Council’s decision. For example, if they have taken other “traffic calming” actions (approaches to traffic control that are self-enforcing) such as installing cameras on traffic lights at busy intersections, they may be inclined to install speed bumps as well. If, however, the City Council perceives itself to have little control over traffic violations, their perceived lack of self-efficacy may lead them to decide that speed bumps will have little impact.

Emotional reactions to the problem may have an influence on the Council’s decision as well. If, for example, the most re- cent death of a child led to rioting or demonstrations outside City Hall, or if one of the Council members has had a child injured by a speeding driver, action may be forthcoming. Again, the City Council would weigh the perceived benefits of installing speed bumps (voter satisfaction and fewer injuries) against the perceived costs (financial costs of installing the speed bumps, need to delay construction of a city park, etc.) to decide whether or not to commit to installing the speed bumps. Even if the Council votes to install the bumps, instal- lation may be sidetracked by a subsequent financial crisis or by

Figure 11-3 elements of the Health Belief Model

Perceived susceptibility

Perceived severity

Modifying factors

Cues to action

Likelihood of Action

Perceived bene�ts of action

Perceived barriers to

action Self-ef�cacy

M11_MARY9591_06_SE_C11.indd 262 06/09/14 6:42 PM

chaPter 11 health Promotion and education Strategies 263

torrential rains that delay construction, both of which would reflect situational constraints that impede action to implement the Council’s decision. Elements of Pender’s model are de- picted in Figure 11-4•.

Population Health Nursing and Health Promotion Use of a health promotion model permits the population health nurse to identify factors involved in the health promo- tion situation and to design health promotion programs that address these factors. Use of a model also focuses attention on all of the factors that influence health promotion, not just per- sonal behaviors, and leads to a more horizontal approach to health promotion. The 2011 Institute of Medicine report “The Future of Nursing: Leading Change, Advancing Health” high- lighted health promotion as one of the “traditional and cur- rent strengths” of the nursing profession. Given their focus on health, health promotion is an even more critical role for popu- lation health nurses than for nurses in other specialty areas.

Some research, however, indicates that population health nurses’ concept of health promotion is narrowly circumscribed and addressed primarily due to their responsibility for health education. Little attention is given in the practice of some popu- lation health nurses to activities related to empowerment of pop- ulations and social determinants of health promotion capabilities (Richard et al., 2010). Some authors have found that additional education assists population health nurses to provide behav- ior change counseling to individual clients (Pfister- Minogue & Salveson, 2010), but further attention is needed to prepare them for the full spectrum of health promotion activities.

Factors Influencing Health Promotion In executing their role in health promotion, population health nurses must consider a number of important factors that may influence the health promotion situation. Four major influ- ences on health promotion will be considered here: fatalism,

readiness for change, health literacy, and the attitudes of health professionals toward health promotion.

FATALISM. Fatalism was defined in Chapter 5 as the belief that one’s fate is fixed and that personal efforts can do little to affect that fate. Other definitions of fatalism include “a belief in a lack of personal power or control over destiny or fate (Drew & Schoenberg, 2011, p. 164) or “the general belief that all events, and in particular, the actions and occurrences that form an in- dividual life, are determined by fate” (Espinosa de los Monteros & Gallo, 2011, p. 311). Fatalistic beliefs have often been found to be associated with lower rates of participation in health pro- motion, prevention, and screening activities (Smith-Howell et al., 2011).

Such beliefs have also been linked to an external locus of control orientation. The concept of locus of control relates to one’s perceptions that one’s life and circumstances are primar- ily under one’s personal control (internal locus of control) or under the control of fate or of powerful others (external lo- cus of control). In the past, fatalism has been seen as a stable global belief associated with decisions not to take preventive or health-promotive actions (Keeley, Wright, & Condit, 2009). People with an external locus of control have been found to be more fatalistic and were often perceived as ignorant and in need of educational efforts to change their perceptions of self- efficacy (Drew & Schoenberg, 2011).

More recent research, however, has suggested that fatalism is a complex construct that may reflect a population’s response to the realities of their life circumstances (Drew & Schoenberg, 2011). For example, when a population consistently sees its members dying from conditions like AIDS in the absence of access to effective treatment, it is not unreasonable to develop a perception that AIDS is life threatening and that little can be done to avoid it or deal with its consequences. Some authors have even suggested that fatalistic beliefs may serve a variety of functions within a population without interfering with propen- sities to take action to promote health and prevent illness. Some suggested functions include stress relief, uncertainty manage- ment, sense making, and face saving (Keeley et al., 2009).

A somewhat fatalistic attitude of “what will be, will be” can promote acceptance of the future without undue worry thereby relieving stress. Similarly, fatalistic beliefs can help to address the unpredictability and uncertainty associated with disease. For example, it is widely known that smoking is associated with lung cancer, but nonsmokers also develop lung cancer. Relegating those cases of cancer in nonsmokers to fate can serve functions of managing uncertainty and making sense of their occurrence. Getting the disease without smoking makes sense if it was one’s fate. Finally, fatalism may serve a face sav- ing function in the presence of existing disease avoiding guilt or blame for the development of an illness. If it was my fate to develop lung cancer, I do not have to fret about actions I might have taken to prevent it but didn’t (Keeley et al., 2009). In some recent studies, people have been found to express

Figure 11-4 elements of Pender’s Health Promotion Model

Individual characteristics

Behavior- speci�c

cognitions Action

Behavior- speci�c affect

Commitment to action

Intent Plan

Competing demands

Preferences

M11_MARY9591_06_SE_C11.indd 263 06/09/14 6:42 PM

264 Unit 3 Population health nursing Strategies

highly fatalistic perceptions while simultaneously taking action to promote their health suggesting that fatalism is a much more complicated concept than previously thought and its pre- cise influence on health-related behaviors remains largely un- known (Flores et al., 2009).

An external locus of control perspective may even serve to facilitate health-promoting behaviors. For example, people who have strong health care provider control expectations or beliefs that health care providers control their health, tend to have an external locus of control and hold fatalistic beliefs. However, they may also be more likely than those with lower health care provider control expectations to follow provider recommendations for health promotion and illness prevention behaviors (Roncancio, Ward, & Berenson, 2011).

Population health nurses engaging in health promotion ac- tivities need to consider the potential effects of fatalistic beliefs and locus of control on health-related behavior by members of the population. Do members of the population have a tendency toward fatalism? If so, what is the basis for those fatalistic be- liefs and do they impede health-promoting behaviors? When fatalism has a basis in realistic appraisal of life circumstances, efforts to change those circumstances may be more effective in fostering health promotion than attempts to change percep- tions of locus of control or belief systems.

READINESS FOR CHANGE. Involvement in health- promoting behaviors often requires a change, either on the part of the individual client or the population. However, people only engage in change when they are good are ready to do so. The smoker, for example, must be ready to quit smoking. Similarly, society must be ready to take the steps needed to provide universal access to health care or to enforce measures to prevent injury, such as seat belt or helmet use. Until the individual or the group is ready for change, change to more healthful behaviors will not occur.

The Transtheoretical Model of Change proposes that readi- ness for change occurs in a series of stages similar to those de- scribed earlier in discussion of the precaution adoption process model. The first stage is one of precontemplation in which one is not even thinking of making a change or aware of the need for change. In the contemplation stage, one is consid- ering change and plans to take action within 6 months. The third stage involves preparation for the change. In the fourth, or action stage, one engages in the new behavior, and in the maintenance stage, one integrates the behavior into one’s usual routine (Prochaska, Redding, & Evers, 2008).

Population health nurses can use this model to foster health-promoting behaviors by determining what stage an in- dividual or a population is in and then engaging in strategies to facilitate movement into the next and subsequent stages of change. Different strategies are appropriate for different stages (Martin et al., 2010). For example, consciousness raising tech- niques highlight the need for change in moving people from the first to the second stage of change. Similarly, emotional support and helpful tips for making a change can facilitate the action stage.

HEALTH LITERACy. Health literacy is another factor that influences health promotion. Literacy is defined as “a person’s ability to read, write, speak, and solve problems at levels needed to function in society” (Office of Disease Prevention and Health Promotion [ODPHP], 2010, p. 3). Health literacy was defined in Chapter 5 , as the extent to which an individual is able to obtain, process, and understand health-related information in order to make informed decisions about health issues. A health literate person is able to use health information “generatively” to make decisions in unfamiliar situations. Poor health literacy, on the other hand, is associated with emergency department use, hospitalization, poor self-reported health, and increased mortality. Limited health literacy also affects people’s ability to search for health-related information, adopt healthy behaviors, and act on health alerts to take appropriate action (ODPHP, 2012). Only approximately 12% of the U.S. population displays proficiency in health literacy. The rest of the population has some level of difficulty understanding and completing health- related tasks (National Network of Libraries of Medicine, 2013).

Health literacy is assessed at several levels, the highest being “proficient.” As noted above, only 12% of the U.S. population falls into this category. Another 52% of the population has in- termediate health literacy, while 22% has basic health literacy, and 14% are below the basic level. Seventy-seven million peo- ple in the United States display basic or below basic levels of literacy (National Network of Libraries of Medicine, 2013), and

Health education can be provided to individuals or groups of people. (WavebreakMediaMicro/Fotolia)

M11_MARY9591_06_SE_C11.indd 264 06/09/14 6:42 PM

chaPter 11 health Promotion and education Strategies 265

90% of U.S. adults have difficulty understanding routine health information. Health literacy levels are lowest among Hispanics compared to other racial and ethnic groups, persons with low educational levels, and the elderly. In fact, two thirds of persons over 60 years of age are at or below basic literacy levels and 39% has below basic levels (National Patient Safety Foundation, 2011).

One’s ability to understand health-related information depends on the complexity or difficulty of the information, the individual’s knowledge and skill levels, and his or her motiva- tion to achieve full understanding. Health literacy is dimin- ished with lack of understanding of medical terms or basic physiology, the inability to interpret numbers or determine levels of risk, the fear and confusion generated by receiving a serious diagnosis, and the need for complicated care for com- plex health conditions (ODPHP, n.d.). For many members of the population, poor health literacy is complicated by limited proficiency in English and the dearth of interpreters in many health care settings (National Patient Safety Foundation, 2011).

Population health nurses would assess the literacy levels of individual clients and population groups and then design health promotion initiatives appropriate to the level of literacy exhibited. Many people today obtain health-related infor- mation from media-based, rather than print-based, sources. Disparities in health literacy, however, are compounded for people who do not have access to media such as the Internet and various forms of social media. For those who do have ac- cess to these resources, population health nurses can use the strategies outlined in the ODPHP publication, “Health Literacy Online: A Guide to Writing and Designing Easy-to-use Health Web Sites” (ODPHP, 2010). ODPHP has also created a “Quick Guide to Health Literacy” that provides tips for working with individuals and populations with low levels of health literacy. In addition, ODPHP provides access to a number of other resources to address limited health literacy in the population. For further information about the guide and other ODPHP materials, see the resources provided in the External Resources section of the student resources site.

HEALTH PROFESSIONALS’ ATTITuDES TO HEALTH PROMOTION. Health professionals’ attitudes toward and involvement in health promotion activities also influence health promotion behaviors among individual clients and the general public. Although health promotion is the primary focus of public health professionals, health care providers involved in direct care of individuals and families have a role to play as well. Lack of time and reliance on written materials can lead to poor care and ineffective health promotion, particularly among population groups with low literacy levels.

Health care providers may often miss opportunities for health promotion in the care of individual clients. For example, Mur- ray and colleagues (Murray, Lewis, Coleman, Britton, & Mc- Neill, 2009) found that 394 attempts to quit smoking were made among 1805 study respondents, and more than one third of these were unplanned attempts. The reason for attempting to quit for

nearly 30% of this group was the advice of a health professional, yet more than half of these attempts received no support in their efforts to stop smoking. Providers of care to individuals should incorporate evidence-based health promotion strategies into their practice on a routine basis. For further information about guidelines for evidence-based strategies from the U.S. Preventive Services Task Force, see the resources provided in the External Resources section of the student resources site.

Health system factors beyond the activities of individual health care providers also influence health promotion behav- iors by members of the population. A study by the Colorado Department of Health indicated that many health insurance plans operating in the state were not covering health promo- tion and illness prevention services recommended by the Preventive Services Task Force. For example, considerable variability was noted in coverage of and restrictions on screen- ing for tobacco use and cessation services including pharmaco- therapy for nicotine addiction. Variability in coverage was also noted for obesity screening and counseling services (Colorado Department of Public Health and Environment, 2011).

Strategies for Health Promotion Population health nurses use a variety of strategies to foster health promotion at the population level. Four particular strat- egies will be discussed here: health education; social marketing, branding, and tailoring; legislation; and the use of community health workers (CHWs). Health education provides the infor- mation and skills required to make effective health-related de- cisions. Social marketing and the related concepts of branding and tailoring emphasize enhancing people’s motivation to act and reflects the view of personal agency. Motivating people to actually take advantage of opportunities for physical activity present in the community exemplifies social marketing.

Social marketing promotes health-related messages. (Harshmunjal/Fotolia)

M11_MARY9591_06_SE_C11.indd 265 06/09/14 6:42 PM

266 Unit 3 Population health nursing Strategies

Legislative action, on the other hand, may mandate health promotion activities, such as motorcycle helmet use, or create conditions conducive to health promotion. Finally, the use of community health workers to promote healthy behavior within the population capitalizes on the influence of trusted members of the community. Often a combination of strategies is most effective in achieving health promotion objectives. Each of the four strategies is briefly addressed below.

HEALTH EDuCATION. The first health promotion strategy to be addressed is health education. Health education is a par- ticipatory learning process that enables people to make informed decisions about health. The World Health Organization (2014, para. 1) defined health education as the use of learning experi- ences to improve people’s knowledge or change their attitudes for the purpose of fostering health.

The primary purpose of health education is to assist cli- ents in making health-related decisions. Health education may equip clients to make any of three types of health-related de- cisions: decisions about self-care, decisions about the use of health resources, and decisions about societal health issues.

Domains of health learning. Different types of learning may be required to facilitate health-promotive action. Types of health learning have been classified into four learning domains: the cognitive, affective, psychomotor, and social interaction skills domains (Tones & Green, 2010). A learning domain is the category or type of learning desired as a result of the health education encounter. The classic taxonomy of learning domains included the cognitive, affective, psychomotor, and perceptual domains (Bloom, Englehart, Furst, Hill, & Krathwohl, 1956). The cognitive domain encompasses intellectual skills related to factual information and its application. In the affective domain, the focus of learning is on attitudes and values. Emphasis in the psychomotor domain is on the learning of physical manipula- tive skills (Bastable, 2013). Finally, in the perceptual domain, emphasis is on learning to perceive and extract information from stimuli. More recent authors have added the social in- teraction skills domain to address learning that is required for communication, persuasion, and influencing others (including policy makers) (Tones & Green, 2010).

Taxonomies of learning tasks classify tasks within each of the established domains in a hierarchical fashion. In the cogni- tive and psychomotor domains, learning tasks are arranged in order of increasing complexity of intellectual or physical skill involved. For example, it requires greater intellectual skill to apply a fact to a particular decision-making situation than sim- ply to recall the fact. Similarly, less skill is required to follow printed knitting instructions than to create one’s own pattern. Hierarchies of learning tasks in the cognitive and psychomotor domains are presented in Table 11-2•.

Tasks in the affective domain are organized in terms of the degree to which an attitude or value has been internal- ized by the learner (Krathwohl, Bloom, & Masia, 1964). For example, the student who consistently displays empathy for

clients is operating at a higher level of internalization than one who merely discusses the importance of empathy in nursing. The taxonomy of the affective domain is also presented in Table 11-2.

Finally, learning tasks in the perceptual domain are arranged in terms of the extent to which the learner is able to extract information from a situation by way of perceptual skills. For example, a nursing student might notice a few salient charac- teristics of a family during a first home visit (e.g., cleanliness of the home, character of mother–child interactions), whereas an experienced community health nurse would derive much more information from the same encounter. The levels of a proposed taxonomy for the perceptual domain are listed in Table 11-2.

Principles of learning. A number of principles of learning have been identified that apply to health education as well as to other forms of learning encounters. These principles can be grouped as general principles of learning and principles related to the health education message and its delivery. The first, and pos- sibly most important, general principle is that effective teaching and learning is based on a need to know and should be preceded by an assessment of learning needs. The learning assessment should also include an evaluation of readiness to learn. Readi- ness may be a function of developmental level as well as atten- tion, motivation, and interest. The second overarching principle is one of accountability in which both teachers and learners are accountable for achievement of the desired learning outcomes. Third, learning should occur in a “safe” environment in which the learner is free to make mistakes and to learn from them. In addition, effective learning involves action or doing combined with reflection on what has been learned. Learners need to be actively engaged in the learning process, as learning depends on some form of neural activity: seeing, hearing, smelling, feeling, thinking, physical or motor activity, or some other kind of ac- tivity. This means that learning is multi-sensory. People process new information with multiple senses, although some people may prefer one sensory modality (e.g., visual learning) over an- other (e.g., auditory learning).

Additional principles of learning reflect its incremental, as well as social, nature. Current learning must be integrated into past learning experiences with learning accumulated over time. In this respect, learning is facilitated by association with past learning. Learning is reinforced by repetition, but rep- etition must occur in circumstances that maintain interest and attention. Retention of learning is also influenced by the recency and frequency of use of learned information and by ex- periences of success or failure in the learning encounter. Both praise and criticism may affect learning and retention, but may do so differently for different people. For example, research has indicated that constructive criticism may be more effective than effusive praise with confident capable learners, but may actually be harmful for less able learners. Balanced feedback including mild encouragement and occasional mild criticism may be more effective in promoting learning than either ful- some praise or extreme criticism.

M11_MARY9591_06_SE_C11.indd 266 06/09/14 6:42 PM

chaPter 11 health Promotion and education Strategies 267

TABLE 11-2 Taxonomy of Learning Tasks in the Cognitive, Psychomotor, Affective, and Perceptual Domains

Domain Learning Tasks and Description

Cognitive • Knowledge: Recall of facts, methods, or processes Sample learning objective: Learners will be able to list elements of the food pyramid.

• Comprehension: Basic understanding of the meaning of facts Sample learning objective: Learners will be able to describe elements of the food pyramid in terms of recommended servings.

• Application: Use of abstractions in concrete situations Sample learning objective: Learners will be able to evaluate their diet in light of the servings recommended for elements of the food pyramid.

• Analysis: Ability to break concepts down into component parts Sample learning objective: Learners will be able to identify the nutrients provided by selected elements of the food pyramid.

• Synthesis: Ability to combine parts into a new pattern or whole Sample learning objective: Learners will be able to incorporate food preferences of a specific ethnic group into a food pyra- mid tailored to that group.

• Evaluation: Judgment about the value of information and processes for specific purposes Sample learning objective: Learners will be able to describe the relative importance of incorporating elements of the food pyramid in diets designed for prevention or treatment of obesity.

Affective • Receiving: Sensitization to the existence of a phenomenon Sample learning objective: Learners will describe protections for the civil rights of gay and lesbian members of the community.

• Responding: Low level of commitment to behaviors embodying a value, performance of the behavior because of outside constraint Sample learning objective: Learners will adhere to legally mandated protections afforded to gay and lesbian members of the community.

• Valuing: Ascribing worth to a thing, behavior, or value accompanied by fairly consistent performance of related behaviors Sample learning objective: Learners will usually refrain from actions discriminating against gay and lesbian members of the community.

• Organization: Organization of values in hierarchical relationships Sample learning objective: Learners will be able to apply the value of nondiscrimination to other segments of the population.

• Characterization: Person can be characterized by consistent behavior in keeping with a specific set of values Sample learning objective: Learners will consistently refrain from discriminatory actions against “undesirable” segments of the population.

Psychomotor • Perception: Awareness of objects and the relationships among them Sample learning objective: Learners will be able to discuss items needed for insulin injection.

• Set: Physical, mental, and emotional readiness to act Sample learning objective: Learners will express willingness to learn insulin injection technique.

• Guided response: Performance of an action with instructor input and guidance Sample learning objective: Learners will demonstrate correct insulin injection technique with instructor coaching.

• Mechanism: Performance of task as a habit Sample learning objective: Learners consistently demonstrate correct insulin injection technique.

• Complex overt response: Performance of task with a high degree of skill Sample learning objective: Learners demonstrate correct insulin injection technique smoothly and rapidly.

• Adaptation: Ability to adjust the skill to meet the needs of new situations Sample learning objective: Learners are able to adjust insulin dosage to accommodate increased exercise.

• Origination: Ability to create new acts or ways of manipulating materials Sample learning objective: Learners are able to switch to use of an insulin pump with little difficulty.

Perceptual • Sensation: Awareness of differences, or change, in stimuli Sample learning objective: Nursing students can distinguish an abnormal tympanic membrane from a normal one.

• Figure perception: Awareness of an object or phenomenon as a distinct entity Sample learning objective: Nursing students can identify the light reflex on a tympanic membrane.

• Symbol perception: Identification of pattern or form, ability to name or classify an object or phenomenon Sample learning objective: Nursing students can distinguish a bulging tympanic membrane from a retracted one.

• Perception of meaning: Awareness of significance of symbols, ability to interrelate symbols Sample learning objective: Nursing students can recognize a bulging tympanic membrane as evidence of possible middle ear infection.

• Perceptive performance: Complex decisions with multiple factors, ability to change behavior based on its effectiveness Sample learning objective: Nursing students can combine evidence of a bulging tympanic membrane, loss of typical tympanic membrane landmarks, fever, and ear pain to derive a diagnosis of probable middle ear infection.

M11_MARY9591_06_SE_C11.indd 267 06/09/14 6:42 PM

268 Unit 3 Population health nursing Strategies

Learning is also social in that we learn best with others or from observing the behavior of others. In addition, learning is affected, either positively or negatively, by emotional expe- riences and relationships in the learning environment. The emotional effect of a specific learning activity can also influ- ence retention of learning. We tend to remember best learn- ing experiences that aroused either highly positive or negative emotions. Relationships within the learning context must be founded on trust. When the audience is a culturally diverse group, health education should be developed and delivered by a culturally diverse team including trusted members of the cul- tural groups involved. Similarly, when the audience involves members of previously disenfranchised communities, time will be required to create trust and rapport between the target au- dience and the health educators. Including community mem- bers in planning health education programs will enhance the development of trust and rapport as well as make the program more culturally appropriate. In addition, there is a need to rec- ognize the culturally specific history of the group and how it influences health behaviors and readiness for health education.

Learning is also a lifelong endeavor and one continues to learn, whether formally or informally, throughout life. Finally, the ability to learn may be affected by physiologic factors such as fatigue, pain, poor nutrition, and so on. These general prin- ciples of learning, as well as self-explanatory principles related to the health education message and its delivery, are summa- rized in Table 11-3•. Assessing health education needs. The health education pro- cess begins with an assessment of the audience, their health ed- ucation needs, and the learning environment. When the client is a population group, the first task in assessment is to identify the target audience. Selection of the target audience may be based on level of need, resources available, or probability of success. Assessment then proceeds to identifying characteristics of the audience that influence the learning situation. The assessment can be conducted in terms of the determinants of health in the population health nursing model, addressing biological, psy- chological, environmental, sociocultural, behavioral, and health system factors that influence the health education situation.

TABLE 11-3 General, Message-Related, and Delivery-Related Principles of Learning

General Principles of Learning Delivery-Related Principles of Learning

• Effective learning is based on an assessment of learning needs and readiness to learn.

• Information should be linked to existing knowledge.

• Teachers and learners must be accountable for achieving desired learning outcomes.

• Information should be presented in fun and interactive ways to promote integration of concepts.

• Learning should occur in a safe environment in which mistakes have minimal consequences.

• Modes of presentation should allow sufficient time for group members to assimilate and interact with it.

• Effective learning involves active participation in the learning encounter and incorporation of multiple sensory modalities.

• Messages should be presented in clear, simple language, and should avoid professional jargon.

• Learning is incremental and new learning should be associated with and integrated into prior learning.

• Materials should generally be developed at grade levels one to two grades below the highest grade completed in school and should employ short sentences and simple, one- and two-syllable words.

• Learning is reinforced by repetition that occurs in circumstances that maintain interest and attention.

• Information should be reinforced and repeated as needed, using illustrations as appropriate.

• Retention of learning is reinforced by recency and frequency of use as well as by positive and negative feedback.

• Written materials should use large type fonts and a mix of upper- and lowercase letters and should employ ample white space to prevent readers from being overwhelmed by content.

• Learning is social and occurs best in interactions with others. • Information in written materials should be bulleted when possible. • Learning is influenced by emotions and requires trust. Time will be

required to develop trust with disenfranchised groups before effective learning can occur.

• Written materials should be reinforced verbally.

• Culturally diverse teams should develop health education programs for culturally diverse audiences. Curriculum development should acknowledge and incorporate the distinct culturally specific history of the target audience.

• Multiple approaches should be used to assess understanding of content (e.g., questioning, demonstration, etc.).

Message-Related Principles of Learning

• Messages personalized to the audience will be more effective than global or generalized messages suitable for mass dissemination. • Health education messages should include content most relevant to the target audience, rather than trying to cover all of the related

information. • The message should highlight important concepts relevant to the audience.

M11_MARY9591_06_SE_C11.indd 268 06/09/14 6:42 PM

chaPter 11 health Promotion and education Strategies 269

When members of the target audience participate in conducting the assessment, the accuracy of the assessment and its relevance to their needs are enhanced.

Biological considerations influence both the learning needs and the learning capabilities of individual clients or popula- tions. To learn effectively, clients may need to have reached a certain level of physical or psychological maturation. For example, small children who have not yet developed abilities for abstract thought will need concrete examples of concepts to be learned. Similarly, a child who still has poorly developed eye–hand coordination will have difficulty learning insulin in- jection techniques, so teaching will most likely involve parents as well. At the other end of the age spectrum, changes associ- ated with aging may lead to sensory impairment that influences learning among older populations. Age or maturation level also affects the client’s need for education. For instance, preschool children do not need information about menstruation, but preadolescent girls do. In addition, clients’ maturational levels may influence existing knowledge of a particular subject. For example, a group of third graders will probably have a broader knowledge of nutrition concepts than preschoolers.

Assessing aspects of physiologic function in the population may reveal special needs for health education or impediments to learning. For example, a high prevalence of diabetes in the population suggests a need for diabetes prevention or self-care education, whereas high incidence rates for sexually transmitted diseases among adolescents indicate other needs for prevention education. Inadequate physiologic function can also give rise to impediments to learning. For example, the presence of physical disabilities may require specialized approaches to health educa- tion. Pain, another biophysical factor, may also impede learning.

Psychological determinants can profoundly influence will- ingness and ability to learn. Attitudes toward health and health behaviors can either enhance or detract from the motivation to learn. Among clients attending a series of parenting classes, for example, those parents who attend only because of a court mandate related to child abuse usually benefit less than those who attend because they perceive a need for help. Fatalistic be- liefs discussed earlier may also influence motivation to learn and to act on health-related information.

Psychological factors such as stress and anxiety can also impede learning, even for those who are motivated to learn. Population health nurses can limit the negative effects of psy- chological determinants by actions designed to decrease stress and anxiety. For example, the nurse can create a climate in which clients do not feel threatened and in which the nurse educator is seen as a source of support rather than a threat. The nurse who has children and who teaches parenting classes for abusive parents might create such a climate by beginning the first session with a description of the frustration the nurse sometimes feels as a parent.

Environmental factors should also be considered in terms of their effects on learning. Is there adequate lighting for the tasks to be accomplished? Is there too much noise? Will clients

be distracted by other activities occurring in the learning environment? During a home visit, for example, the nurse might ask that the television be turned off before attempting to educate a hypertensive client about his or her medication.

Environmental factors may also give rise to the need for health education. For example, population groups affected by natural disasters may need education on how to purify their drinking water to prevent communicable diseases. Similarly, health education efforts might be targeted to persons with chronic respiratory conditions in areas with significant air pollution.

Sociocultural determinants are particularly influential in shaping attitudes about health and health-related behaviors. Examples and attitudes of those around us influence our will- ingness to engage in self-care behaviors in addition to affecting our attitudes to health issues at the societal level.

Sociocultural factors also influence one’s exposure to health- related information. People with lower education levels are less likely than those with more formal education to have been ex- posed to prior health education. The education level of the pop- ulation and of specific target audiences essentially influences the nurse’s choice of teaching strategies and content to be presented. Health literacy, discussed earlier, is another example of a socio- cultural factor that influences the health education situation.

Cultural influences on health education with population groups include typical communication styles, concepts of time and personal space, values, and perceptions of environmen- tal control. Client life roles and role expectations, which are culturally defined, are other factors that may affect interest in health education and motivation to learn. When content is per- ceived to be relevant to the roles one is expected to fulfill, one’s motivation to learn is likely to be high. Roles may also influ- ence one’s ability to attend to health messages. For example, if members of the audience are responsible for the care of chil- dren, they are unlikely to be able to attend educational presen- tations unless child care is arranged.

Culture may also influence the effectiveness of health educa- tion in terms of the trust placed in health professionals. Many culturally diverse audiences may distrust health professionals as a result of past experiences or cultural misunderstandings. Language is a particularly important sociocultural consider- ation in health education initiatives in the United States, where in 2010, 21% of the population spoke a language other than English at home and approximately 40% of those spoke English “less than very well” (U.S. Census Bureau, 2011). Research has indicated that non-English-speakers are less likely than their English-speaking counterparts to have a regular source of health care and to receive preventive care and may be at higher risk for medical error.

Occupation is another social factor that can give rise to health education needs. Trash collectors, for example, might re- quire education related to body mechanics and techniques for lifting heavy objects, whereas nurses require information about how to handle contaminated needles and other equipment.

M11_MARY9591_06_SE_C11.indd 269 06/09/14 6:42 PM

270 Unit 3 Population health nursing Strategies

Behavioral factors also influence needs for health education. For example, the extent of obesity in the United States suggests the need for intensive dietary education. Similarly, smokers may need help with smoking cessation and education on al- ternative ways to meet needs satisfied by smoking. As another example, sexually active clients may need education regarding contraceptives and safe sexual practices.

Preventive and therapeutic recommendations related to health system determinants may precipitate a need for health education. For example, clients may need to be educated on the correct use of medications or how to keep a sprained ankle im- mobilized to promote healing. Elements of the health care regi- men may also influence clients’ abilities to learn. For example, pain medication may make a client drowsy and inhibit the abil- ity to learn material presented. As we saw earlier, the degree of emphasis placed on health promotion and health education by health care providers and providers’ expertise in using the health education process are other health system determinants that

influence clients’ health-related knowledge and attitudes. Tips for assessing a health education situation are presented below. In addition, an assessment tool is provided in the Assessment Guidelines section of the student resources site. Population health nurses would use these tools to assess the need for health education at individual and population levels and to design health education programs that address those needs.

Planning and implementing health education programs. In the context of health education, planning involves determina- tion of the topic to be addressed, content to be covered, teaching strategies to be employed, and mechanisms to assess learning. Elements of the planning process include prioritizing learning needs, developing goals and objectives, and selecting content and teaching/learning strategies. Other considerations in plan- ning and implementing health education programs include lan- guage and health literacy and the use of the Internet as a teach- ing medium.

FOCuSED ASSESSMENT Assessing the Health Education Situation

• What is the level of health literacy in the population?

• What is the primary language spoken by members of the target audience?

• Are there cultural beliefs and practices that are likely to influence learning?

• Do the occupations of group members give rise to a need for health education?

• Are there other facets of the social situation (e.g., SES, time for or transportation to educational opportunities) that may influence health education? What effect do these facets have on the health education situation?

Behavioral Determinants

• Do health behaviors prevalent in the population give rise to the need for health education?

Health System Determinants

• Do local health care providers emphasize health promotion and health education? Do members of the population have access to health care services where they might receive health education?

• Does the population have a need for education regarding the use of health care services?

• Do health care recommendations give rise to a need for health education? Are there elements of the health care regimen that may influence learning abilities (e.g., medications)?

• Will attitudes toward health care services and providers influence the ability to learn?

Biological Determinants

• What is the age composition of the target audience? What learning needs arise from the age and developmental level of the audience? Will the developmental level of the audience affect the ability to learn or the teaching strategies used?

• Do physical health problems in the population give rise to the need for health education or pose any impediments to learning?

Psychological Determinants

• Is the target population aware of the need for health education? What is the level of motivation to learn? Will population attitudes toward health and health behaviors enhance or detract from learning ability?

• Does the target audience exhibit levels of stress or anxiety that will interfere with learning?

• Do fatalistic beliefs influence learning motivation or ability to learn?

Environmental Determinants

• Are there conditions in the physical environment that give rise to a need for health education? What effects, if any, will the physical environment have on learning?

Sociocultural Determinants

• What effects will the learners’ peers have on motivation to learn?

• What is the current education level of the learners? What prior exposure to health information has the population received?

M11_MARY9591_06_SE_C11.indd 270 06/09/14 6:42 PM

chaPter 11 health Promotion and education Strategies 271

Prioritizing learning needs. Planning health education pro- grams begins with prioritizing learning needs. Generally speak- ing, a learning needs assessment will indicate several areas of need, not all of which can be addressed in a single health edu- cation effort. Prioritization involves determining the relative effects of behaviors and risk factors present in the population and the benefits to be achieved by changing them. Another consideration in prioritizing health education needs is the ease with which contributing factors can be changed. For example, members of the population may not use seat belts, get too little exercise, and fail to obtain periodic mammograms. A change to using seat belts would result in the most immediate and dra- matic benefit to the community and be the easiest of the three behaviors to change. For these reasons, the population health nurse might first begin with health education efforts in this area. Members of the community can help determine priori- ties, ensuring that topics of greatest interest and relevance to the target audience are addressed.

Developing goals and objectives. Goal identification involves specifying the broad purpose of the health education encoun- ter. Some authors distinguish between program goals—the intended purpose of the overall health education program— and educational goals—the learning outcome expected for the audience. For example, the program goal for a nutrition program might be to prevent obesity in school-age children. The educational goal, on the other hand, might be for parents to become knowledgeable regarding appropriate nutrition for their children.

Objectives describe specific outcomes to be achieved as a re- sult of the health education encounter. An objective related to the nutrition program goal might be that the community incidence (number of new cases) of childhood obesity will decline by 50%

within 2 years. An educational objective might be that parents are able to correctly describe the number of servings of each element of the food pyramid required by an elementary school student.

Objectives should be stated in measurable terms that al- low one to evaluate whether the expected results have been achieved. Evaluation of outcomes also requires that they be specific. For example, an outcome objective such as “reduce adolescent tobacco use” is somewhat vague. If one adolescent smoker stops smoking, have we met our objective? Similarly, an objective to “stop adolescent tobacco use” is not particu- larly realistic. No matter what interventions are employed, it is unlikely that we will ever prevent all adolescents from using tobacco. A more realistic, and more measurable, objective for tobacco education might be to “reduce the prevalence of to- bacco use among high school seniors by 50% within 1 year.” As stated, the objective provides a target measure for accomplish- ment (a 50% decline in the number of seniors who use tobacco) as well as a time frame for expected accomplishment (1 year from program initiation).

Selecting content and teaching strategies. The content se- lected for inclusion in a health education program will depend on its relevance to the target population. Audiences are more likely to attend to information that they perceive as highly rel- evant to their own situations. One must be selective in plan- ning the content because no audience needs or wishes to learn everything about a particular topic that the health educator may know. Going back to the general principles discussed earlier, an effective educator chooses the content that is most relevant to the target audience.

Selection of teaching strategies will depend on a number of factors, including characteristics of the audience, the content and objectives to be achieved, program budget, time available, cultural appropriateness, and the environment for health edu- cation. In educating individual clients, health education mes- sages may make use of tailored or customized communication based on the needs and characteristics of an individual learner or target audience. For example, cancer screening messages that focus on surviving to watch one’s children grow and develop will be more effective for parents than for single individuals.

Recently, a number of authors have suggested using highly graphic messages in health education initiatives to motivate healthful behaviors. For example, truth advertising—focusing on making adolescents aware of the tobacco industry’s special efforts to target them for smoking initiation—has been as- sociated with an increase in antitobacco attitudes and beliefs among youth (Hopwood & Merritt, 2011).

Much of the work of population health nurses is directed toward educating individuals, families, and population groups regarding health promotion. Population health nurses can use the educational processes described here to promote healthy behavior at all of these levels.

Using media in health education and health promotion. Media portrayal of health-related behavior can influence health

Health promotion messages should be tailored to individual or group risks, attitudes, and values. (Tntdesigns/Fotolia)

M11_MARY9591_06_SE_C11.indd 271 06/09/14 6:42 PM

272 Unit 3 Population health nursing Strategies

promotion either positively or negatively. For example, depiction of smoking in movies has been linked to smoking initiation among youth. In spite of decreases in the extent of smoking depic- tion in popular movies, approximately 45% of the 137 top-gross- ing movies in 2010 included on-screen tobacco- related incidents. Six members of the Motion Picture Association of America have policies designed to reduce tobacco use in movies, and among three of these, the number of tobacco-related incidents in youth- rated movies decreased by 96% from 2005 to 2010. Decreases are less noticeable among independent companies and members of the association without tobacco policies (National Center for Chronic Disease Prevention and Health Promotion, 2011).

Media can also be used, however, to support health- promoting behaviors in at least three ways. First, media can be used for public education (Daniels, Glickstein, & Mason, 2012). For example, researchers and community members collaborated on the creation of a fotonovela, a type of graphic novel popular with many Latinos, to promote good nutrition in the local Latino population (Hinojosa, et al., 2011).

Second, media can be used for social marketing, creating motivation to change unhealthful behaviors or to engage in healthful ones. Social marketing is discussed in more detail below. Finally, media can be used for media advocacy, which is the purposeful use of media messages and approaches to

Evidence-Based Practice

Effective Health Promotion Strategies There is a general lack of evidence for the effectiveness of health promotion initiatives that is compounded by the reliance on ran- domized clinical trials (RCTs) as the highest and most credible source of evidence. Much of health promotion research, however, is population-based, which makes conducting RCTs difficult. Conversely, the results of RCTs conducted in rigorously controlled settings may or may not be generalizable to the real world of population health. In addition, RCTs focus on individual health- related behaviors and do not account for the myriad social and political factors that influence health-promoting behaviors in the general population (Carter et al., 2011).

In spite of these difficulties, however, there is some indication of the use of evidence-based population level health promotion and illness prevention practices. Much of this evidence has been com- piled by the Community Preventive Services Task Force, an inde- pendent body appointed by the Director of the Centers for Disease

Control and Prevention. The Community Preventive Services Task Force was developed as a complement to the U.S. Preventive Services Task Force, which focuses on health promotion and pre- vention at the individual client level. Thus far, the Community Preventive Services Task Force has conducted systematic reviews of evidence and compiled recommendations for effective interven- tions related to topics included in Table 11-4•. For example, com- munity wide campaigns to promote use of folic acid supplements in pregnancy have been found to have a strong evidence base for their efficacy. Similarly, the use of sobriety checkpoints has been found to be an effective strategy to prevent motor vehicle-related injuries (Community Preventive Services Task Force, 2013). For a complete description of evidence-based strategies for population level health promotion and prevention see the resource provided for The Guide to Community Preventive Services in the External Resources section of the student resources site.

TABLE 11-4 Topic Areas Addressed by Community Preventive Services Task Force Reviews

Adolescent health Mental health Preventing excessive alcohol consumption Motor vehicle injury prevention Asthma control Nutrition Prevention of birth defects Obesity Cancer prevention and control Oral health Cardiovascular disease prevention Physical activity Diabetes prevention and control Social environment Emergency preparedness Tobacco use Health communication and social marketing Vaccination Health equity Violence prevention HIV/AIDS, other STIs and pregnancy Worksite health promotion

Data from: Community Preventive Services Task Force. (2014). The Community Guide. Retrieved from http://www.thecommunityguide.org/index.html

M11_MARY9591_06_SE_C11.indd 272 06/09/14 6:42 PM

chaPter 11 health Promotion and education Strategies 273

promote a social agenda or policy initiative (Daniels et al., 2012). Media advocacy mobilizes constituents and stakeholders to take action, targets policy makers, and often focuses on changing environmental conditions to promote health. For example, media advocacy has been used to highlight the un- healthful effects of junk food availability in school settings and has led to restrictions on food and drinks available to students. Similarly, a mass media campaign effectively promoted smok- ing cessation among people exposed to the campaign (Vallone, Duke, Cullen, McCausland, & Allen, 2011).

Media depictions can also be used to understand the in- sights and motivations of particular groups of people. For example, Black and Peacock (2011) examined depictions of a “strong Black woman script” in media sources popular among African American women. The strong Black woman script represents efforts to live up to cultural expectations to protect their families at the expense of their own needs. They recom- mended capitalizing on information gleaned from popular depictions to develop alternative approaches and to design culturally tailored interventions to promote health in this population.

The Internet is another medium often used by individual clients, the general public, and health care providers as a source of health-related information. Using the Internet as a medium for health education has both advantages and disad- vantages. Two general problems that may be encountered are inaccurate information and biased information. To address these problems, the Health on the Net Foundation (HON, 2013a), a non-government organization designed to pro- mote dissemination of accurate health-related information on the Internet, has developed a code of ethics and criteria for certification of health-related websites. These criteria in- clude elements related to authority, complementarity, confi- dentiality, attribution, justifiability, transparency, financial disclosure, and advertising (HON, 2013b). The criteria for

website certification are described in Table 11-5•. Visitors to a particular Internet site can also look for the display of the HON approval logo or that of other organizations that evalu- ate health-related websites on the website’s home page. For further information about approval organizations, see the re- sources provided in the External Resources section of the stu- dent resources site.

The Internet can be an effective mode of health education and health promotion even for persons with low literacy lev- els. For that reason, the U.S. Office of Disease Prevention and Health Promotion (ODPHP, 2010) has developed guidelines for the creation of easy-to-use health websites described earlier. For further information about the guidelines, see the resources provided in the External Resources section of the student re- sources site. One should keep in mind, however, that people of lower socioeconomic status or members of some ethnic groups may not have the same access to these modalities as those in the dominant society. It has also been suggested that the Inter- net may be an effective way of disseminating health promotion messages to people who do not regularly interact with formal health care networks except on an emergency basis (Crilly, Keefe, & Volpe, 2011).

Other forms of social media may also be helpful in fostering health promotion. At the same time, such media may impede successful health promotion activities by disseminating incor- rect information. Social media include a set of Internet-based tools that enable people to communicate with each other in real time (Stokowski, 2011). Applications like My Space, Facebook, Twitter, Instagram, and blogs are examples of so- cial media. Population health nurses can use social media to disseminate health-related information to a wide segment of the population, but they must also consider these media as po- tential sources of misinformation. They should also remember that personal postings to social media, if they reflect poorly on the nursing profession, can minimize the public’s trust and

TABLE 11-5 Criteria for Health Website Accreditation

Criterion Description

Authoritative The website indicates the qualifications of contributing authors. Complementarity The website provides information designed to support or complement, rather than replace, the relationship

between the user and his or her health care provider. Privacy The website respects the privacy and confidentiality of information obtained from users. Attribution The website cites the source(s) of information provided and provides modification dates for web pages. Justifiability The website provides balanced and appropriate evidence for any claims regarding the benefits or performance

of a particular treatment, product, or service. Transparency The website provides information on the ownership of the site and provides accessible contact information. Financial disclosure The website clearly identifies its source(s) of financial support. Advertising policy The website clearly states whether advertising is included in the site and describes its advertising policy.

Advertising is clearly differentiated from health-related information.

Data From: Health on the Net Foundation. (2013b). The HON Code of Conduct for medical and health Web sites (HONcode). Retrieved from http://www.hon.ch /HONcode/Patients/Conduct.html

M11_MARY9591_06_SE_C11.indd 273 06/09/14 6:42 PM

274 Unit 3 Population health nursing Strategies

impede effective health promotion efforts. For this reason, nurses using social media as avenues for health education and health promotion should take care to present balanced infor- mation that has a strong foundation in scientific evidence.

Elements to consider in designing effective health-related websites and other media include the target audience’s access to and ability to use the Internet, their ability to read and un- derstand printed material, the complexity of the material to be provided, and the usability of the website. Media designed for people with low literacy levels or limited technology skills will need easily navigated sites that contain clear information. Web- site and other media designers should consider the following in developing effective health education media:

• People often scan or skip large sections of print, so bullet important points in small, easy to digest segments.

• People may have difficulty spelling search terms, so an al- phabetical index of subjects should also be included.

• People tend to focus on the center of the screen so important messages should be positioned above the mid-point, and navigation functions should be positioned in the center or on the left.

• Too much material overwhelms users, so keep content and presentation simple.

• Many people may lack navigational skills, so use step- by- step navigational prompts with active “next” and “back” buttons.

• Media designers should learn as much as possible about potential users and their goals for use. Cultural and moti- vational characteristics are particularly important areas of information.

• Designers should write “actionable” content that highlights desired behavioral changes and provides specific actions for accomplishing the change. Change is also facilitated by describing the benefits of the change.

• Content should be displayed clearly on the page in a well- organized format that is easy to navigate.

• Engaging users with interactive content maintains interest and attention.

• The effectiveness of the site should be regularly evaluated and revised as needed (ODPHP, 2010).

Population health nurses can use this information to create effective health-related websites to disseminate health promo- tion information and to influence population and individual health-related behaviors.

SOCIAL MARKETING, BRANDING, AND TAILORING. Decisions regarding health-related behaviors occur within a social and cultural context, and changes in health behavior re- quire an understanding of the influences exerted by that con- text. These social influences on behavior tend to exist in a hi- erarchy; one is influenced in turn by one’s peer group, one’s nuclear and extended family, community norms, and national norms promulgated via mass media (Tones & Green, 2010). Social marketing, as a health promotion strategy, uses informa-

tion about the factors that influence behavior in specific popu- lation groups to promote adoption of health-related behaviors or elimination of unhealthy behaviors. Social marketing is a process designed to change negative behaviors or maintain positive ones for the benefit of the individual and the society (The NMSC, 2010).

Social marketing involves the use of commercial marketing techniques to achieve a health-related goal. The aim is to use commercial marketing principles to address social problems rather than generate profit. In essence, social marketing, as it relates to health promotion, involves conveying a health- related message in a way that is relevant and of interest to a particular target audience. The effectiveness of social market- ing is enhanced by “cultural grounding,” which involves an appeal based on the values and cultural beliefs and behaviors of the target population. For example, successful antismoking campaigns for young people have been based on social mar- keting principles grounded in adolescent “culture.” Teenagers value being part of the group and being attractive to others. Social marketing campaigns were directed toward making nonsmoking the social norm by emphasizing the unattractive aspects of smoking. Other campaigns focused on the adoles- cent’s need for independence by highlighting the manipulative nature of tobacco industry advertising directed toward teens. The “Truth Campaign,” designed to make visible the tobacco industry’s manipulative strategies, is credited with prevent- ing 450,000 young people from initiating smoking in its first 4 years (Hopwood & Merritt, 2011).

A social marketing tool kit developed by the Centers for Disease Control and Prevention (CDC, 2010) addresses six phases in the social marketing process. The first phase is describing the problem to be resolved. The second phase involves conducting market research to determine the char- acteristics of the target audience. The third phase involves creating a marketing strategy or plan of action for the so- cial marketing program. In this phase, the health promotion practitioner identifies the target audience to be reached and influenced by the intervention. More than one target audi- ence may be identified based on market segmentation. Be- havioral goals and strategies to achieve them are developed for each target market. For example, the goal of an antito- bacco campaign for adults might be smoking cessation by current smokers. This goal might be expanded in a campaign for youth to include cessation by current smokers and non- initiation of smoking by nonsmokers. Similarly, different promotion strategies would be devised for each group based on group characteristics and circumstances that influence smoking behaviors. The last element in creating the market- ing strategy is identifying and allocating resources.

In the fourth phase of the social marketing process, the ac- tual intervention is planned. For example, billboards might be designed to convey the message and located where they will be seen by specific targeted audiences. Graphic flyers and posters might be placed in school settings, and so on. The fifth phase involves planning strategies for monitoring and evaluating

M11_MARY9591_06_SE_C11.indd 274 06/09/14 6:42 PM

chaPter 11 health Promotion and education Strategies 275

the intervention, and the sixth phase involves actually imple- menting the interventions and evaluating their effects. This last phase may also include revising the campaign based on con- sumer feedback. The phases of social marketing are summa- rized in Table 11-6•. The focused assessment on the next page can help to guide development of a social marketing plan.

Although they use similar methods, social marketing and commercial marketing differ in a number of respects. The goal of social marketing is to promote health-related behavior, while commercial marketing is designed to promote the purchase of a particular product or service. They also differ in terms of de- mand. Commercial marketing focuses on “selective demand,” the choice of one brand over another competing brand. Social marketing, on the other hand, focuses on “primary demand,” the choice of whether or not to engage in a behavior that is of- ten perceived as being counter to one’s self-interest and desires. In commercial marketing, the competition is another brand of the same product, while in social marketing, the competing force is an unhealthful behavior, such as smoking. Finally, the two approaches differ in terms of the time involved to witness “delivery” on product promises. For example, smoking can al- most instantly enhance one’s reputation as “cool,” but the ben- eficial effects of health-promoting behaviors may take decades to be noted (Blitstein, Evans, & Driscoll, 2008).

Social marketing is characterized by the concept of ex- change, the use of research to direct action, and the develop- ment of a “marketing mix” and positioning strategy. Each of these characteristics will be addressed briefly using the example of smoking among adolescents. In social marketing,

adolescents are being asked to exchange something, in this case smoking, for a more healthful behavior, not smoking. The cen- tral issue is to determine what exchange will satisfy the target audience, so that the perceived benefits of the change outweigh its costs (Hopwood & Merritt, 2011). For adolescents, being ac- cepted by the group or being more attractive to others might be benefits for which they would exchange smoking.

Social marketing is based on research that describes the tar- get population, their attributes, interests, and concerns. Using our adolescent smoking example, researchers would be inter- ested in exploring what motivates smoking behavior in teen- agers. The assessment of the target population is followed by research to develop and test marketing messages and strategies with the target population, in this case adolescents. The de- sign of these messages might make use of another marketing research strategy, focus groups of adolescents to develop and/ or react to antismoking messages. Finally, research methods are also used to study the application and effectiveness of the marketing interventions. At this point, antismoking messages would be widely disseminated and their effectiveness studied in deterring adolescent smoking.

A marketing mix is based on the four Ps of social marketing: product, price, place, and promotion (Hopwood & Merritt, 2011). The product is the need, service, or desired behav- ior that the target audience is being asked to adopt (e.g., not smoking). Price reflects the cost of or barriers to adopting the desired behavior or giving up an unhealthy behavior (e.g., pos- sible weight gain, irritability, or being thought “uncool”). The place element of social marketing is the location where the product or service can be obtained (e.g., where smoking cessa- tion programs or nicotine patches are available) as well as the places where members of the target group can be reached. In our adolescent smoking example, this might include junior and senior high schools, sporting events, or rock concerts. Promo- tion refers to the communication strategies and messages used to motivate members of the target audience to act. This might include posters or radio or television messages that present the less attractive aspects of smoking (e.g., smoker’s breath, discol- ored hands and teeth). Promotion strategies include informa- tion related to the product, price, and place where the product or service can be obtained (Hopwood & Merritt, 2011).

Some authors include additional social marketing Ps, such as publics (the different audiences for social marketing strat- egies), partnerships between social and health agencies to achieve social marketing goals, and policy that addresses envi- ronmental changes that promote the desired behavior. A final P involves the “purse strings,” or funding to support social marketing strategies (Weinrich, n.d.).

A positioning strategy addresses the price or costs of the behavior vis-à-vis the competing behavior. Developing a positioning strategy involves identifying the benefits of the desired behavior and its costs and comparing them to the benefits and costs of the competing behavior. For example, smoking and nonsmoking are competing behaviors. The pri- mary cost of smoking, of course, is death. However, if the

TABLE 11-6 Phases of the Social Marketing Process

Phase Description

1. Problem Description • Identification of the health problem or description of the issue to be resolved, including contributing factors and the target audience for intervention

2. Market research • Determination of characteristics of the target audience

3. Strategy • Creation of a tailored marketing development strategy or plan of action for each segment of the target audience

• Identification and allocation of resources

4. Intervention • Development of actual marketing design messages

5. Monitoring plan • Development of strategies for monitoring intervention effectiveness

6. Implementation • Dissemination of marketing messages • Evaluation of the effectiveness of

marketing messages

Data from: Centers for Disease Control and Prevention. (2010). CDCynergy lite: Social marketing made simple: A guide for creating effective social marketing plans. Retrieved from http://www.cdc.gov/healthcommunication/pdf/cdcynergylite.pdf

M11_MARY9591_06_SE_C11.indd 275 06/09/14 6:42 PM

276 Unit 3 Population health nursing Strategies

target audience is youth for whom death is a distant event, focusing on this cost will not prove very effective. Focusing on the unattractive aspects of smoking highlights elements of the price of smoking that are apt to get the attention of young people, who are very conscious of personal appearance and attractiveness to others.

Critical elements of social marketing include understand- ing the competition, understanding the target market, creation of a mutually beneficial exchange, and segmenting the market and targeting interventions to the specific interests of par- ticular market segments. Segmentation is the process of iden- tifying subgroups or segments of the population who share certain characteristics that can form the basis for a marketing strategy. For example, knowing the particular communication channels used by a group can help inform appropriate media campaigns. Antismoking information disseminated to young people through Facebook and other social media reflects au- dience segmentation. Another example is the use of a text messaging service, SEXINFO, to provide sexual health infor- mation and referrals to sexually active young people in the San Francisco area (Youth+Tech+Health, 2014). Other nontech- nological strategies might be used for other segments of the population, such as older adults who are less computer savvy. Segmentation leads to decisions about the most effective use of resources and promotion strategies for a particular segment of a target population. The Focused Assessment below presents some questions to be addressed in designing social marketing campaigns.

Branding is a particular application of social marketing that endeavors to create an image to which consumers can re- late and display loyalty. A brand is a set of beliefs or values one associates with a product or service when one encounters a particular name, mark, or symbol (Evans & Hastings, 2008b). For example, the BMW symbol gives rise to connotations of luxury, quality engineering, and so on. Branding has been ef- fectively used in commercial marketing to attract and retain customer loyalty to a particular product. As another example,

the Virginia Slims brand of cigarettes and branding communi- cations stating “You’ve come a long way, baby” conjured visions of strong, independent women who thought for themselves. A branding communication is more than an advertisement; it is a message designed to associate valued benefits with a spe- cific product in the minds of consumers (Blitstein et al., 2008). Because of these associations, the particular “brand” becomes the preferred choice. Public health practitioners have been chal- lenged to develop healthy “brands” or behaviors that become a preferred choice over unhealthy options (Evans & Hastings, 2008a). Public health brands are associations that individuals hold for healthy lifestyles that make them a better option than unhealthy ones (Evans & Hastings, 2008b).

There are three main concepts related to branding: a re- lationship with the consumer, the value the brand adds to the particular product or service, and an exchange with the consumer. The relationship to the consumer is grounded in a promise of delivery of some good valued by the consumer. For example, branding has been used in youth antitobacco campaigns, promising increased independence through rebel- lion against manipulation by the tobacco industry. The value added concept includes value beyond the obvious health ben- efit of the desired behavior. Again, antismoking campaigns have capitalized on values of attractiveness (no “cigarette breath”) and “being cool” that are of importance to adoles- cents. Finally, exchange deals with the concept that the behav- ior or product is worth the cost or effort involved in obtaining it. Branding involves creating an aspiration to a desirable ideal (being thought attractive), modeling a socially desired behavior, such as exercise, and association with an idealized imagery, such as an attractive and popular person (Evans & Hastings, 2008b).

Branding, attempts to create broad perceptions and asso- ciations of the desired behavior within populations. Tailoring, on the other hand, is directed toward the individual. A tai- lored message is specifically focused on promoting behavior change in an individual and addresses that individual’s unique

FOCuSED ASSESSMENT Strategic Questions for Social Marketing Design

• What would make the behavior easier or more desirable?

• Who has influence with the desired audience?

• What media channels will reach the target audience?

Data from: Centers for Disease Control and Prevention. (2010). CDCynergy lite: Social marketing made simple: A guide for creating effective social marketing plans. Retrieved from http:// www.cdc.gov/healthcommunication/pdf/cdcynergylite.pdf

• What is the problem to be addressed?

• What behavior change is required to address the problem?

• Who is the audience?

• What are the benefit and barriers to the desired behavior? To competing behaviors?

• What benefits does the audience desire?

• How, when, and where does the behavior occur?

M11_MARY9591_06_SE_C11.indd 276 06/09/14 6:42 PM

chaPter 11 health Promotion and education Strategies 277

characteristics (Lewis & McCormack, 2008). Tailoring focuses on making the message more relevant to a particular individual or subgroup within the population. For example, your insur- ance provider may send you health-related information based on the fact that you are of a certain age, ethnicity, and a smoker, information gleaned from your health records.

Population health nurses can use the concept of tailoring to create individualized health messages to promote health in a particular person. This may also be done at a population level by creating tailored message libraries. Creating such libraries involves the development of an assessment tool to identify de- terminants of health and behavior in a given individual, devel- oping messages related to specific determinants, and creating tailoring algorithms that link specific messages to determinants identified in an assessment. For example, one might use a com- puterized health-risk assessment that obtains information on age, gender, family history of particular conditions, dietary habits, alcohol and drug consumption, use of safety precau- tions, and so on. Then on the basis of the person’s responses, specific health-promoting messages would be generated. For example, data indicating that one is 16 years old, female, and sexually active, might trigger automated messages related to prevention of pregnancy and sexually transmitted diseases (Lewis & McCormack, 2008).

Population health nurses can use the concepts of social marketing, branding, and tailoring to disseminate health infor- mation and promote healthful behaviors. These strategies can also be used to influence policy makers to develop policies that promote health and create conditions conducive to healthful behaviors.

LEGISLATION. Legislation is another approach to health promotion that mandates individual behavior or creates condi- tions that promote health. For example, a ban on the display of tobacco products in stores in Ontario, Canada decreased tobacco promotion and youth exposure to tobacco marketing (Cohen et al., 2011). Because tobacco has been linked to alco- hol use, a similar ban on sales and promotion in places where alcohol is sold might have similar effects (Jiang & Ling, 2011). Legislation with a similar intent was enacted in China man- dating that filmmakers limit the extent of on-screen smoking. The legislation also prohibits identifying a cigarette brand and showing smokers in scenes that include teenagers, teens buy- ing cigarettes, or smoking in places where smoking is banned (Currie, 2011).

Legislation has also been used to promote other health- related behaviors. For example, state laws mandating seat belt use were first passed in 1984. As of 2008, all U.S. states except New Hampshire had mandatory seat belt laws. The effects of such laws, however, depend on their enforcement. With re- spect to seat belt legislation, for example, laws may involve pri- mary or secondary enforcement. Primary seat belt laws permit law enforcement officers to issues tickets solely on the basis of failure to use seat belts. In states with secondary enforce- ment laws, tickets for nonuse of seat belts can only be issued if

drivers are stopped for some other violation. According to data from the 2008 Behavioral Risk Factor Surveillance System, the prevalence of seat belt use was higher in states with primary enforcement laws (National Center for Injury Prevention and Control, 2011). Legislative efforts have also been used to pro- mote healthier diets by limiting trans fats used in restaurants in multiple cities. In 2011, California became the first state to en- act a statewide ban on trans fats in food establishments (Assaf, 2014).

On occasion, legislation may undermine health promotion efforts. For example, at the end of 2010, 12 states had legislation that preempted local restrictions on smoking. Preemptive state legislation prohibits local jurisdictions from enacting laws that are more stringent than those of the state. One of the Healthy People 2020 objectives calls for a reduction in the number of states with preemptive tobacco legislation. From 2000 to 2010, the number of states with preemptive tobacco control laws de- clined from 18 to 12, and most of the change in such laws dealt with restrictions on smoking in specific places. Laws in several states continue to prohibit local laws related to tobacco adver- tising and youth access to tobacco products (Office on Smoking and Health, 2011). Legislative mandates may also have un- intended consequences. For example, increases in cigarette taxes in some states have led to decreased levels of smoking, but also increased black market sales and decreased tax reve- nues targeted for smoking cessation programs (Henchman & Drenkard, 2014).

Population health nurses can actively support legisla- tion that promotes health. Using the strategies discussed in Chapter 9 , they can alert law makers to the need for legis- lation in a particular area. They can also campaign for and educate the public about such legislative efforts. In addition, population health nurses should keep abreast of legislative at- tempts to undermine health.

uSE OF COMMuNITy HEALTH WORKERS. The final strategy for promoting health in populations is the use of CHWs to disseminate health promotion messages and to fos- ter health-promoting behaviors in the population. Because of the growing shortage of health care professionals, there are not enough personnel to meet the needs for health promotion ef- forts among the population. CHWs can help to fill this gap. In 2009, the American Public Health Association issued a policy statement on the need to employ CHWs to increase access to care and reduce health-related inequities in the U.S. popula- tion. The policy statement called for a systematic approach to the use of CHWs and highlighted the need for policy and prac- tice changes to more fully realize their potential.

Community health workers (CHWs) are “frontline pub- lic health workers who are trusted members of and/or have an unusually close understanding of the community served. This trusting relationship enables a CHW to serve as a liaison /link/intermediary between health/social services and the com- munity to facilitate access to service and improve the quality and cultural competence of service delivery” (American Public

M11_MARY9591_06_SE_C11.indd 277 06/09/14 6:42 PM

278 Unit 3 Population health nursing Strategies

Health Association, 2009, p. 1). CHWs may be paid staff or volunteers working in concert with local health care profes- sionals. They usually share the ethnicity, language, socioeco- nomic status, and life experiences of other members of the community (Health Resources and Services Administration

[HRSA], 2011). Generally speaking, CHWs enact one or more of several roles and functions as depicted in the Highlights box below.

CHWs have been found to be effective in a number of ar- eas. For example, a systematic review of CHW effectiveness found that they contributed to improved disease prevention and cancer screening knowledge, improvement in various health-related behaviors, improved outcomes for conditions such as back pain and asthma, and increased use of some types of health promotion services (Viswanathan et al., 2009). In another study, incorporation of CHWs from multiple community organizations and adding dissemination of im- munization information to their other responsibilities was effective in increasing and maintaining immunization rates in New York City (Findley et al., 2009). Promotores, Latino CHWs, have also been found to be effective in promoting physical activity; improving blood pressure, fitness, and flex- ibility; improving community resource use; decreasing de- pression; and increasing community support for physical activity (Ayala & the San Diego Prevention Research Center Team, 2011). Similarly, peer worker interventions improved rates of eye protection use among migrant citrus harvesters (Monaghan et al., 2011).

Mutual support groups, a strategy related to the use of CHWs, have also been found to be effective in support- ing health-promoting behaviors. For example, the AMIGAS program (a Spanish acronym for “friends, Latina women, informing each other, guiding each other, and supporting each other against AIDS”) changed gender role perceptions, improved self-efficacy for negotiating safer sex and condom use, and increased HIV knowledge among Latino women in Miami. The program was based on a similar widely dis- seminated program among African American women, SISTA (Sisters informing sisters about topics on AIDS) (Wingood et al., 2011).

Community health workers have long been used to promote health and prevent illness in international venues and have proven quite effective. For example, Iranian CHWs reported an in-depth understanding of health and factors influencing it and executed a wide range of activities related to health in rural Iran. They noted the importance of trust-based relation- ships with the communities served and discussed heavy work- loads and lack of an effective support system as impeding their effectiveness (Javanparast, Baum, Labonte, & Sanders, 2011). CHWs are often the mainstay of numerous other international health promotion initiatives from use of mosquito netting to water purification efforts.

HRSA has identified six health service models incorporat- ing the use of CHWs. In the first model, the CHWs were lay health workers who advocated for members of the popula- tion, educated and mentored them regarding health issues, and served as outreach workers and translators. In the second model, CHWs functioned as members of the health care team completing tasks delegated by the health care team leader.

Outreach workers from the community can help to identify and address community member’s needs. (EdBockStock/Shutterstock)

Community Health Worker Roles

• Bridging and providing cultural mediation between communities and their members and health and social service systems, par- ticularly by facilitating effective provider–client communication

• Providing culturally appropriate health education and information • Improving access and continuity of care • Providing informal counseling and social support • Monitoring and promoting treatment adherence • Advocating for individual, family, and community needs • Providing direct services and conducting screening tests • Monitoring individual and population health status • Building individual and community capacity

Data from: American Public Health Association. (2009). Support for community health workers to increase health access and to reduce health inequities. Policy Number 20091. Retrieved from http://www.apha.org/advocacy/policy/policysearch/ default.htm?id=1393; Balcazar, H., Rosenthal, L. E., Brownstein, N. J., Rush, C. H., Matos, S., & Hernandez, L. (2011). Community health workers can be a public health force for change in the United States: Three actions for a new paradigm. American Journal of Public Health, 101, 2199–2203. doi: 10.2105/ AJPH.2011.300386

Highlights

M11_MARY9591_06_SE_C11.indd 278 06/09/14 6:42 PM

chaPter 11 health Promotion and education Strategies 279

In the third model, CHWs played the role of health care navi- gator or care coordinator, assisting clients to negotiate health care systems with a focus on improving access to care and fos- tering appropriate use of services. The fourth type of model employed CHWs in screening and provision of health educa- tion. In the fifth model, CHWs functioned as outreach work- ers, informing clients of service availability and enrolling them in service programs. Finally, some CHWs functioned as com- munity organizers and capacity builders.

Population health nurses may have a variety of responsi- bilities with respect to community health workers. As people knowledgeable about local communities, they can identify community members who may be effective CHWs. Population health nurses may also develop and implement curricula to train CHWs for their roles in any given project and may super- vise and monitor their performance. Finally, population health nurses may participate in evaluating the effectiveness of CHW initiatives. Population health nurses may advocate for the use of CHWs to participate in health promotion activities in local communities. Likewise, they may use the other strategies de- scribed here to foster health-promoting behaviors among pop- ulation groups and to advocate for policies and conditions that support health promotion.

Evaluating Health Promotion Programs Like all population health nursing activities, the effectiveness of health promotion initiatives should be evaluated. Several authors have noted the difficulty involved in such an evalua- tion, primarily because it is difficult to determine, when an event does not occur, if it would have occurred without the in- tervention. Another area of difficulty lies in the fact that the unit of analysis in community-based health promotion evalua- tion should be the community, but resource constraints in both programs and program evaluations rarely allow participation by an entire community. Therefore, one has the problem of identifying who in the community was exposed to the program and who was not. In addition, the quasi-experimental nature of most program evaluations leads to selection effects among participants, involving those most interested in a program and possibly more highly motivated regarding the particular topic. Similarly, evaluation measures may focus on complete avoidance of a negative behavior (or always engaging in a positive one) and, thus, may miss small gains (e.g., reduction in the number of cigarettes smoked versus stopping smoking altogether).

In spite of these difficulties, however, health promotion pro- grams can and should be evaluated. This evaluation may occur at different levels. For example, diagnostic evaluation assesses the accuracy of the needs assessment on which the health pro- motion program was based. Formative evaluation, also called process evaluation, examines the way in which the program was carried out. Finally, summative evaluation may focus on program outcome, impact, or both.

Health promotion programs may also be evaluated in terms of the extent to which they achieve criteria of empow- erment, participation, holism, intersectoral collaboration, equity, use of multiple strategies, and sustainability (Tones & Green, 2010). First and foremost, programs should be em- powering, allowing beneficiaries to assume control of the program. They should also foster participation of the target population at all stages of development, implementation, and evaluation. Third, they should be holistic, with a focus on multiple aspects of health. They should also involve par- ticipation and collaboration by multiple community sectors to achieve desired ends and should be guided by concerns for equity and social justice. Effective health promotion programs also employ a variety of approaches to achieving change. Finally, the results of effective health promotion pro- grams are sustainable, with changes that can be maintained beyond the initial period of funding.

A number of the Healthy People 2020 objectives reflect health promotion efforts, and the relevant targets can be used to evaluate the effectiveness of specific health promo- tion initiatives. Many of the objectives related to the leading health indicators emphasize health promotion. For example, objectives related to injury and violence prevention include reductions in pedestrian deaths on public roads, an objective in keeping with our speed bump example earlier in the chap- ter, as well as increased use of seat belts. Similarly, objectives related to nutrition and obesity include increasing the per- centage of people who eat sufficient fruits and vegetables and decreasing fat intake, both of which reflect health promotion. Specific objectives and the degree of progress toward their accomplishment are included in relevant chapters through- out this book. For further information on the Healthy People 2020 objectives and data on their accomplishment, see the resources provided in the External Resources section of the student resources site.

Population health nurses are actively involved in health promotion and health education efforts with individuals, families, and population groups. Table 11-7• describes the elements of a health promotion program and considerations related to assessing the health promotion situation, planning the program, and evaluating its effectiveness. In the table, the assessment of factors influencing the health promotion situa- tion is framed in the context of the determinants of health. The program described is an actual population-based health pro- motion initiative undertaken by population health nursing stu- dents to promote disaster preparedness in a culturally diverse community.

As we have seen, health promotion is more than promoting behavior change among individuals or population groups or providing health-related information. It also involves activity to change the social, political, economic, and/or physical environ- ment in ways that are conducive to health. Achieving changes at these levels requires advocacy and empowerment as well as information giving and motivation.

M11_MARY9591_06_SE_C11.indd 279 06/09/14 6:42 PM

280 Unit 3 Population health nursing Strategies

TABLE 11-7 Elements of a Community Health Promotion Program for Disaster Preparedness

Element Considerations

Assessment Biological Determinants • Many older people and families with young children live in the community. • There are several disabled community members.

Psychological Determinants • There is apathy regarding family disaster preparedness among community residents. • Residents do not believe disasters are likely to affect them.

Environmental Determinants • The community sits on a major geologic fault. • The community is surrounded by dry canyons with potential for wildfires. • The community is in a coastal area that could be subjected to tsunamis. • Many residences are old and might be heavily damaged in an earthquake. • Most of the residences are older homes and rental units. Few of them are equipped with smoke alarms.

Sociocultural Determinants • The community includes several large groups of Hispanic immigrants and Asian refugees as well as small groups of

African Americans, Sudanese and Somali refugees, and older White residents. • Many residents do not speak English. Major languages spoken are English, Spanish, Vietnamese, and Hmong. • Community income levels are low and many community residents have less than a high school education. • Most families in the community have little knowledge of disaster preparedness. • Several homeless individuals live in makeshift shelters in the canyons. • Fire department services are central to the community and respond rapidly to emergency calls.

Behavioral Determinants • Homeless persons living in the canyons often cook over open fires, posing a wildfire hazard. • Many people in the community smoke, increasing the potential for house fires. • Many of the Hmong population cook over open braziers in their homes, increasing the potential for house fires. • Few families in the community have gathered supplies in the event of potential disasters.

Health System Determinants • Health care providers in the community do not routinely educate clients regarding disaster preparedness. • The local health department has concentrated on community response to possible bioterrorist attacks and has not

actively promoted preparation for other types of disasters. Purpose/goal To increase disaster preparedness among families in the community Objectives Affective Domain

• Community residents will demonstrate an understanding of the need for smoke detectors in homes. • Community residents will demonstrate an understanding of the need for disaster preparedness.

Cognitive Domain • Community residents will be able to identify critical supplies needed for disaster preparedness. • Community residents will demonstrate appropriate responses to specific emergencies.

Content • Content was chosen to address the two types of disasters most likely to occur in the community: fire and earthquake. • Information about preventing fires, responding to fires and earthquakes, and needed disaster supplies was gathered

from a variety of sources (e.g., local fire officials, the Internet, Red Cross, and county health department disaster divisions).

• Content was reviewed to pick out the five or six most salient pieces of information. Teaching strategies/ materials

• The project was planned to be implemented as an exhibit at the multicultural fair held annually in the community. This fair attracts approximately 10,000 people each year, most of whom are community residents.

• Because of the fair venue, messages were developed for the limited time people were likely to spend at the booth. • According to community informants, many of the Hmong population were not literate, even in Hmong (which did not

have a written form until recently), so information brochures were developed in English, Spanish, and Vietnamese, and pictorial messages were used for the Hmong population.

• Pictures and samples of necessary disaster supplies were exhibited. • Fire prevention and response coloring books were obtained from the local fire department and crayons were purchased

and wrapped in sets of three to give out with the coloring books. • Posters indicating needed disaster supplies and information families should have were created and hung in the booth. Key information was included on refrigerator magnets given to fair participants.

• Donations were solicited for raffle prizes related to disaster prevention and preparedness (e.g., smoke alarms, flashlights) and raffles were held throughout the day to attract fair participants to the booth.

M11_MARY9591_06_SE_C11.indd 280 06/09/14 6:42 PM

chaPter 11 health Promotion and education Strategies 281

TABLE 11-7 (Continued)

Element Considerations

Evaluation • Visitors to the booth were asked to select pictures from a collection of items that they would include in disaster prepared- ness supplies and attach them to a felt board. This was a highly popular activity and although it was designed primarily for children, many adults participated as well. Most participants were able to select correct items.

• Visitors were also asked what they would do in the event of an earthquake (get outside or under a sturdy doorway or table) or a fire (e.g., stop, drop, and roll) and how to prevent fires. Most participants answered correctly.

• Ideally, a community survey would be conducted after the fair to determine how many community residents actually collected disaster preparedness supplies or installed smoke detectors, but this was not possible in the time frame available for the project.

Health promotion efforts are critically needed to address the increasing cost of health care services for existing illnesses. A number of models have been developed to explain health- promoting behaviors by individuals and population groups and to guide health promotion initiatives. Models presented in the chapter include the Precaution Adoption Process Model, the theories of Reasoned Action and Planned Behavior, the Health Belief Model, and Pender’s Health Promotion Model.

Several factors influence the effectiveness of health promotion efforts, including fatalistic behaviors, readiness for change, health literacy, and the attitudes and behaviors of health professionals and health care systems related to health promotion. Four major

strategies for health promotion were presented in the chapter: health education; social marketing, branding, and tailoring; leg- islation; and the use of community health workers to disseminate health promotion messages to selected population groups. The process of health education involves assessment and prioritiza- tion of health education needs, developing goals and objectives for health education programs, selecting and implementing health education strategies, and evaluating the effectiveness of health education programs. Population health nursing involve- ment in health education, social marketing and related activities, legislation, and the use of community health workers in health promotion initiatives were also addressed.

CHAPTER RECAP

New legislation in your state has mandated that the majority of funds allocated for public health efforts be devoted to health promotion activities rather than to care of clients with existing health problems. Some of the major health problems encoun- tered in the state at this time include heart disease, family vio- lence, and social isolation among the elderly. 1. Which of these issues would be most amenable to health

promotion efforts? Why?

2. Choose one of the three problems and design a set of inter- ventions to address it. How might you employ each of the four health promotion strategies discussed in the chapter to address the problem selected?

3. Discuss the four Ps of social marketing related to the prob- lem selected. How might you segment your target audience?

Promoting Population HealthCASE STuDy

Action on Smoking and Health. (n.d.). Tobacco is a global epidemic. Retrieved from http://ash.org/globaltc.html

Action on Smoking and Health. (1999). How Banzhaf ’s successful antismoking crusade began. Retrieved from http://www.no-smoking.org/nov99/11-18- 99-1.html

American Public Health Association. (2009). Support for community health workers to increase health access and to reduce health inequities. Retrieved from http://www.apha.org/advocacy/policy/policysearch/default .htm?id=1393

REFERENCES

M11_MARY9591_06_SE_C11.indd 281 06/09/14 6:42 PM

282 Unit 3 Population health nursing Strategies

Arnold, C. M., Aragon, D., Shephard, J., & Van Sell, S. L. (2011). The coming of the blessing: A successful cross-cultural collaborative effort for American Indian/Alaska Native families. Family & Community Health, 34, 196–201. doi:10.1097/FCH.0b013e3182196279

Assaf, R. R. (2014). Overview of local, state, and national government legis- lation restricting transfats. Clinical Therapeutics, 36, 3298-332. doi: http:// dx.doi.org/10.1016/j.clinthera.2014.01.005

Awofeso, N. (2004). What’s new about the new public health? American Journal of Public Health, 94, 705–709.

Ayala, G. X., & The San Diego Prevention Research Center Team. (2011). Effects of a promotor-based intervention to promote physical activ- ity: Familias Sanas y Activas. American Journal of Public Health, 101, 2261–2268. doi:10.2105/AJPH.2011.300273

Balcazar, H., Rosenthal, L. E., Brownstein, N. J., Rush, C. H., Matos, S., & Hernandez, L. (2011). Community health workers can be a public health force for change in the United States: Three actions for a new paradigm. American Journal of Public Health, 101, 2199–2203. doi:10.2105/AJPH.2011.300386

Banzhaf, et al. v. Federal Communications Commission, et al. (n.d.). Retrieved from http://www.tobaccocontrollaws.org/litigation/decisions /us-19681121-banzhaf,-et-al.-v.-federal-com

Bastable, S. B. (2013). Nurse as educator: Principles of teaching and learning for nursing practice (4th ed.). Sudbury, MA: Jones and Bartlett.

Black, A. R., & Peacock, N. (2011). Pleasing the masses: Messages for daily life management in African American women’s popular media sources. American Journal of Public Health, 101, 144–150. doi:10.2105/ AJPH.2009.167817

Blitstein, J. L., Evans, W. D., & Driscoll, D. L. (2008). What is a public health brand. In W. D. Evans & G. Hastings (Eds.), Public health branding: Applying marketing for social change (pp. 25–41). New York: Oxford University Press.

Bloom, B. S., Englehart, M. D., Furst, E. J., Hill, W. F., & Krathwohl, D. R. (1956). Taxonomy of educational objectives: The classification of educational goals: Handbook 1: The cognitive domain. New York: David McKay.

Carter, S. M., Rychetnik, L., Lloyd, B., Kerridge, I. H., Baur, L., Bauman, A., & Hooker, C. (2011). Evidence, ethics, and values: A framework for health promotion. American Journal of Public Health, 101, 465–272. doi:10/2105/ AJPH.2010.195545

Centers for Disease Control and Prevention. (2010). CDCynergy lite: Social marketing made simple: A guide for creating effective social marketing plans. Retrieved from http://www.cdc.gov/healthcommunication/pdf/ cdcynergylite.pdf

Cohen, J. E., Planinac, L., Lavack, A., Robinson, D., O’Connor, S., & DiNardo, J. (2011). Changes in retail tobacco promotions in a cohort of stores before, during, and after a tobacco product display ban. American Journal of Public Health, 101, 1879–1881. doi:10.2105/AJPH.2011.300172

Colorado Department of Public Health and Environment. (2011). Health plan implementation of U. S. Preventive Services Task Force A and B recommendations—Colorado, 2010. Morbidity and Mortality Weekly Report, 60, 1348–1350.

Community Preventive Services Task Force. (2013). Annual report to Congress and to agencies related to the work of the task force, 2013. Retrieved from http://thecommunityguide.org/annualreport/2013-congress-report-full.pdf

Community Preventive Services Task Force. (2014). The Community Guide. Retrieved from http://www.thecommunityguide.org/index.html

Cory, S., Ussery-Hall, A., Griffin-Blake, S., Easton, A., Vigeant, J., Balluz, L., . . ., Greenlund, K. (2010). Prevalence of selected risk behaviors and chronic diseases and conditions—Steps Communities, United States, 2006–2007. Morbidity and Mortality Weekly Report, 59(SS-8), 1–37.

Crilly, J. F., Keefe, R. H., & Volpe, F. (2011). Use of electronic technologies to promote community and personal health for individuals unconnected to

health care systems. American Journal of Public Health, 101, 1163–1167. doi:10.2105/AJPH.2010.300003

Currie, D. (2011, April). China tells filmmakers to limit smoking. The Nation’s Health, 21.

Daniels, J., Glickstein, B., & Mason, D. J. (2012). Using the power of media to influence health policy and politics. In D. J. Mason, J. K. Leavitt, & M. W. Chaffee (Eds.), Policy & politics in nursing and health care (6th ed., pp. 88–104). St. Louis, MO: Elsevier Saunders.

de Salazar, L., & Anderson, L. M. (2008). Health promotion in the Americas: Divergent and common ground. In L. Potvin, & D. V. McQueen (Eds.), Health promotion evaluation practices in the Americas: Values and research (pp. 13–23). New York: Springer.

Drew, E. M., & Schoenberg, N. A. (2011). Deconstructing fatalism: Ethnographic perspectives on women’s decision making about cancer prevention and treatment. Medical Anthropology Quarterly, 24, 164–182. doi:10.1111/j.1548-1387.2010.01136.x

Eadie, C. (2014). Health literacy: A conceptual review. Academy of Medical Surgical Nurses, 23(1), 1, 10–13.

Espinosa de los Monteros, K., & Gallo, L. C. (2011). The relevance of fatalism in the study of Latina’s cancer screening behavior: A systematic review of the literature. International Journal of Behavioral Medicine, 18, 310–318. doi:10.1007/s12529-010-9119-4

Evans, W. D., & Hastings, G. (2008a). Preface. In W. D. Evans & G. Hastings (Eds.), Public health branding: Applying marketing for social change (pp. vii– xii). New York: Oxford University Press.

Evans, W. D., & Hastings, G. (2008b). Public health branding: Recognition, promise, and delivery of healthy lifestyles. In W. D. Evans & G. Hastings (Eds.), Public health branding: Applying marketing for social change (pp. 1–24). New York: Oxford University Press.

Findley, S. E., Sanchez, M., Mejia, M., Ferreira, R., Pena, O., Matos, S., . . ., Irigoyen, M. (2009). REACH 2010: New York City. Effective strategies for integrating immunization promotion into commu- nity programs. Health Promotion Practice, 10(Suppl. 2), 128S–137S. doi:10.1177/1524839909331544

Fishbein, M. (2009). An integrative model for behavioral prediction and its ap- plication to health promotion. In R. J. DiClemente, R. A. Crosby, & M. C. Kegler (Eds.), Emerging theories in health promotion practice and research: Strategies for improving public health (2nd ed., pp. 215–234). San Francisco: Jossey-Bass.

Fisher, J. D., Fisher, W. A., & Shuper, P. A. (2009). The information- motivation- behavioral skills model. In R. J. DiClemente, R. A. Crosby, & M. C. Kegler (Eds.), Emerging theories in health promotion practice and research: Strategies for improving public health (2nd ed., pp. 21–63). San Francisco: Jossey-Bass.

Fisher, W. A., Kohut, T., Salisbury, C. M. A., & Salvadori, M. I. (2013). Understanding human papillomavirus vaccination intentions: Comparative utility of the theory of reasoned action and the theory of planned behav- ior in vaccine target age women and men. Journal of Sexual Medicine, 10, 2455–2464. doi: 10.1111/jsm.12211

Flores, K., R., Aguirre, A. N., Viladrich, A., Cespedes, A., De La Cruz, A. A., & Abraido-Lanza, A. F. (2009). Fatalism or destiny? A qualitative study and interpretative framework on Dominican women’s breast cancer be- liefs. Journal of Immigrant and Minority Health, 11, 291–301. doi:10.1007/ s10903-008-9118-6

Health on the Net Foundation. (2013a). The commitment to reliable health and medical information on the internet. Retrieved from http://www.hon.ch /HONcode/Patients/Visitor/visitor.html

Health on the Net Foundation. (2013b). The HON Code of Conduct for medical and health Web sites (HONcode). Retrieved from http://www.hon.ch /HONcode/Patients/Conduct.html

M11_MARY9591_06_SE_C11.indd 282 06/09/14 6:42 PM

chaPter 11 health Promotion and education Strategies 283

Health Resources and Services Administration. (2011). Community health workers evidence-based models toolbox. Retrieved from http://www.hrsa .gov/ruralhealth/pdf/chwtoolkit.pdf

Henchman, J., & Drenkard, S. (2014). Cigarette taxes and cigarette smuggling by state. Retrieved from http://taxfoundation.org/article/cigarette-taxes- and-cigarette-smuggling-state

Hinojosa, M. S., Nelson, D., Hinojosa, R., Delgado, A., Witzack, B., Gonzales, M., . . ., Farias, R. (2011). Using fotonovelas to promote healthy eating in a Latino community. American Journal of Public Health, 101, 258–259. doi:10.2105/AJPH.2010.198994

Hopwood, T., & Merritt, R. (2011). The big pocket guide to using social marketing for behavior change. Retrieved from http://www.thensmc.com/sites/default /files/Big_pocket_guide_2011.pdf

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.

Javanparast, S., Baum, F., Labonte, R., & Sanders, D. (2011). Community health workers’ perspectives on their contribution to rural health and well-being in Iran. American Journal of Public Health, 101, 2287–2292. doi:10.2105/ AJPH.2011.300355

Jiang, N., & Ling, P. M. (2011). Reinforcement of smoking and drinking: Tobacco marketing strategies linked with alcohol in the United States. American Journal of Public Health, 101, 1942–1954. doi:10.2105/AJPH.2011.300157

Keeley, B., Wright, L., & Condit, C. M. (2009). Functions of health fatal- ism: Fatalistic talk as face saving, uncertainty, management, stress relief, and sense making. Sociology of Health & Illness, 31, 734–747. doi:10.1111/j.1467-9566.2009.01164.x

Krathwohl, D. R., Bloom, B. S., & Masia, B. B. (1964). Taxonomy of educational objectives: The classification of educational goals: Handbook 1: The affective domain. New York: David McKay.

Lewis, M. A., & McCormack, L. A. (2008). The intersection between tailored health communication and branding for health promotion. In W. D. Evans & G. Hastings (Eds.), Public health branding: Applying marketing for social change (pp. 251–269). New York: Oxford University Press.

Li, C., Balluz, L. S., Okoro, C. A., Strine, T. W., Lin, J.-M. S., Town, M., . . ., Valluru, B. (2011). Surveillance of certain health behaviors and conditions among states and selected local areas—Behavioral Risk Factor Surveillance System, United States, 2009. Morbidity and Mortality Weekly Report, 60 (SS-9), 1–248.

Maclosek, M. V., Coffield, A. B., Flottemesch, T. J., Edwards, N. M., & Solberg, L. I. (2010). Greater use of preventive services in U. S. health care could save lives at little or no cost. Health Affairs, 9, 1656–1660. doi:10.1377/ hlthaff.2008.0701

Martin, L. R., Haskard-Zolnierek, K. B., & DiMatteo, M. R. (2010). Health behav- ior change and treatment adherence. New York, NY: Oxford University Press.

Mathar, T., & Jansen, Y. J. F. M. (2010). Introduction: Health promotion and prevention programmes in practice. In T. Mathar & Y. J. F. M. Jansen (Eds.), Health promotion and prevention programmes in practice (pp. 9–27). New Burnswick, NJ: Transaction.

Monaghan, P. F., Forst, L. S., Tovar-Aguilar, J. A., Bryant, C., A., Israel, G. D., Galindo-Gonzalez, S., . . ., McDermott, R. J. (2011). Preventing eye injuries among citrus harvesters: The community health worker model. American Journal of Public Health, 101, 2269–2274. doi:10.2105/AJPH.2011.300316

Murray, R. L., Lewis, S. A., Coleman, T., Britton, J., & McNeill, A. (2009). Un- planned attempts to quit smoking: Missed opportunities for health promo- tion? Addiction, 104, 1901–1909. doi:10.1111/j.1360-0443.2009.02647.x

National Center for Chronic Disease Prevention and Health Promotion. (2011). Smoking in top-grossing movies—United States, 2010. Morbidity and Mortality Weekly Report, 60, 909–913.

National Center for Chronic Disease Prevention and Health Promotion. (2013). State indicator report on fruits and vegetables, 2013. Retrieved from

http://www.cdc.gov/nutrition/downloads/State-Indicator-Report-Fruits- Vegetables-2013.pdf

National Center for Health Statistics. (2011). Percentage of adults aged > 18 years who engaged in leisure-time strengthening activities at least twice a week, by race/ethnicity and sex—National Health Interview Survey, United States, 2009. Morbidity and Mortality Weekly Report, 60, 1429.

National Center for Injury Prevention and Control. (2011). Vital signs: Nonfatal, motor vehicle-occupant injuries (2009) and seat belt use (2008) among adults—United States. Morbidity and Mortality Weekly Report, 59, 1681–1686.

National Highway Traffic Safety Administration. (2014). Seat belt use in 2013 – Overall results. Retrieved from http://www-nrd.nhtsa.dot.gov/Pubs/811875.pdf

National Network of Libraries of Medicine. (2013). Health Literacy. Retrieved from http://nnlm.gov/outreach/consumer/hlthlit.html

National Patient Safety Foundation. (2011). Health literacy: Statistics at-a- glance. Retrieved from http://www.npsf.org/wp-content/uploads/2011/12/ AskMe3_Stats_English.pdf

The NMSC. (2010). What is social marketing? Retrieved from http://www .thensmc.com/content/what-social-marketing-1

Office of Disease Prevention and Health Promotion. (n.d.). A quick guide to health literacy. Retrieved from http://www.health.gov/communication/lit- eracy/quickguide/Quickguide.pdf

Office of Disease Prevention and Health Promotion. (2010). Health literacy online: A guide to writing and designing easy-to-use health Web sites. Washington, DC: Author.

Office of Disease Prevention and Health Promotion. (2012). Health literacy overview. Retrieved from http://health.gov/communication/literacy /Default.asp

Office on Smoking and Health. (2011). State preemption of local tobacco con- trol policies restricting smoking, advertising, and youth access—United States, 2000–2010. Morbidity and Mortality Weekly Report, 60, 1124–1127.

Office on Smoking and Health. (2012). Smoking and tobacco use: Legislation Retrieved from http://www.cdc.gov/tobacco/data_statistics/by_topic /policy/legislation/

Ormond, B. A., Spillman, B. C., Waldmann, T. A., Caswell, K. J., & Tereshchenko, B. (2011). Potential national and state medical care savings from primary disease prevention. American Journal of Public Health, 101, 157–164. doi:10.2105/AJPH.2009.182287

Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2010). Health promotion in nursing practice (6th ed.). Upper Saddle River, NJ: Prentice Hall.

Pfister-Minogue, K. A., & Salveson, C. (2010). Training and experiences of public health nurses in using behavior change counseling. Public Health Nursing, 27, 544–551. doi:10.1111/j.1525-1446.2010.00884.x

Prochaska, J. O., Redding, C. A., & Evers, K. E. (2008). The transtheoretical model and states of change. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice (4th ed., pp. 97–122). San Francisco, CA: John Wiley & Sons.

Professor John F. Banzhaf, III. (n.d.). Retrieved from http://banzhaf.net/ Pucher, J., Buehler, R., Merom, D., & Bauman, A. (2011). Walking and cycling in

the United States, 2001–2009: Evidence from the National Household Travel Surveys. American Journal of Public Health, 100(Suppl. 1), S310–S317. doi:10.2105/AJPH.2010.300067

Richard, L., Gendron, S., Beaudet, N., Boisvert, N., Sauve, M. S., & Garceau- Brodeur, M.-H. (2010). Health promotion and disease prevention among nurses working in local public health organizations in Montreal, Quebec. Public Health Nursing, 27, 450–458. doi:10.1111/j.1525-1446.2010.00878.x

Roncancio, A. M., Ward, K. K., & Berenson, A. B. (2011). Hispanic women’s health provider control expectations: The influence of fatalism and accul- turation. Journal of Health Care for the Poor and Underserved, 11, 482–490. doi:10.1353/hpu.2011.0038

M11_MARY9591_06_SE_C11.indd 283 06/09/14 6:42 PM

284 Unit 3 Population health nursing Strategies

Shelley, D., Cantrell, M. J., Moon-Howard, J., Ramjohn, D. Q., & VanDevanter, N. (2007). The $5 man: The underground economic response to a large cig- arette tax increase in New York City. American Journal of Public Health, 97, 1483–1488. doi:10.2105/AJPH,2005.079921

Smith-Howell, E. R., Rawl, S. M., Champion, V. L., Skinner, C. S., Springston, J., Krier, C., . . ., Myers, L. J. (2011). Exploring the role of cancer fatalism as a barrier to colorectal cancer screening. Western Journal of Nursing Research, 33, 140–141. doi:10.1170/0193945910378810

Social Marketing Institute. (n.d.). Social marketing. Retrieved from http://www .social-marketing.org/sm.html

Southey, G. (2011). The theories of reasoned action and planned behavior ap- plied to business decisions: A selective annotated bibliography. Journal of New Business Ideas and Trends, 9(1), 43–50. Retrieved from http://www .apha.org/advocacy/policy/policysearch/default.htm?id=1460

Stokowski, L. A. (2011). Social media and nurses: Promising or perilous? http:// www.medscape.com/viewarticle/753317?src=mp&spon=24.

Tones, K., & Green, J. (2010). Health promotion: Planning and strategies (2nd ed.). Thousand Oaks, CA: Sage.

U.S. Census Bureau. (2011). Language spoken at home by ability to speak English for the population 5 years and over. Retrieved from http:// factfinder2.census.gov/faces/tableservices/jsf/pages/productview .xhtml?pid=ACS_10_1YR_B16001&prodType=table

U.S. Department of Health and Human Services. (2003). The power of preven- tion. Retrieved from http://www.Healthierus.gov/steps

Vallone, D. M., Duke, J. C., Cullen, J., McCausland, K. L., & Allen, J. A. (2011). Evaluation of EX: A national mass media smoking cessation cam- paign. American Journal of Public Health, 101, 302–309. doi:10.2105/ AJPH.2009.190454

Verstraeten, R., Van Royen, K., Ochoa-Avilés, A., Penafiel, D., Holdsworth, M., Donoso, S., . . . Kolsteren, P. (2014). A conceptual framework for healthy eating behavior in Ecuadorian adolescents: A qualitative study. Plos One, 9(1), e87183. doi: 10.1371/journal.pone.0087183

Viswanathan, M., Kraschnewski, J., Nishikawa, B., Morgan, L. C., Thieda, P., Honeycutt, A., . . ., Jonas, D. (2009). Outcomes of community health worker interventions. http://www.ahrq.gov/downloads/pub/evidence/pdf/com- healthwork/comhwork.pdf.

Weinrich, N. K. (n.d.). What is social marketing? Retrieved from http://www .social-marketing .com/Whatis.html.

Weinstein, N. D., Sandman, P. M., & Blalock, S. J. (2008). The precaution adop- tion process model. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice (4th ed., pp. 123–147). San Francisco, CA: John Wiley & Sons.

Wingood, G. M., DiClemente, R. J., Villamizar, K., Er, D. L., DeVarona, M., Taveras, J., . . ., Jean, R. (2011). Efficacy of a health educator-delivered HIV prevention intervention for Latina women: A randomized controlled trial. American Journal of Public Health, 101, 2245–2252. doi:10.2105/ AJPH.2011.300340

World Health Organization. (1986). Ottawa charter for health promotion. Geneva, Switzerland: Author.

World Health Organization. (2005). Bangkok charter for health promotion in a globalized world. Geneva, Switzerland: Author.

World Health Organization. (2014). Health education. Retrieved from http:// www.who.int/topics/health_education/en/

Xu, F., Town, M., Balluz, L. S. Bartoli, W. P., Murphy, W., Chowdury, P. P., . . ., Crawford, C.A. (2013). Surveillance for certain health behaviors among states and selected local areas—United States, 2010. Morbidity and Mortal- ity Weekly Report, 62(SS-1), 1-247.

Youth+Tech+Health. (2014). SEXINFO. Retrieved from http://yth.org/projects /sexinfo/