Week 2 discussion

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Week 2: Omaha System Case Study & Home Visiting

Go to Omaha System Case Studies: https://www.omahasystem.org/casestudies
The case studies are listed at the bottom of the page (Emma, Janice, Francis, Bill, John, Julie, Tamika, or Joe). Choose one of the case studies and use your textbooks and other resources to answer the following questions:
1. What key criteria will the PHN need to consider for a successful first visit?
2. How will the PHN establish and maintain professional boundaries?
3. What is an ethical challenge that the PHN may encounter with the client?
4. How does the scope of PHN practice guide the responsibilities of the public health nurse in the chosen case study?
5. Identify key communication skills to assure respectful interaction with the client.
6. Describe the components of the nursing process in the planned home visit?
7. Identify components of a Family Assessment that could be used to assess this individual/family (refer to Family Assessment tools used in Nurs 362).
8. Identify priority problems for this individual/family.
9. Identify a plan and nursing interventions for this individual/family. Expand on what was written in the case study.
10. Identify a plan to evaluate the problem outcome.

Public/Community Health
and Nursing Practice

CARING FOR POPULATIONS

SECOND EDITION

7711_FM_i-xviii 21/08/19 11:08 AM Page i

Public/Community Health
and Nursing Practice

CARING FOR POPULATIONS

SECOND EDITION

Christine L. Savage, PhD, RN, FAAN
Professor Emerita

Johns Hopkins University School of Nursing
Baltimore, Maryland

7711_FM_i-xviii 21/08/19 11:08 AM Page iii

F. A. Davis Company
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Library of Congress Cataloging-in-Publication Data

Names: Savage, Christine L., author.
Title: Public/community health and nursing practice : caring for populations

/ Christine L. Savage.
Other titles: Public health science and nursing practice
Description: 2nd edition. | Philadelphia : F.A. Davis Company, [2020] |

Preceded by: Public health science and nursing practice / Christine L.
Savage, Joan E. Kub, Sara L. Groves, 2016. | Includes bibliographical
references and index.

Identifiers: LCCN 2019007149 (print) | LCCN 2019008721 (ebook) | ISBN
9780803699878 (ebook) | ISBN 9780803677111 (pbk.)

Subjects: | MESH: Public Health Nursing | Community Health Nursing | Health
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7711_FM_i-xviii 21/08/19 11:08 AM Page iv

To my husband, Joe, for all his love and support.

7711_FM_i-xviii 21/08/19 11:08 AM Page v

Preface

The World Health Organization (WHO) partnered with
the International Council of Nursing and began the
Nursing Now campaign that “… aims to improve health
by raising the profile and status of nursing worldwide”
(WHO, 2018). They recognized that nurses provide care
essential to the optimizing of health for individuals, fam-
ilies and communities. Health occurs from the cellular
to the global level; thus nurses must have knowledge re-
lated to health across this continuum. Nursing education
often begins with understanding health at the cellular
level through courses related to pathophysiology and
physical assessment. Building on this knowledge, this
text covers health, disease, and injury within the context
of the world we live in. No matter what settings nurses
work in, they apply public health science on a daily basis
to prevent disease, reduce mortality and morbidity in
those who are ill, and contribute to the health of the com-
munities we serve. Our goal with this book is to lead you
on the journey of discovering how the public health sci-
ences are an integral part of nursing practice and how
nurses implement effective public health interventions.

About This Book
This book presents public health in a way that captures
the adventure of tackling health from a community- and
population-based perspective. Public health helps us to
answer the question, “Why is this happening?” and to im-
plement interventions that improve the health of popu-
lations. Public health issues are usually messy real-world
problems that do not always have obvious solutions. You
will learn through the examples provided how to gather
the needed information to understand important health
issues, especially those included in Healthy People. You
will have an opportunity to explore population-level,
evidence-based interventions and learn how to evaluate
the effectiveness of those interventions. We aim to pro-
vide you with the knowledge to achieve the competencies
in public health you increasingly need as a professional
nurse across multiple settings. You will be provided with
numerous examples of how public health nurses integrate
nursing and public health, with a focus on promoting the
health of populations.

The application of public health knowledge in the
provision of care and the prevention of disease is not
new to the nursing profession. Florence Nightingale is
often viewed as the first nurse epidemiologist because of
her work in the Crimean War. She applied public health
science to nursing practice in a way that saved lives and
improved outcomes, both in the context of war and back
in England, with the development of professional nurs-
ing in hospital and home settings. As nurses practicing
in the 21st century, we follow in her footsteps. Consider
nurses working in primary care with mothers and chil-
dren or those working in low-income countries facing
epidemics of tuberculosis and HIV/AIDS. How does
knowledge of public health science enhance our ability
to address these complex health issues? Before we can
improve health outcomes, we must understand the nat-
ural history of disease, the social context in which these
health issues arise, and the resources critical to address-
ing all of the barriers to care. Knowledge of public health
and how it applies to nursing practice has taken on in-
creased importance as we move from a fee-for-service
model of care to a health-care system that rewards pre-
vention of disease.

Nurses must know how to apply the basics of the pub-
lic health sciences such as epidemiology, social and be-
havioral sciences, and environmental health. They must
also meet the Quad Council generalist core competencies
such as community assessment, health planning, and
health policy. To help you to do that, we have employed
a problem-based learning approach to the presentation
of the material in this book so that you can apply the
principles of public health to real-life nursing settings.

Throughout the book, case studies demonstrate how
the application of the public health sciences and public
health practice to nursing practice is essential to the pro-
motion of health and the prevention of disease. At times,
the focus will be on solving health-related mysteries and
how that leads to the implementation of interventions to
address the health problems at the population level. At
other times, the focus will be on the application of the
public health sciences to the development and imple-
mentation of evidence-based, population-level interven-
tions aimed at addressing the health issue.

vii

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Although there have been significant improvements
in health during the past 100 years, achieving our
stated health goals, whether it be Healthy People goals
and objectives or global goals, continues to be a chal-
lenge. The ability of each individual, family, and com-
munity to lead a healthy and productive life involves
an interaction among ourselves, our environment, and
the communities in which we live. Understanding
the multiple determinants of health, including social
determinants that significantly influence health dispar-
ities and health inequities, is an essential skill for
nurses. The public health sciences help us understand
the complexity of the interaction of external and inter-
nal forces that shape our health. The premise of this
book is that all nurses require adequate knowledge of
the public health sciences and how to apply it to nurs-
ing practice across all settings and populations. With
this knowledge, we can truly contribute to the building
of a healthy world.

Organization of the Text
The philosophical approach to this text is that all profes-
sional nurses incorporate population-level interventions
no matter what the setting. We include not only chapters
on the traditional public health settings such as the public
health department and school health, but also chapters
on acute and primary care settings. The book uses a con-
structivist learning approach by which the learner con-
structs her or his own knowledge. Thus, the content is
delivered by applying the information within the context
of the real world.

This text uses a problem-based learning approach so
that the student can apply the content to nursing prac-
tice. It is organized into three units. Unit I, Basis for
Public Health Nursing Knowledge and Skills, covers the
essential knowledge based in the public health sciences
and core public health nursing competencies needed to
solve health problems and implement evidenced-based
interventions at the population level. This unit provides
the basic public health knowledge needed by all gener-
alist nurses. The content covered in these chapters is
applied across the next two units of the book. Unit II,
Community Health Across Populations: Public Health
Issues, covers health issues that span populations and
settings including communicable and noncommunica-
ble disease, health disparity, behavioral health, and
global health. Unit III, Public Health Planning, covers
the settings in which nurses practice, public health
policy, and disaster management.

Understanding health within the context of commu-
nity includes understanding the role of culture. To help
underscore the importance of culture, it has been inte-
grated across each of the chapters rather than have a
stand-alone chapter dedicated to culture. In each chapter
there is a callout box related to the role of culture specific
to the subject of that chapter.

Global health is the other concept now integrated
across all of the chapters. In earlier public health textbooks,
the term most often used was ‘international health’. As it
became clearer that the health of one nation does not
occur in a vacuum, but rather contributes to the health of
the globe, global health became the accepted term. To truly
adhere to the concept that health is global across all set-
tings, we have included a cellular to global box in every
chapter relevant to the content in that chapter. As nurses
dedicated to optimizing health for all, visualizing health
within a global context will help us join with the WHO in
promoting nursing as a true force in health.

Key Features
t CASE STUDIES
Throughout the book, the student will find case studies
embedded in the chapters that provide essential content
within the context of actual nursing practice. This ap-
proach begins with the issue and walks the reader through
the process of deciding how best to address the problem
presented. In some of the cases presented, the object is to
solve the mystery (Solving the Mystery), such as the case
in Chapter 8 that walks through how to solve the mystery
of why people are presenting at the emergency depart-
ment with severe gastrointestinal symptoms. Other cases
(Applying Public Health Science) describe how nurses
apply the public health sciences, such as epidemiology, to
help develop and implement evidence-based interven-
tions at the population level. There is a standard case
study at the end of selected chapters. For instructors, there
is online access on the DavisPlus website for the book to
a problem-based learning exercise that can be used to fur-
ther apply the content presented in the chapter.

n HEALTHY PEOPLE
Healthy People is referenced throughout, including
Healthy People 2020 and information on Healthy People
2030 available prior to publication. Boxes are included
that present the Healthy People 2020 objectives and the
midcourse reviews on progress towards meeting those
objectives.

viii Preface

7711_FM_i-xviii 21/08/19 11:08 AM Page viii

n EVIDENCE-BASED PRACTICE
BOXES

Evidence-Based Practice (EBP) boxes illustrate how re-
search and its resulting evidence can support and inform
public health nursing practice. Cutting-edge EBP is a
strong underpinning of the book as a whole.

LEARNING OUTCOMES AND KEY TERMS

Each chapter begins with Learning Outcomes and a list
of Key Terms that appear in boldface and color at first
mention in a chapter.

Teaching/Learning Package
Instructor Resources
Instructor Resources on DavisPlus include the following:

• NCLEX-Style Test Bank
• PowerPoint Presentations
• Instructor’s Guide with PBL exercises

• Problem-Based Learning PowerPoint Presentation
• Case Study Instructor’s Guides for end-of-chapter

case studies
• QSEN Crosswalk
• Quad Council Competencies
• Simulation Experiences

Student Resources
Student Resources on DavisPlus include the following:

• Student Quiz Bank
• Student Guide to Problem-Based Learning
• List of Web Resources
• QSEN Crosswalk
• Quad Council Competencies

We hope you will enjoy this book and, most of all,
we hope as nurses you will always care for the health
of populations no matter the setting, thus increasing
the contribution of nursing to the goal of optimal
health for all.

Preface ix

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Contributors

Laurie Abbott, PhD, RN, PHNA-BC
Assistant Professor

Florida State University College of Nursing
Tallahassee, Florida

Chapter 13

Kathleen Ballman, DNP, APRN, ACNP-BC, CEN
Associate Professor of Clinical Nursing, Coordinator,
Coordinator of Adult-Gerontology Acute Care
Programs

University of Cincinnati, College of Nursing
Cincinnati, Ohio

Chapter 14

Derryl E. Block, PhD, MPH, MSN, RN
Dean, College of Health and Human Sciences

Northern Illinois University
DeKalb, Illinois

Chapter 21

Susan Bulecza, DNP, RN, PHCNS-BC
State Public Health Nursing Director

Florida Department of Health
Tallahassee, Florida

Chapter 13

Deborah Busch, DNP, RN, CPNP-PC, IBCLC
Assistant Professor

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapter 17

Amanda Choflet, DNP, RN, OCN
Director of Nursing, Johns Hopkins Medicine
Department of Radiation Oncology & Molecular
Radiation Sciences

Baltimore, Maryland
Chapter 11

Christine Colella, DNP, APRN-CNP, FAANP
Professor, Executive Director of Graduate Programs

University of Cincinnati, College of Nursing
Cincinnati, Ohio

Chapter 15

Joanne Flagg, DNP, CRNP, IBCLC, FAAN
Assistant Professor, Director MSN Programs

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapter 17

Gordon Gillespie, PhD, DNP, RN, PHCNS-BC, CEN,
CPEN, FAEN, FAAN
Professor, Associate Dean for Research, Deputy
Director Occupational Health Nursing Program

University of Cincinnati
Cincinnati, Ohio

Chapters 5, 20, & 22

Bryan R. Hansen, PhD, RN, APRN-CNS, ACNS-BC
Assistant Professor

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapter 10

Barbara B. Little, DNP, MPH, RN, PHNA-BC, CNE
Senior Teaching Faculty

Florida State University
Tallahassee, Florida

Chapter 13

Minhui Liu, RN, PhD
Post-doctoral

Johns Hopkins University School of Nursing
Baltimore, Maryland

Chapter 19

Donna Mazyck, MS, RN, NCSN, CAE
Executive Director

National Association of School Nurse
Silver Spring, Maryland

Chapter 18

Paula V. Nersesian, RN, MPH, PhD
Assistant Professor

Johns Hopkins University School of Nursing
Baltimore, Maryland

Chapter 16

xi

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Michael Sanchez, DNP, ARNP, NP-C, FNP-BC,
AAHIVS
Assistant Professor

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapters 8 & 11

Phyllis Sharps, RN, PhD, FAAN
Professor
Associate Dean for Community Programs
and Initiatives

Johns Hopkins University School of Nursing
Baltimore, Maryland

Chapter 17

Christine Vandenhouten, PhD, RN, APHN-BC
Associate Professor (Nursing & MSHWM Programs
Chair of Nursing and Health Studies, Director
of BSN-LINC

University of Wisconsin, Green Bay Professional
Program in Nursing
Green Bay, Wisconsin

Chapter 21

Erin Rachel Whitehouse, RN, MPH, PhD
Epidemic Intelligence Service Officer at Centers
for Disease Control and Prevention

Atlanta, Georgia
Chapter 3

Erin M. Wright, DNP, CNM, APHN-BC
Assistant Professor

Johns Hopkins School of Nursing
Baltimore, Maryland

Chapter 17

Contributors to Previous Edition

Sheila Fitzgerald, PhD

Sara Groves, RN, MPH, MSN, PhD

Joan Kub, PhD, MA, PHCNS-BC, FAAN

William A. Mase, Dr.PH, MPH, MA

Mary R. Nicholson, RN, BSN, MSN CIC

xii Contributors

7711_FM_i-xviii 21/08/19 11:08 AM Page xii

Reviewers

Kathleen Keough Adee, MSN, DNP, RN
Associate Professor

Salem State University
Salem, Massachusetts

Lynn P. Blanchette, RN, PhD, PHNA-BC
Associate Dean, Assistant Professor

Rhode Island College School of Nursing
Providence, Rhode Island

Dia Campbell-Detrixhe, PhD, RN, FNGNA, CNE,
FCN
Associate Professor of Nursing

Oklahoma City University Kramer School of Nursing
Oklahoma City, Oklahoma

Kathie DeMuth, MSN, RN
Assistant Professor

Bellin College
Green Bay, Wisconsin

Bonnie Jerome-D’Emilia, RN, MPH, PhD
Associate Professor

Rutgers University School of Nursing-Camden
Camden, New Jersey

Vicky P. Kent, PhD, RN, CNE
Clinical Associate Professor

Towson University
Towson, Maryland

Kimberly Lacey, DNSc, RN, MSN, CNE
Assistant Professor

Southern Connecticut State University
New Haven, Connecticut

Charlene Niemi, PhD, RN, PHN, CNE
Assistant Professor

California State University Channel Islands
Camarillo, California

Phoebe Ann Pollitt, PhD, RN, MA
Associate Professor of Nursing

Appalachian State University
Boone, North Carolina

Lisa Quinn, PhD, CRNP, MSN
Associate Professor of Nursing

Gannon University
Erie, Pennsylvania

Delbert Martin Raymond III, BSN, MS, PhD
Professor

Eastern Michigan University
Ypsilanti, Michigan

Meredith Scannell, PhD, MSN, MPH, CNM,
SANE, CEN
Nursing Faculty

Institute of Health Professions
Charlestown, Massachusetts

Elizabeth Stallings, RN, BSN, MA, DmH
Assistant Professor

Felician University
Lodi, New Jersey

xiii

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Acknowledgments

This book exists because of the wonderful students I have had over the years and their
dedication to improving the health of individuals, families, and communities. Their
thirst for knowledge fed my own. I am grateful to my colleagues who I have had the
privilege to work with over my nursing career, with a very special thanks to those who
contributed to the writing of this book. I would also like to thank Jeannine Carrado,
Elizabeth Hart, and Terri Allen at F. A. Davis for their support and guidance throughout
the writing of this book. Improving the health of communities thrives on respectful and
thoughtful collaboration between many different people, and so does the writing of a
text book.

xv

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Table of Contents

Unit I n Basis for Public Health Nursing Knowledge and Skills 1

Chapter 1 Public Health and Nursing Practice 1
Chapter 2 Optimizing Population Health 23
Chapter 3 Epidemiology and Nursing Practice 55
Chapter 4 Introduction to Community Assessment 77
Chapter 5 Health Program Planning 107
Chapter 6 Environmental Health 128

Unit II n Community Health Across Populations: Public Health Issues 157

Chapter 7 Health Disparities and Vulnerable Populations 157
Chapter 8 Communicable Diseases 191
Chapter 9 Noncommunicable Diseases 218
Chapter 10 Mental Health 239
Chapter 11 Substance Use and the Health of Communities 256
Chapter 12 Injury and Violence 283

Unit III n Public Health Planning 313

Chapter 13 Health Planning for Local Public Health Departments 313
Chapter 14 Health Planning for Acute Care Settings 343
Chapter 15 Health Planning for Primary Care Settings 372
Chapter 16 Health Planning with Rural and Urban Communities 398
Chapter 17 Health Planning for Maternal-Infant and Child Health Settings 420
Chapter 18 Health Planning for School Settings 447
Chapter 19 Health Planning for Older Adults 479
Chapter 20 Health Planning for Occupational and Environmental Health 509
Chapter 21 Health Planning, Public Health Policy, and Finance 537
Chapter 22 Health Planning for Emergency Preparedness and Disaster Management 569

Index 607

xvii

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1

Basis for Public Health Nursing
Knowledge and Skills

Chapter 1

Public Health and Nursing Practice
Christine Savage, Joan Kub, and Sara Groves

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Identify how public health plays a central role in the
practice of nursing across settings and specialties.

2. Describe public health in terms of current frameworks,
community partnerships, and the concept of population
health.

3. Investigate determinants of health within the context of
culture.

4. Explore the connection between environment, resource
availability, and health.

5. Identify the key roles and responsibilities of public health
nurses (PHNs).

6. Identify the formal organization of public health services
from a global to local level.

Aggregate
Assessment
Assurance
Community
Core functions
Cultural competency
Cultural humility
Cultural lenses
Culture

Determinants of
health

Diversity
Ethnicity
Global health
Globalization
Health
High-income countries

(HICs)

Life expectancy
Low-income countries

(LICs)
Lower middle-income

countries (LMICs)
Policy development
Population health
Population-focused

care

Public health
Public health nursing
Public health science
Race
Upper middle-income

countries (UMICs)

n Introduction
Every day the media presents us with riveting stories: “The
flu season—the worst in a decade,” “Flint’s water supply
contaminated with high levels of lead,” “School shooting
leaves 17 dead,” “Hurricane Maria leaves 80% of Puerto
Rico without power and water,” “Zika virus results in con-
genital brain damage,” “The homicide rate in Chicago rises,”
“More than 80 dead from the Camp Fire in California.” All
of these stories reflect the connections among the health of
individuals and families, the communities they live in, the

quality of the public health infrastructure, and population-
level events such as disasters (natural and manmade), com-
municable diseases (CDs), and violence. As nurses, we
provide care directly to individuals and families within
the context of the communities we serve. That context
encompasses diverse and unifying cultures, demographics,
geography, infrastructure, resources, and the vulnerability
of certain members of the community. That is why under-
standing health from a cellular to global level requires
a sound grounding in public health science, a central
component of nursing science and practice.

U N I T I

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As nurses, we apply public health science daily. Ob-
vious examples include infection control nurses, school
nurses, and nurses in the public health department.
Nurses working in an acute care setting also apply public
health science when using protective equipment and
caring for a patient in isolation to prevent transmission
of a CD. Public health science applies to every setting
where nurses work; understanding public health and the
science behind it is a core competency of professional

nursing. It is expected that upon graduation an entry-
level nurse will be able to integrate knowledge from pub-
lic health into their nursing practice. Nurses must apply
the nursing process and incorporate knowledge of the
ecological and social determinants of health as they care
for individuals and families, and by extension commu-
nities and populations. Finally, they are expected to be
able to evaluate health within a global context and
demonstrate cultural humility in the care of individuals,
families, communities, and populations.1 According to
the American Nurses Association’s (ANA) Scope and
Standards, the importance of public health is clear.2
Other competencies grounded in public health include
infection control (Chapter 8), emergency preparedness
and disaster management (Chapter 22), environmental
health (Chapter 6), and a basic understanding of epi-
demiology (Chapter 3).

Public Health Science and Practice
What exactly is public health science? Public health sci-
ence is the scientific foundation of public health practice
and brings together other sciences including environ-
mental science, epidemiology, biostatistics, biomedical
sciences, and the social and behavioral sciences.3,4

Thus, public health science, as a combination of sev-
eral other sciences, allows us to tackle health problems
using a wide range of knowledge. We apply the results of
public health science to deal with health problems on a
regular basis. For example, the evidence that underlies
the reliability and validity of screening and diagnostic
test results comes from the analysis of population-level
data using the science of epidemiology. Public health sci-
ence also provides the tools needed to try and solve a
problem in the community or in a geographical area.

When confronted with a health problem, health care
providers begin with the question “What can we do
about it?” This requires an examination of the underlying
risks and protective factors related to the health problem,
both individual and population based. Based on this type
of examination, lead experts in nursing used a population
health framework to develop a conceptual model of nurs-
ing that reflects the shift from a concentration on indi-
vidual health alone to an understanding that health
occurs within the context of a population and factors that
support or undermine the health of the population as a
whole.5 Understanding the factors that contribute to
health, both negative and positive, from both a popula-
tion and an individual/family perspective allows us to de-
velop nursing interventions that incorporate the full
continuum of health from individuals to populations,

2 U N I T I n Basis for Public Health Nursing Knowledge and Skills

n CELLULAR TO GLOBAL
Health Across the Continuum

The health of individuals occurs across a continuum
from the cellular level to the global level. When we
care for individuals and their families, understanding
the context of their health is vital to the promotion of
optimum health. For example, a person with type 2 dia-
betes who is seeking care may or may not have access
to the needed resources depending on what exists in
their community as well as their own financial status.
Providing care to that person requires use of pre-
scribed medication, encouragement to exercise, and
encouragement to maintain a healthy diet. As you
learned in pathophysiology, type 2 diabetes occurs at
the cellular-level, but external factors may increase the
risk for being diagnosed with the disease. In addition,
the community in which a person lives, both locally
and at the state level, has an impact on their ability to
pay for medications, to have access to safe areas for
exercise, and to obtain affordable fresh food.

Likewise, individual health at the cellular level de-
pends on the health of the Earth from a global level.
Optimal health requires access to basic resources
such as potable water, a secure food supply, sanitation,
and adequate shelter. Events at the global level such
as climate change can result in the inability to obtain
these needed resources. For example, following the
2018 Camp Fire in California, which was associated
with climate change, many people lost their homes.
Outbreaks of communicable diseases (see Chapter 8)
in one part of the world can spread and affect many
other parts of the world, such as the Zika virus
outbreak in the summer of 2016. Natural disasters
often have far-reaching effects such as the tsunami
of 2004 that resulted in deaths and injury across
multiple countries including Indonesia, India, Malaysia,
Myanmar, Thailand, Sri Lanka, and the Maldives. Thus,
all disease and injury occur within the context of the
health of the community and the globe.

7711_Ch01_001-022 23/08/19 10:19 AM Page 2

and, it is hoped, to contribute with each intervention to
the goal of the World Health Organization (WHO), the
public health arm of the United Nations (UN): “… to
build a better, healthier future for people all over the
world.”6

According to Issel,7 individuals do not achieve health
through uninformed, individualistic actions. Instead, in-
dividual health occurs within the surrounding context of
the population and the environment. Therefore, all
nurses need skills and knowledge related to their pa-
tients’ informed actions within the context of the health
of their community. During the last century and into the
21st century, public health science has been the backbone
of the nursing interventions we provide to individuals,
families, and communities. Standard care, such as flu
vaccinations, lead poisoning screening, and prevention
programs, comes from work done using the principles
of public health science. As nurses, we must be suffi-
ciently competent to understand the basics of this science
and apply it daily in our care. After all, it is our heritage.
The modern founder of our profession, Florence
Nightingale, was an early pioneer in epidemiology and
public health science.

Although public health has contributed significantly
to the health of the nation over the past century, it is
often difficult to define. In 1920, a respected public health
figure, C.E.A. Winslow, defined public health as:

… the science and art of preventing disease, prolonging life
and promoting health and efficiency through organized
community effort for the sanitation of the environment,
the control of communicable infections, the education of
the individual in personal hygiene, the organization of
medical and nursing services for the early diagnosis and
preventive treatment of disease, and for the development
of the social machinery to insure everyone a standard of
living adequate for the maintenance of health, so organiz-
ing these benefits as to enable every citizen to realize his
birth right of health and longevity.3

Winslow’s definition reflects what public health is, the
scientific basis of public health, and what it does, and it
remains relevant to this day.4

In 1988, the Institute of Medicine (IOM), now known
as the Health and Medicine Division (HMD) of the
National Academies of Sciences, Engineering, and Med-
icine, in its report The Future of Public Health, added
clarity to the term by defining public health as what so-
ciety does collectively to assure the conditions for people
to be healthy.8 It identified three core functions that en-
compass the purpose of public health: (1) assessment,
(2) policy development, and (3) assurance. Assessment

focuses on the systematic collection, analysis, and mon-
itoring of health problems and needs. Policy develop-
ment refers to using scientific knowledge to develop
comprehensive public health policies. Assurance relates
to assuring constituents that public health agencies pro-
vide services necessary to achieve agreed-upon goals.

In 1994, the Public Health Functions Steering Com-
mittee, a group of public and private partners, added fur-
ther clarification to the definition by establishing a list of
essential services (Chapter 13). The committee developed
the list of essential services through a consensus process
with federal agencies and major national public health
agencies (see Box 1-1). 9

Although the government is likely to play a leadership
role in ensuring that essential services are provided, pub-
lic, private, and voluntary organizations are also needed
to provide a healthy environment and are a part of
the public health system. In a 2012 report by the IOM,
experts concluded that “… funding for governmental

C H A P T E R 1 n Public Health and Nursing Practice 3

The 10 essential public health services provide the
framework for the National Public Health Performance
Standards Program (NPHPSP). Because the strength
of a public health system rests on its capacity to effec-
tively deliver the 10 Essential Public Health Services,
the NPHPSP instruments for health systems assess how
well they perform the following:

1. Monitor health status to identify community health
problems.

2. Diagnose and investigate health problems and health
hazards in the community.

3. Inform, educate, and empower people about health
issues.

4. Mobilize community partnerships to identify and
solve health problems.

5. Develop policies and plans that support individual
and community health efforts.

6. Enforce laws and regulations that protect health and
ensure safety.

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

8. Assure a competent public health and personal
health-care workforce.

9. Evaluate effectiveness, accessibility, and quality of
personal and population-based health services.

10. Research for new insights and innovative solutions to
health problems.

BOX 1–1 n Ten Essential Public Health Services

Source: (9)

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public health is inadequate, unstable, and unsustain-
able.”10 Thus the promotion of population level health
requires a comprehensive public health infrastructure.
According to Healthy People 2020 (HP 2020) the three
essential infrastructure components include a capable
and qualified workforce, up-to-date data and informa-
tion systems, and public health agencies capable of
assessing and responding to public health needs (see
Box 1-2). 11

Public Health Frameworks: Challenges
and Trends
Public health in the 21st century is facing new challenges
and trends that are likely to demand different frameworks
for its practice. Over the past 2 decades, numerous events
both here in the U.S, and globally have brought this fact
to the forefront including the attacks of September 11,
2001; numerous hurricanes; mass shootings; emerging
CDs such as Ebola and the Zika virus; and massive
migrations of populations due to war. These events have
brought recognition to alarming public health concerns
related to both manmade and natural disasters. These
events result in disease, death, displacement of commu-
nities, and serious damage to essential public health
infrastructures.

To better understand the impact of both natural and
manmade disasters, it is helpful to revisit Hurricane

Katrina, which savaged the Gulf Coast of the United
States in the summer of 2005. A horrified TV audience
watched news stories detailing the collapse of the emer-
gency systems in New Orleans. This collapse left people
to suffer and die, not only from the destruction of the
hurricane, but also from a lack of water, food, sanitation,
and medical attention. The aftermath of Katrina and
the attacks of September 11, 2001, highlighted the need
to strengthen the public health infrastructure, with an
increasing emphasis on disaster preparedness and emer-
gency response. Unfortunately, responses to natural
disasters continue to challenge the United States as
exemplified by Hurricane Maria and the devastation
to Puerto Rico, and Hurricane Harvey in Houston,
Texas, both in 2017. Full restoration of power and access
to food and potable water remained a challenge in
Puerto Rico long after the hurricane was over. Individ-
ual health requires essential services at the population
level including adequate sanitation, potable water, and
power. Understanding the interaction among cultural
considerations, the economy of a country, and public
health infrastructure is essential to promotion of health
and adequate response to disasters and subsequent
threats to health.

Any disaster can quickly escalate from direct injuries
and deaths to indirect illness and risk of mortality be-
cause of the destruction of the public health infrastruc-
ture and the lack of public health resources especially for
vulnerable populations. CD outbreaks challenge com-
munities to respond in a way that provides care for those
with the disease as well as protection for those who are
in danger of getting the disease. Care for those with long
term noncommunicable disease (NCD) requires access
to care and to environments that support healthy living.
Across the continuum from cellular to global, public
health systems are a key component in the promotion of
health and adequate care for those with disease. How-
ever, much of the emerging threats to population health
are tied to increasing globalization.

Globalization is “the process of increasing economic,
political, and social independence and integration as cap-
ital, goods, persons, concepts, images, ideas, and values
cross state boundaries.”12 It is associated with increased
travel, trade, economic growth, and diffusion of technol-
ogy, resulting sometimes in greater disparities between
rich and poor, environmental degradation, and food
security issues. It has also resulted in greater distribution
of products such as tobacco or alcohol. With globaliza-
tion, there is also an emergence and re-emergence of
CDs, including Zika, human immunodeficiency virus
(HIV), acquired immunodeficiency syndrome (AIDS),

4 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Public health infrastructure is fundamental to the provi-
sion and execution of public health services at all levels.
A strong infrastructure provides the capacity to prepare
for and respond to both acute (emergency) and chronic
(ongoing) threats to the nation’s health. Infrastructure is
the foundation for planning, delivering, and evaluating
public health. Public health infrastructure includes three
key components that enable a public health organization
at the federal, tribal, state, or local level to deliver public
health services. These components are:

A capable and qualified workforce
Up-to-date data and information systems
Public health agencies capable of assessing and respond-

ing to public health needs

These components are necessary to fulfill the previ-
ously discussed 10 Essential Public Health Services.

BOX 1–2 n Healthy People 2020: Public Health
Infrastructure

Source: (11)

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severe acute respiratory syndrome (SARS), hepatitis,
malaria, diphtheria, cholera, measles, and Ebola virus.
Planning for CD outbreaks, including pandemics, may
require new ethical frameworks to guide decision making
regarding appropriate action with limited resources.13

Despite climate change, wars, terrorism, and other
challenges, population health at the global level is
improving. Infrastructure, educational opportunities,
and a growing global economy are some of the factors
that contribute to this improvement. According to global
data made available through the “Our World in Data”
Web site, run by Oxford University economist Max
Weber, fewer people are experiencing poverty, life ex-
pectancy is up, and more people have access to electricity
and drinking water.14 Some interesting statistics using
these data demonstrate the positive news related to global
improvements in indicators of a healthy life. In the 1950s,
more than 60% of the world’s population was illiterate;
today, only 14.7% are illiterate.15 In 1980, 44% of the
world’s population lived in extreme poverty, which is
living with less than $1.90 USD per day. The 2015 pro-
jections bring that down to just 9.6%.16 Another common
indicator of the health of a community is access to
potable water. According to Richie and Roser, access to
potable water also rose from 76% in 1990 to 91% in
2015.17 A key measure of the health of populations is life
expectancy, which is the average number of years a per-
son born in a given country would live if mortality rates
at each age were to remain constant in the future. The
WHO reported a 5-year rise in the global average life
expectancy to 71.4 years (73.8 years for females and
69.1 years for males) between 2000 and 2015. According
to the WHO this was the fastest increase since the 1960s.18

Another challenge facing public health is the advance-
ment of scientific and medical technologies that pose
ethical questions.13 The increasing use of genomics, for
example, raises questions of how to protect against
discrimination. Another challenge is aging and increas-
ing diversity within populations. With aging, comes an
increase in persons living with NCDs and CDs that re-
quire long-term care. Examples of disease that require
long-term care include diabetes and HIV. In addition,
some long-term diseases and health concerns relate to
lifestyle choices such as smoking and poor nutrition. In
1926, Winslow discussed the need for new methods to
address heart disease, respiratory diseases, and cancer.19

We still need frameworks to help improve NCD and
CD outcomes and, from a global perspective, to address
how international collective action becomes essential
to combating preventable risk factors associated with
development of disease such as the tobacco epidemic.20,21

Emerging Public Health Frameworks
In 2003, the IOM (now HMD) produced The Future of
the Public’s Health in the Twenty-First Century as an
update of the 1988 IOM report.22 The new report pre-
sented the ecological model as the basis not only for un-
derstanding health in populations but also for assuring
conditions in which populations can be healthy. The
committee built on an ecological model created by
Dahlgren and Whitehead,23 and based its model on the
assumption that health is influenced at several levels:
individuals, families, communities, organizations, and
social systems (Fig. 1-1). The model is also based on the
assumptions that:

• There are multiple determinants of health.
• A population and environmental approach is critical.
• Linkages and relationships among the levels are

important.
• Multiple strategies by multiple sectors are needed to

achieve desired outcomes.24

Conventional public health models such as the epi-
demiological model of the agent, host, and environment
(Chapter 3) are grounded in the ecological model. How-
ever, the ecological model reflects a deeper understand-
ing of the role not only of the physical environment but
also of the conditions in the social environment creating
poor health, referred to as an “upstream” approach.10,21,24

C H A P T E R 1 n Public Health and Nursing Practice 5

Individual

Relationship

Community

Societal

Figure 1-1 The Social-Ecological Model. (Adapted by
CTLT by Dahlgren and Whitehead, 1991; Worthman, 1999)

7711_Ch01_001-022 23/08/19 10:19 AM Page 5

Upstream refers to determinants of health that are some-
what removed from the more “downstream” biological
and behavioral bases for disease. These upstream deter-
minants include social relations, neighborhoods and
communities, institutions, and social and economic poli-
cies (see Chapter 2).24

Community Partnerships
One of the recommendations of the 2003 IOM report
was to increase multisectored engagement in partner-
ships with the community. In 2016, the National Acad-
emy of Sciences published a detailed report Communities
in Action: Pathways to Health Equity that addresses the
importance of community-level efforts aimed at improv-
ing health.25 In the past, the community’s role in health
programs had often been that of a passive recipient, ben-
eficiary, or research subject, with the active work carried
out by public health experts. There is now a growing
commitment to collaboration in promoting the health of
communities and populations. Evidence shows that such
efforts increase effectiveness and productivity, empower
the participants, strengthen social engagement, and
ensure accountability.25, 26

Population Health and Population-
Focused Care
According to Caldwell,27 a population is a mass of peo-
ple that make up a definable unit to which measurements
pertain. The WHO defined health as “the state of com-
plete physical, mental, and social well-being, and not
merely the absence of disease or infirmity.”28 However,
population health is more than just a combination of
these two terms, because it requires an understanding of
all the factors listed in the ecological model that con-
tribute to the health of a population.

Much of the curricular content in nursing programs
pertains to acquiring the knowledge and skill the nurse
needs to deliver nursing care to individuals. When nurses
deliver care to an individual, the outcomes of interest are
at the individual level. The goal is to implement nursing
interventions that contribute to the individual’s ability
to achieve a maximum health state. However, achieving
a complete state of health and well-being usually extends
beyond the interventions that nurses and other health-
care professionals provide on an individual level during
a single episode of care. A state of health and well-being
requires meeting an individual’s mental, social, and eco-
nomic needs as well as their immediate health needs. To
take in this wider scope of influences on the person’s
health, the nurse must consider the individual as a part

of a greater whole, which includes the individual’s inter-
actions with other individuals and groups. This requires
placing the individual within his or her socioecological
context.

With individuals, nurses always start their care with
an assessment. This requires knowledge of the biomed-
ical, social, and psychological sciences. When providing
population-focused care, nurses need a basic knowledge
of the different scientific disciplines that make up public
health science. When nurses assess a community and/or
a population, they use their knowledge of epidemiology
and biostatistics to help identify priority health issues
at the population level. Some terms relevant to a discus-
sion of public health—aggregate, population, and
community—are sometimes used interchangeably, but
there are differences among them (see Box 1-3 for

6 U N I T I n Basis for Public Health Nursing Knowledge and Skills

For this book, these terms are defined within the context
of public health building on standard dictionary defini-
tions and definitions used in the literature.

Aggregate: In public health, this term represents individual
units brought together into a whole or a sum of those
individuals. In public health science, the term aggregate
often refers to the unit of analysis, that is, at what level
the health-care provider analyzes and reports data.

Population: Refers to a larger group whose members
may or may not interact with one another but who
share at least one characteristic such as age, gender,
ethnicity, residence, or a shared health issue such as
HIV/AIDS or breast cancer. The common denomina-
tor or shared characteristic may or may not be a
shared geography or other link recognized by the
individuals within that population. For example, peo-
ple with type 2 diabetes admitted to a hospital form a
population but do not share a specific culture or place
of residence and may not recognize themselves as
part of this population. In many situations, the terms
aggregate and population are used interchangeably.

Community: Refers to a group of individuals living within
the same geographical area, such as a town or a
neighborhood, or a group of individuals who share
some other common denominator, such as ethnicity
or religious orientation. In contrast to aggregates and
population, individuals within the community recog-
nize their membership in the community based on
social interaction and establishment of ties to other
members in the community, and often join collective
decision making.

BOX 1–3 n Definitions for Aggregate, Population,
and Community

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detailed definitions).29,30 All of these interventions,
grounded in public health science, when framed beyond
the individual ultimately improve the health of aggre-
gates, populations, and communities.

Determinants of Health and Cultural
Context
Determinants of health include a range of personal, so-
cial, economic, and environmental factors.31 Before de-
veloping an intervention to improve health outcomes in
a population, a nurse must first identify these determi-
nants of health. MacDonald explained that earlier models
related to population health were built on the assump-
tion that patterns of disease and health occur through a
complex interrelationship between risk and protective
factors.32 This resulted in a focus on biological and be-
havioral risk factors that require changes at the individ-
ual level. Multiple examples exist of health promotion
activities that focus on changing individual behavior to
reduce risk, such as smoking cessation, healthy eating,
and increased exercise. Some success has occurred with
this approach. However, there have also been successful
efforts at the macrosocioecological level. These interven-
tions focus on population behavioral change that then
trickles down to the individual. Population behavioral
change addresses risk factors that affect the whole popu-
lation, such as provision of potable water to prevent
cholera. The underlying assumption is that the popula-
tion level of risk affects health outcomes independent of
individual/family-level risk factors.

Take, for example, lung cancer. One of the well-
documented determinants of this disease is the use of to-
bacco. Efforts to reduce this risk factor focus on changing
individual behavior. Theories have emerged that help to
explain behavior, such as the Transtheoretical Model of
Change.33 This model theory helps a health-care provider
determine in what stage of change a person is and helps
the provider put together a plan of care that fits the indi-
vidual’s readiness to quit smoking. Many of the inroads
made in tobacco use cessation in this country began with
a broader population health approach, including media
campaigns related to smoking cessation and governmen-
tal nonsmoking policies that resulted in a cultural shift
within our society. Once researchers made the case for
the hazards of secondary smoke, tolerance of smoking
within the community dramatically decreased. The pop-
ulation’s exposure to tobacco smoke has decreased be-
cause the cultural view of tobacco use has changed. An
increasingly negative perception of smoking has also in-
creased the willingness of communities to implement

policies that reduce the community’s risk. A cultural shift
reducing tolerance of smoking in public places and
increasing the ostracism experienced by smokers has
reduced the prevalence of smoking. Healthy behaviors
remain a key issue in the health of populations. Taking a
population approach allows for elevation of behavioral
changes from the individual/family level to the popula-
tion level.

Serious disparities in health exist at the global level,
which can be seen by comparing life expectancies between
high-income countries and low-income countries. For ex-
ample, the estimated life expectancy in 2017 in Monaco
was 89.4 years, whereas in Chad it was 50.6 years. The U.S.
was ranked 43 with a life expectancy of 80.0 years.34 To
address these disparities, public health as a science has
shifted from focusing on dramatic cases to focusing on
existing disparities and addressing the underlying social
determinants of health, such as poverty.35

Cultural Context, Diversity, and Health
Understanding the determinants of health begins with
the cultural context and the diversity of populations
across the globe. Diversity reflects the fact that groups
and individuals are not all the same but differ in relation
to culture, ethnicity, and race. Culture as defined in the
Merriam Webster Dictionary as “… the customary be-
liefs, social forms, and material traits of a racial, religious,
or social group; also: the characteristic features of every-
day existence (such as diversions or a way of life) shared
by people in a place or time.”36

C H A P T E R 1 n Public Health and Nursing Practice 7

n CULTURAL CONTEXT
AND NURSING CARE

Knowledge and understanding of the cultural context
of persons constitutes a key aspect in the development
of effective nursing interventions. This context includes
many aspects of life that affect the health of individuals,
such as food preferences, gender roles, birthing prac-
tices, language, and spiritual beliefs to name a few.
Spector equated culture to a set of luggage that a
person carries that contains such things as beliefs,
habits, norms, customs, and rituals that are handed
down from one generation to the next through both
verbal and nonverbal communication. Spector goes on
to state, “All facets of human behavior can be inter-
preted through the lens of culture.”37 Thus, nurses
must have an appreciation for cultures represented
within the population they are caring for while ac-
knowledging and understanding their own cultural
views of the world, also known as cultural lenses.

7711_Ch01_001-022 23/08/19 10:19 AM Page 7

Ethnicity, Race, and Culture
Having clear definitions of race and ethnicity helps in the
understanding of what is meant by cultural context. Race
and ethnicity are often used interchangeably but are
actually different constructs. Multiple definitions exist
for ethnicity. Commonalities across definitions include
shared geographical origin, language or dialect, religious
faith, folklore, food preferences, and culture. O’Neill38

included physical characteristics as well and suggested
that we use ethnicity in two distinct ways: to classify peo-
ple who may have no specific cultural traditions in com-
mon into a loose group, and to classify groups that have
a shared language and cultural traditions. For example,
to classify an ethnic group under the name Native Amer-
ican results in grouping together people who are actually
diverse in both culture and language. However, if the eth-
nic group is a specific Native American tribe, such as the
Navajo, then the group does share specific cultural tra-
ditions, beliefs, and language that may not be shared with
other Native American tribes such as the Inuit. There-
fore, care is required when using the term ethnicity be-
cause of the variation in its use. Identifying the ethnicity
of a group of people, which only considers broad shared
characteristics, may miss key cultural differences within
the group.

Geographical differences also play a part in diversity
across groups and can result in shared cultural traditions
that extend across ethnic groups within that geograph-
ical region. In the United States, cultural differences
exist among specific regions, such as New England, the
South, and the West Coast. These three regions differ in
dialect, accepted protocol for social interactions, and
food preferences.

Race categorizes groups of people based on superficial
criteria such as skin color, physical characteristics, and
parentage. In the United States, we continue to use racial
categories; these are increasingly less accurate as ethnic
groups become less defined. The U.S. Census Bureau
acknowledges that the use of racial categories is limited,
especially because some people may classify themselves
as belonging to more than one category.39,40 As the field
of genetics grows, so does the evidence that there is no
scientific basis for placing an individual into one racial
group. In a classic article in Newsweek, “What Color Is
Black?” Morganthau challenged the myth of race and
concluded that it is not a legitimate method for classify-
ing groups of people. Scientists found that people with
very dissimilar racial characteristics such as skin color
and facial features were in some cases more closely
related genetically than groups with similar skin color.41

However, race continues to be used to identify groups.

Traditionally, scientists report epidemiological data
using racial categories as a means of identifying disparity
between racial groups, especially in relation to health
outcomes and access to care. The U.S. 2010 Census
shows that the ability to group people using racial cate-
gories is increasingly difficult as these categories expand
to include individuals who identify themselves as biracial
and multiracial.

Understanding diversity in a population enhances the
process of partnering with communities and improves
the likelihood of the potential success of an intervention.
By contrast, if a nurse plans an intervention without tak-
ing into account the cultural and ethnic diversity within
the population, violation of ethnic and cultural values or
beliefs can lead to failure to achieve the goals of the
intervention. If the nurse only views an intervention
through his or her cultural lens, and if that lens differs
from those who will receive the intervention, then a key
piece is missing. Does the population view the interven-
tion as culturally relevant? Is the desired health outcome
valued? For example, if a nurse develops an intervention
aimed at increasing the number of women who breast-
feed their infants, the first step is to evaluate the cultural
view of breastfeeding. If the target population includes
all the women giving birth at a large urban hospital, the
population is probably diverse and may include cultures
with different practices related to breastfeeding. If
the nurse fails to acknowledge this fact and incorporate
possible cultural differences into the assessment and
planning stage (Chapters 4 and 5), the intervention may
not succeed with women who have specific cultural
beliefs surrounding breastfeeding.

Respecting culture and diversity when planning
population level interventions requires the inclusion of
the community members as partners in the process.
Interventions planned for communities rather than with
communities ignore the point made by Murphy that
communities interpret their own health. In addition,
Murphy stated that communities themselves can come
up with ways to improve their health. From a population
health perspective, collaboration and community partic-
ipation are essential when developing interventions.42

Engagement with the community can occur only within
the context of culture and ethnic heritage and the com-
munity’s own perception of what constitutes optimal
health.

Cultural Competency and Cultural Humility
Cultural competency is a core aspect of care for health-
care providers. It is traditionally defined as the attitudes,
knowledge, and skills the health-care provider uses to

8 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch01_001-022 23/08/19 10:19 AM Page 8

provide quality care to culturally diverse populations. It
requires an understanding and capacity to provide care
in a diverse environment. This implies an endpoint of
acquired knowledge related to the culture of others.
Cultural humility, conversely, acknowledges that the
understanding of the multitude of diverse cultures in the
world today may be too big a task. Cultural humility is
an understanding that self-awareness about one’s own
culture is an ongoing process, and an acknowledgment
that we must approach others as equals, with respect
for their prevailing beliefs and cultural norms.43 One is
not exclusive of the other. Cultural competence is the
standard to help guide the delivery of health care to in-
dividuals and to populations, whereas cultural humility
is the underlying quality needed to truly implement
interventions to improve health in partnership with
communities and populations.

Developing cultural humility takes self-reflection. This
provides an essential beginning point for nurses to de-
velop the insight and knowledge needed to provide care
to those who differ culturally from themselves. How do
nurses create health-care environments that are safe and
welcoming for clients and patients from all backgrounds?
The first step in this process for individual nurses should
be a cultural self-assessment. Cultural self-assessment
involves a critical reflection of one’s own viewpoints,
experiences, attitudes, values, and beliefs. When one can
honestly identify learned stereotypes and ethnocentric
attitudes, enlightenment can occur. Nurses cannot begin
to effectively consider the cultural context while provid-
ing care without first exploring their own cultures using
basic questions (Box 1-4).

Creating a culturally welcoming health-care environ-
ment requires purposeful action by health-care providers.
This necessitates commitment to principles and practices
on all levels that support inclusion. These principles and
practices should be a part of the systemic workings of
health-care organizations. There should be visible and tan-
gible signs of culturally welcoming health-care environ-
ments. However, more important are nurses who provide
care that is inclusionary and culturally appropriate.

Environment and Resource Availability
The environment is another factor that affects health
(see Chapter 6). Availability of clean air, abundant
and potable water, and adequate food supplies all affect
the health of an environment. For much of humankind’s
existence, the health of a population was concerned
with the short-term survival of that population and cen-
tered on food sources, predators, and pestilence. This
changed dramatically during the industrial revolution

as populations moved from rural communities to urban
areas. As large groups of people congregated in these
urban areas, new issues arose related to sanitation, food
supplies, and water. Communities with fewer resources
and inadequate infrastructure to provide these essential
components of a healthy life are at greater risk for
disease. Poor sanitation and lack of potable water sig-
nificantly increase the possibility of the spread of CDs.
For example, in April of 2015, Uganda experienced a
typhoid epidemic. As you can see in Figure 1-2, there
are serious environmental risks to children and an
increased risk for contaminated water sources.

Epidemiology, the study of the occurrence of disease
in humans, identifies environment as a key factor con-
tributing to morbidity and mortality (see Chapter 3).
Epidemiology emerged in the 19th century in response
to these new challenges brought by the industrial revo-
lution. Though early epidemiologists did not understand
that microscopic pathogens caused disease (the germ
theory), they firmly established the role that environment
plays in the health of humans. Efforts during the last half
of the 19th century and into the 20th century focused
on the introduction of sanitary measures, including
management of sewage and providing clean water and
adequate ventilation.32

John Snow was an epidemiologist who first studied as-
pects of the environment related to sanitation (see Chap-
ter 3). He conducted a classic investigation of a cholera

C H A P T E R 1 n Public Health and Nursing Practice 9

The following questions can be used to guide cultural
self-reflection:

• Where did I grow up? How did this environment influ-
ence my worldview (country, region, rural, urban)?

• What values were emphasized in my family of origin?
• Who were the people most influential to me in

shaping my worldview?
• Who were the people within my circle of friends and

acquaintances during my years of growing up? How did
they differ from me?

• What privileges did I enjoy while growing up?
• What are some of the key experiences that have

shaped my view of the world and the people in it?
• What are my religious beliefs, if any?
• What are the values and morals that I adhere to?
• What does “good health” mean to me? How do I

obtain and maintain good health?
• How do I view those individuals whose values differ

from my own?

BOX 1–4 n Personal Cultural Assessment

7711_Ch01_001-022 23/08/19 10:19 AM Page 9

outbreak in the Soho area of London in 1854.44 Snow
mapped out cholera deaths block by block and found
that they clustered around the Broad Street pump, lead-
ing him to conclude that the pump was the source of the
contamination. He even examined the water under a
microscope and identified “white, flocculent particles”
that he thought were the causative agents. Though other
authorities dismissed his evidence of a microscopic
agent, he convinced others of the link between the
disease and the water pump. He was successful in getting
the water company to change the pump handle.55

Snow’s work brought attention to the importance of safe
water. The measures taken did not require a change in
individual behavior but rather a change in how the water
company delivered water to the populace.

Initial public health efforts focused on the develop-
ment of a public health infrastructure related to sanita-
tion and delivery of safe water supplies. In the late 19th
and early 20th centuries, large metropolitan municipal-
ities initiated the development of underground sewerage
systems and water pipes that are still in service today. The
implementation of similar systems in smaller towns and
rural areas occurred later, with outhouses still in use in
the 1950s. In the United States, long before antibiotics
were available, addressing these sanitation and safe water
issues directly reduced the spread of CDs such as infan-
tile diarrhea and cholera. In undeveloped countries with-
out this public health infrastructure, these two diseases
continue to contribute to the morbidity and mortality of
their populations.

To survive, humans need adequate water and food
supplies, shelter from the elements, and protection from

pestilence and disease. In modern developed societies,
geopolitical groups come together to supply adequate
potable water and sewerage. Agricultural businesses pro-
vide food. In most developed societies, most individuals
and families have the means to purchase adequate shelter
and the health care needed to protect them from both
CDs and NCDs. In some societies, government-based
programs provide the means for obtaining health-care
resources aimed at protection from pestilence and dis-
ease, and in other societies individuals purchase the
health care either directly or indirectly through health
insurance. Governments and individuals need adequate
money to provide these resources; thus, obtaining
adequate resources to promote the health of a population
depends on that population’s economic health. When
the economy is healthy, the majority of the population
generally has access to adequate water, food, and shelter.
However, an economy in jeopardy may result in a
reduced ability to meet these basic needs. In all societies,
nurses must be aware of the environment in which the
patient resides. Does the patient live in a community
with a healthful environment? Is there adequate, safe,
and usable water? Is food available, affordable, and
nutritionally beneficial? Is the economy strong enough
to provide access to health-care resources? Environment
is one of the main determinants of health for individuals,
populations, and the communities they live in.

Public Health as a Component of Nursing
Practice Across Settings and Specialties
Nursing practice requires the application of knowledge
from multiple sciences, including public health. Health
is not just a result of individual factors such as biology,
genetics, and behavior; it is also a product of an indi-
vidual’s social, cultural, and ecological environment.
To meet our obligation to maximize health on all levels,
we must incorporate public health science into our
nursing care.

Public Health Science and Nursing Practice
In 2010, the IOM (now HMD) published a report on the
future of nursing.45 The stated goal was to have 80% of
all registered nurses prepared at the baccalaureate of
science in nursing (BSN) level or higher. The rationale
for this goal was that BSN programs emphasize liberal
arts, advanced sciences, and nursing coursework across
a wide range of settings, along with leadership develop-
ment and exposure to community and public health
competencies. In addition, the authors emphasized that

10 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 1-2 Children in Uganda during typhoid out-
break. (Courtesy of the CDC/Jennifer Murphy)

7711_Ch01_001-022 23/08/19 10:19 AM Page 10

entry-level nurses need to be able to transition smoothly
from their academic preparation to a range of practice
environments, with an increased emphasis on commu-
nity and public health settings.45

Population-Focused Care Across Settings
and Nursing Specialties
Nurses provide population-focused care every day, in
every setting. For a staff nurse working in an urban hos-
pital, the population of interest is the patients who come
to that hospital for care. The population may include var-
ious subpopulations based on shared geographical resi-
dence, age group, primary diagnosis, culture, and ethnic
group. Staff nurses in an acute or community-based set-
ting take care of patients on an individual level, often
serving as the member of the health-care team that de-
livers the interventions and evaluates the effectiveness of
those interventions. Nurses actively participate in re-
viewing how well the team is delivering care to the pa-
tient population as a whole. Over time, the health-care
team begins to group patients based on diagnosis or
other identifying characteristics to provide better care.
This may occur when nurses are engaged in performance
improvement activities, the development of a care map,
or in response to changes in the population.

Across settings and specialties, nurses work to success-
fully answer the “who, what, when, where, why, and how”
of health problems within the context of populations.
Providing individual care alone after disease has occurred
is an essential part of what nurses do. In a sense, all nurses
are Public Health Nurses (PHN) because our mandate is
not only to provide state-of-the-art care to individuals but
also to safeguard the public’s health and actively partici-
pate in optimizing health for all populations.

Public Health Nursing as a Specialty
Public health nursing is the practice of promoting and
protecting the health of populations using knowledge
from nursing, social, and public health sciences. Public
health nursing is a specialty practice within nursing and
public health. It focuses on improving population health
by emphasizing prevention and attending to multiple de-
terminants of health. Often used interchangeably with
community health nursing, this nursing practice includes
advocacy, policy development, and planning, which ad-
dresses issues of social justice. With a multi-level view of
health, public health nursing action occurs through com-
munity applications of theory, evidence, and a commit-
ment to health equity. In addition to what is put forward
in this definition, public health nursing practice is guided

by the ANA Public Health Nursing: Scope and Standards
of Practice and the Quad Council of Public Health Nurs-
ing Organizations’ Core Competencies for Public Health
Nurses.46

Public health nursing is different from other nursing
specialties because of its focus on eight principles
outlined in an unpublished white paper by the Quad
Council in 199747 and cited in the Public Health Nursing:
Scope and Standards of Practice.48 (See Box 1-5.) These
principles define the client of public health nursing as the
population and further delineate processes and strategies
used by PHNs.

Public Health Nursing as a Core Component
of Nursing History
The roots of public health nursing lie in the work of
women who provided comfort, care, and healing to indi-
viduals during the Middle Ages. During that time, nuns,
deaconesses, and women of religious orders provided
comfort and care to the sick in their homes.49 The imme-
diate precursor to public health nursing was district
nursing, which began in England. William Rathbone
employed a nurse to care for his wife during her terminal
illness and after this experience realized that home visiting
to the sick poor could benefit society. This resulted in the

C H A P T E R 1 n Public Health and Nursing Practice 11

1. The client or unit of care is the population.
2. The primary obligation is to achieve the greatest good

for the greatest number of people or population as a
whole.

3. The processes used by PHNs include working with
the client as an equal partner.

4. PRIMARY prevention is the priority in selecting appro-
priate activities.

5. Public health nursing focuses on strategies that create
healthy environmental, social, and economic condi-
tions in which populations may thrive.

6. A PHN is obligated to actively identify and reach out
to all who might benefit from a specific activity or
service.

7. Use of available resources must be optimal to assure
the best overall improvement in the health of the
population.

8. Collaboration with a variety of other professions,
populations, organizations, and other stakeholder
groups is the most effective way to promote and
protect the health of the people.

BOX 1–5 n The Eight Principles of Public Health
Nursing

Source: (1)

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development of district nursing, under which towns were
divided into districts, and health visitors provided nursing
care and education to the sick poor within those districts.
In 1861, Rathbone wrote Florence Nightingale to request
the development of a training school for both infirmary
and district nursing, which eventually resulted in trained
nurses in 18 districts of Liverpool.53 Public health nursing
owes much of its early development to Florence Nightin-
gale. She was concerned about the care of the sick poor
and the quality of their homes and workhouses. She is also
widely known for her work during the Crimean War,
during which she kept impeccable statistical records on
the living conditions of the soldiers and on the presence
of disease. She is also known for her promotion of health
reform.50,51

Beginnings of Public Health Nursing
in the United States
Public health nursing in the United States evolved from
district nursing in England. In 1877, the New York City
Mission hired Francis Root to make home visits to the
sick. Other sites followed suit, and visiting nurse associ-
ations were set up in Buffalo (1885), Boston (1886), and
Philadelphia (1886). Trained nurses cared for the sick
poor and provided instruction on improving the clean-
liness of their homes. Originally these associations bore
the name District Nursing Services, with the Boston
association referred to as the Boston Instructive District
Nursing Association. Eventually they all changed their
names to Visiting Nurse Associations.52

In 1893, Lillian Wald and Mary Brewster established
a district nursing service called the Henry Street Settle-
ment on the Lower East Side of New York and coined the
term public health nurse.53 In her work, Wald emphasized
the role that social and economic problems played in
illness and developed unique programs to address the
health needs of the immigrant population. During the
early part of the 20th century, poverty was increasingly
seen as a cause of social problems and poor health in com-
munities. Wald believed that environmental and social
conditions were the causes of ill health and poverty.54,55

For Lillian Wald and her colleagues, efforts of social re-
form were focused on civil rights for minorities, voting
rights for women, the prevention of war, child labor laws,
and improving unsafe working conditions.55

Public Health Nursing in the 20th Century
Wald’s accomplishments were the background for the
development of the public health nursing specialty. Pub-
lic health efforts in the early part of the 20th century
made great strides in reducing disease, especially due to

advances related to the provision of potable water, regu-
lations around food and milk supply, removal of garbage,
and disposal of sewage. However, authorities realized
that they needed to implement other programs to work
on improving health education among those most at risk,
especially the poor. PHNs filled this need and provided
care to the sick while educating families on personal
hygiene and healthy practices.55 The visiting nurse move-
ment, with a focus on caring for the sick poor, joined
forces with public health to focus on prevention. Accord-
ing to Buhler-Wilkerson, “By 1910, the majority of
the large urban visiting nurse associations had initiated
preventive programs for school children, infants, moth-
ers, and patients with tuberculosis.”56

Public health nursing continued to grow with the
expansion of the federal government. The Social Security
Act of 1935 provided funding for expanded opportuni-
ties in health protection and promotion, resulting in the
employment of PHNs, increased education for nurses in
public health, the establishment of health services, and
research. World War II increased the need for nurses
both for the war effort and at home. PHNs also played
a role in surveillance and treatment of CDs such as
tuberculosis and Hanson’s disease, also known as lep-
rosy. As seen in the photo in Figure 1-3, taken in 1950,
PHNs worked with other nurses caring for the patients
receiving care for CDs.

The 1960s and 1970s saw the implementation of neigh-
borhood health centers, maternal-child health programs,
and Head Start programs. By the 1980s, however, there
was another shift in funding to more acute services, med-
ical procedures, and long-term care. The use of health
maintenance organizations (HMOs) was encouraged. By

12 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 1-3 Public Health Nurses in the 1950s. (Courtesy
of the CDC/Elizabeth Schexnyder, National Hansen’s Disease
Museum, Curator)

7711_Ch01_001-022 23/08/19 10:19 AM Page 12

the latter part of the 1980s, public health as a focus had
declined and the percentage of PHNs working as govern-
ment employees had dropped.

Public Health Nursing in the 21st Century
In this century, the move toward population health and
the need for more services to communities outside of
traditional hospital settings has the potential to increase
the demand for PHNs. Currently, PHNs work in a wide
variety of settings. Some are based in schools, commu-
nity clinics, local health departments, and visiting nurse
associations. PHNs also work at the national level in the
United States Public Health Service, a branch of the
armed services in the U.S. (Fig. 1-4).

Based on a report completed by the Health Resources
and Services Administration on the registered nurse pop-
ulation in the United States, in 2017, 61% of nurses work
in hospital settings, 18% work in primary care, 5% work
in government, 7% in extended care facilities, and 3% in
education.57 If the predictions of Ezekiel J. Emanuel, vice
provost of the University of Pennsylvania Hospital, are
correct, hospitals will continue to downsize as health care

moves out into the community and individual homes.58

This may require an increase in the number of practicing
PHNs. This will also increase the need for all nurses to
have sufficient knowledge and skills to provide care
across the continuum from individuals to populations
within the context of community.

Public Health Nursing Scope and Standards
of Practice
The Public Health Nursing: Scope and Standards of
Practice outlines the expectations of the professional
role of the PHN and sets the framework for public
health nursing practice in the 21st century.1 As with the
other nursing specialties’ scope and standards, these are
based on the nursing scope and standards established
by the ANA.1,2

Public Health Nursing Standards
Included in the 11 Standards of Professional Performance
for Public Health Nursing (see Box 1-6)1 are six standards
of practice that describe a competent level of care using
the nursing process: (1) Assessment, (2) Population
Diagnosis and Priorities, (3) Outcomes Identification,
(4) Planning, (5) Implementation, and (6) Evaluation.
Specific standards related to implementation include the
coordination of care, health teaching, and health promo-
tion, consultation, and regulatory activities. These stan-
dards of practice are differentiated for the PHN and the
advanced PHN.

Public Health Nursing Competencies
The Scope and Standards of Practice delineates compe-
tencies for practice based on the ANA nursing frame-
work assuring that public health nursing fits as a
recognized nursing specialty. In addition, the Council of
Linkages Between Academia and Public Health Practice,
a coalition of organizations concerned with the public
health workforce, produced a document in 2001 that has
been used as a framework for the development of addi-
tional public health nursing competencies. The 2018 re-
vised version of the PHN Core Competencies includes
eight domains (Box 1-7) and incorporates three tiers of
practice: Basic or generalist (Tier 1); Specialist or mid-
level (Tier 2); and Executive and/or multisystem level
(Tier 3).59 These tiers reflect the different levels of respon-
sibility for those working in public health.60

Public Health Nursing Roles
and Responsibilities
There are roles and responsibilities specific to public
health nursing practice built on nursing practice for all

C H A P T E R 1 n Public Health and Nursing Practice 13

Figure 1-4 United States Public Health Service Nurse at
a blood pressure clinic. (Courtesy of the CDC/Nasheka Powell)

7711_Ch01_001-022 23/08/19 10:19 AM Page 13

14 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Standard 1. ASSESSMENT

The PHN collects comprehensive data pertinent to the
health status of populations.

Standard 2. DIAGNOSIS

The PHN analyzes the assessment data to determine the
diagnoses or issues.

Standard 3. OUTCOMES IDENTIFICATION

The PHN identifies expected outcomes for a plan specific
to the population or situation.

Standard 4. PLANNING

The PHN develops a plan that prescribes strategies and
alternatives to attain expected outcomes.

Standard 5. IMPLEMENTATION

The PHN implements the identified plan.

Standard 5A. COORDINATION OF CARE

The PHN coordinates care delivery.

Standard 5B. HEALTH TEACHING AND HEALTH
PROMOTION

The PHN employs multiple strategies to promote health
and a safe environment.

Standard 5C. CONSULTATION

The PHN provides consultation to influence the identi-
fied plan, enhance the abilities of others, and effect
change.

Standard 5D. PRESCRIPTIVE AUTHORITY

The advanced practice registered nurse practicing in the
public health setting uses prescriptive authority, proce-
dures, referrals, treatments, and therapies in accordance
with state and federal laws and regulations.

Standard 5E. REGULATORY ACTIVITIES

The PHN participates in applications of public health laws,
regulations, and policies.

Standard 6. EVALUATION

The PHN evaluates progress toward attainment of
outcomes.

Standard 7. ETHICS

The PHN practices ethically.

Standard 8. EDUCATION

The PHN attains knowledge and competence that reflect
current nursing practice.

Standard 9. EVIDENCE-BASED PRACTICE AND
RESEARCH

The PHN integrates evidence and research findings into
practice.

Standard 10. QUALITY OF PRACTICE

The PHN contributes to quality nursing practice.

Standard 11. COMMUNICATION

The PHN communicates effectively in a variety of formats
in all areas of practice.

Standard 12. LEADERSHIP

The PHN demonstrates leadership in the professional
practice setting and the profession.

Standard 13. COLLABORATION

The PHN collaborates with the population, and others in
the conduct of nursing practice.

Standard 14. PROFESSIONAL PRACTICE
EVALUATION

The PHN evaluates her or his own nursing practice in
relation to professional practice standards and guide-
lines, relevant statutes, rules, and regulations.

Standard 15. RESOURCE UTILIZATION

The PHN utilizes appropriate resources to plan and
provide nursing and public health services that are safe,
effective, and financially responsible.

Standard 16. ENVIRONMENTAL HEALTH

The PHN practices in an environmentally safe, fair, and just
manner.

Standard 17. ADVOCACY

The PHN advocates for the protection of the health,
safety, and rights of the population.

BOX 1–6 n Standards of Public Health Nursing Practice

Source: (1)

7711_Ch01_001-022 23/08/19 10:19 AM Page 14

specialties. They are in alignment with the Scope and
Standards of Nursing Practice in general and build in the
care of communities and populations.

Coordination, Consultation, and Leadership: A PHN
is responsible for coordinating programs, services, and
other activities to implement an identified plan.46 A PHN
acts as a consultant when he or she works with commu-
nity organizations or groups to develop a local health fair
or provide the latest information about a CD outbreak
to the community. At a more complex level, Advanced
Public Health Nurses (APHN) act as consultants when
providing expert testimony to the federal or state gov-
ernments about a health promotion program. As leaders,
PHNs can serve in coalition-building efforts around a
health issue such as teen smoking prevention or opioid
overdose prevention.

Advocacy: Advocacy refers to the responsibility of
PHNs to speak for populations and communities that
lack the resources to be heard.1 Assisting families living
in poverty to access appropriate services is one example
of an important role of PHNs. Another example of ad-
vocacy is engaging in strategies to affect policy at the
local, state, or national level.

Health Education and Health Promotion: The
PHN selects teaching and learning methods to help com-
munities address health issues, presenting the informa-
tion in a culturally competent manner, implementing the
health education program in partnership with the com-
munity, and evaluating the effectiveness of the program
by collecting feedback from participants.

Regulatory Activities: Since the beginning of public
health nursing, health policy has been an important
aspect of practice. Responsibilities include identifying,
interpreting, and implementing public health laws, reg-
ulations, and policies.1 Activities include monitoring and
inspecting regulated entities such as nursing homes. It

also includes educating the public on relevant laws, reg-
ulations, and policies.

Ongoing Education and Practice Evaluation:
PHNs are responsible for maintaining and enhancing
their knowledge and skills necessary to promote popu-
lation health. This requires PHNs to take the initiative to
seek experiences that develop and maintain their com-
petence as PHNs. Thus, as with nurses in other settings,
PHNs must engage in self-evaluation, seek feedback
about performance, and implement plans for accom-
plishing their own goals and work plans.

Professional Relationships and Collaboration:
Effective partnerships with communities and stakehold-
ers provide the mechanism for moving the public
health agenda forward.1 For example, nurses working in
health departments often join with other human service
providers to develop effective programs aimed at ad-
dressing a health issue of mutual concern such as the
opioid epidemic. PHNs seek collegial partnerships with
peers, students, and colleagues as a means of enhancing
public health interventions.

Public Health Nursing Ethics
The principles guiding any ethical discourse in nursing
include autonomy, dignity, and rights of individuals.
The same is true for public health nursing. Assuring
confidentiality and applying ethical standards are critical
in advocating for health and social policy.60,61 Equally
important to any discussion of public health ethics is the
fact that public health is concerned with the public good,
which can override individual rights.62 This is evident in
the enforcement of laws that are aimed at the whole
population (e.g., immunizations, disease reporting, or
quarantines). Underlying public health ethics is the con-
cept of social justice defined as: “… acting in accordance
with fair treatment regardless of economic status, race,
ethnicity, citizenship, disability, or sexual orientation.”1

This includes the eradication of poverty and illiteracy,
the establishment of sound environmental policy, and
equality of opportunity for healthy personal and social
development.1

Global Health
Global health is “the collaborative transnational research
and action for promoting health for all.”63 This definition
aligns with the WHO classic definition of health: “a state
of complete physical, mental, and social well-being
and not merely the absence of disease or infirmity.”64

The constitution of the WHO further recognizes “the

C H A P T E R 1 n Public Health and Nursing Practice 15

1. Assessment and analytical skills
2. Policy development/program planning skills
3. Communication skills
4. Cultural competency skills
5. Community dimensions of practice skills
6. Public health science skills
7. Financial planning, evaluation and management skills
8. Leadership and systems thinking skills

BOX 1–7 n PHN Core Competencies includes
Eight Domains

Source: (60)

7711_Ch01_001-022 23/08/19 10:19 AM Page 15

enjoyment of the highest attainable standard of health …
as one of the fundamental rights of every human
being.”65 The WHO recognizes that nurses play a large
role in the promotion of global health. In February of
2018, the WHO launched a new global campaign, called
Nursing Now, to “… empower and support nurses in
meeting 21st century health challenges.”66

One of the variables associated with differences
among countries is their economic well-being. The terms
most often used to differentiate countries based on
country-level income data are high-income countries
(HICs), upper middle-income countries (UMICs),
lower middle income countries (LMICs), and low-
income countries (LICs). These terms replace the earlier
terms of developed and developing countries. The World
Bank classifies countries based on current economic
ranges of the annual per capita gross national income
(GNI). In 2016, a LIC was a country with a per capita
GNI equal to or less than U.S. $1,005; LMIC’s per capita
GNI ranged from U.S. $1,006 to $3,955; UMIC’s per
capita GNI ranged from $3,956 to $12,235; and an
HIC’s per capita GNI was equal to or greater than U.S.
$12,236.67 From a global health perspective, a major con-
cern is the growing disparity between the two lower
groups (LIC and LMIC) and the two higher groups
(HIC and UMIC). Previously, international health-care
workers in LICs and LMICs looked for solutions to
health care within the country or collaborated with
one other country. The key conceptual change in global
health over the past 2 decades is the recognition of
the interdependence of countries; the interdependence
of the health of people in all countries; and the interde-
pendence of the policies, economics, and values that arise
related to health.68 The 2018 WHO launch of “Nursing
Now” with the stated purpose “… to empower and sup-
port nurses in meeting 21st century health challenges”
showcases this conceptual change.66

An example of global efforts to assist countries
with fewer resources to improve health is the effort to
improve access to vaccines for common childhood
illnesses. For example, in 2008 the Cairo M/R Catch-Up
Campaign was initiated (Fig. 1-5), a national supple-
mental immunization activity in Egypt. Another exam-
ple, in 2018, is the plan by the Bill and Melinda Gates
Foundation to pay off the $76 million debt that Nigeria
owes Japan for their program to eradicate polio. These
efforts demonstrate the importance of health of children
as a primary focus of health at the global level. World-
wide in 2016, the number of children under the age
of 5 who died was 5.6 million, down from 6.6 million
children in 2012 and a sharp decrease from 1990 when

the total number of deaths was 12.4 million.69 Despite
these gains, efforts continue to help lower the number
as most of the deaths are preventable.

Public Health Organizations and Management:
Global to Local
Public health organizations constitute an essential
part of improving health from the cellular to the global
level. These organizations provide essential public health
services such as conducting surveillance, responding to
CD outbreaks and disasters, and evaluating the evidence
to make recommendations for action. In addition, these
organizations set goals related to the improvement of
health such as the UN’s Sustainable Development Goals
(SDGs).70

World Health Organization
The WHO, established in 1948, is the world health
authority under the auspices of the UN. Their “… primary
role is to direct and coordinate international health

16 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 1-5 Vaccinating children for measles and rubella
in Egypt. (Courtesy of the CDC/Carlos Alonso)

7711_Ch01_001-022 23/08/19 10:19 AM Page 16

within the United Nations’ system.”64 Their stated areas
of work include health systems, promoting health
through the life-course, NCD, CD, and corporate serv-
ices.76 Based in Geneva, the WHO employs 7,000 people
working in 150 country offices, 6 regional offices, and at
the central headquarters.64

In 1978, the WHO held a conference in Alma-Ata
(now Almaty), Kazakhstan, that supported the resolu-
tion that primary health care was the means for attaining
health for all. At the beginning of the first decade in
the 21st century, a new model emerged of integrated
services that respond to multiple threats to health. The
WHO has expanded to include emergency response and
disaster preparedness initiatives (see Chapter 22). An-
other key initiative was the institution of International
Health Regulations (IHRs) that countries must follow
in response to disease outbreaks and to increase the abil-
ity of the WHO to respond to public health emergencies
brought on by natural or manmade disasters.64 The
WHO continues to set global population heath goals
and tracks the attainment of these goals. The current
SDGs built on the Millennial Development Goals
(MDGs) that ended in 2015. There are 17 goals with a
target date of 2030 and, unlike the MDGs, the goals
apply to all countries, and there is no distinction be-
tween LIC and other countries (Box 1-8). The stated
purpose of the SDGs is to “… end poverty, protect the
planet, and ensure prosperity for all.”70

National Health Organizations
Individual countries have their own national organiza-
tions dedicated to the promotion of health and the pro-
tection of their populations. They coordinate with the
WHO and, as evidenced by the new interdependency
framework mentioned earlier, often work together to ad-
dress threats to heath. Some countries, including the
U.S., have public health departments, also known as
boards of public health. Even though these governmental
bodies do not encompass the entirety of the field of pub-
lic health, they are key to providing infrastructure as well
as oversight of the health of populations.

The U.S. Constitution provides for a two-layer pub-
lic health system composed of the federal level and the
state level. However, the Constitution did not make any
specific provisions for the management of public health
issues at the federal level, therefore, public health man-
agement now comes under state authority.30 After rat-
ification of the 14th Amendment, states were required
to provide protections to their own citizens, which
helped to legalize activities of local health departments
to take such actions as imposing quarantines.

Centers for Disease Control and Prevention
The CDC, founded in 1946, grew out of the wartime
effort related to malaria control. In the beginning, the
CDC employed approximately 400 people, including en-
gineers and entomologists (scientists who study insects).
Only seven employees functioned as medical officers.71

The work of the CDC contributed to the 10 great public
health achievements over the past century (Box 1-9).72

These included immunizations, fluoridation of water,
and workplace safety. The implementation of childhood
vaccination programs resulted in the eradication of
smallpox and the banishment of mumps and chickenpox
from schools in the United States.79 Without an active
public health infrastructure, the marked increases in life
expectancy in the 20th century would not have occurred.

Activities of the CDC: From this humble beginning,
the CDC has grown into one of the major operating
components of the Department of Health and Human

C H A P T E R 1 n Public Health and Nursing Practice 17

According to the United Nations, “The SDGs build
on the success of the Millennium Development Goals
(MDGs) and aim to go further to end all forms of
poverty. The new Goals are unique in that they call for
action by all countries, poor, rich and middle-income to
promote prosperity while protecting the planet. They
recognize that ending poverty must go hand-in-hand with
strategies that build economic growth and addresses a
range of social needs including education, health, social
protection, and job opportunities, while tackling climate
change and environmental protection.”70

The 17 sustainable goals include:

1. No poverty
2. Zero hunger
3. Good health and well-being
4. Quality education
5. Gender equality
6. Clean water and sanitation
7. Affordable and clean energy
8. Decent work and economic growth
9. Industry, innovation, and infrastructure

10. Reduced inequalities
11. Sustainable cities and communities
12. Responsible production and consumption
13. Climate action
14. Life below water
15. Life on land
16. Peace, justice, and strong institutions
17. Partnerships for the goals

BOX 1–8 n United Nations’ Sustainable
Development Goals

Source: (70)

7711_Ch01_001-022 23/08/19 10:19 AM Page 17

Services (DHHS). The scope of the agency’s efforts includes
the prevention and control of CDs and NCDs, injuries,
workplace hazards, disabilities, and environmental health
threats. In addition to health promotion and protection,
the agency also conducts research and maintains a national
surveillance system. It also responds to health emergencies
and provides support for outbreak investigations.73 Ac-
cording to the CDC, it is distinguished from its peer agen-
cies for two reasons: the application of research findings to
people’s daily lives and its response to health emergencies.74

The CDC collaborates with state and local health de-
partments in relation to disease and injury surveillance
and outbreak investigations, including bioterrorism. It
sets standards for the implementation of disease preven-
tion strategies and is the repository for health statistics.
Health statistics are available to health providers, health
departments, and the public.74 Web sites of interest to
nurses needing population level information include
CDC WONDER, FASTSTATS, and VITALSTATS (see
Box 1-10 for details).

Healthy People: Every decade Healthy People releases
a set of goals and health topics with specific objectives
aimed at improving health across the life span. As the tar-
get date of 2020 approached, the CDC and the USDHHS
worked on the development of the next iteration of
Healthy People, HP 2030 (see Box 1-11).73

18 U N I T I n Basis for Public Health Nursing Knowledge and Skills

1. Immunizations
2. Motor vehicle safety
3. Workplace safety
4. Control of communicable diseases
5. Declines in deaths from health disease and stroke
6. Safer and healthier foods
7. Healthier mothers and babies
8. Family planning
9. Fluoridation of drinking water

10. Tobacco as a health hazard

BOX 1–9 n Top 10 Public Health Achievements

Source: (79)

CDC WONDER provides online data sources (AIDS
public use data, births, cancer statistics); environment
(daily air temperature, land service temperatures,
fine particulate matter, sunlight, and precipitation);
mortality (detailed mortality, infant deaths, online
tuberculosis information systems); population (bridged
population, census); sexually transmitted morbidity;
and vaccine adverse event reporting.

Source: http://wonder.cdc.gov/.
FASTSTATS provides statistics on topics of public health

importance.
Source: http://www.cdc.gov/nchs/fastats/.
VITAL STATISTICS ONLINE DATA PORTAL is a

Web site that provides users with the ability to access
vital statistics, specifically birth and mortality data.
Source: https://www.cdc.gov/nchs/data_access/
vitalstatsonline.htm.

BOX 1–10 n Centers for Disease Control
and Prevention Web Resources

n HEALTHY PEOPLE 2030
Proposed Framework

For 2030, there are five overreaching goals and a plan
of action for reaching those goals.

Vision: “Where we are headed”

A society in which all people achieve their full potential
for health and well-being across the life span.

Mission: “Why we are here”

To promote and evaluate the Nation’s efforts to im-
prove the health and well-being of its people.

Overarching Goals: “What we plan to achieve”

• Attain healthy, purposeful lives and well-being.
• Attain health literacy, achieve health equity, eliminate

disparities, and improve the health and well-being of
all populations.

• Create social and physical environments that pro-
mote attaining full potential for health and well-being
for all.

• Promote healthy development, healthy behaviors,
and well-being across all life stages.

• Engage with stakeholders and key constituents across
multiple sectors to act and design policies that im-
prove the health and well-being of all populations.65

Public health systems are commonly defined as “all
public, private, and voluntary entities that contribute to
the delivery of essential public health services within a
jurisdiction.” This means that all entities’ contributions
to the health and well-being of the community or state
are recognized in assessing the provision of public health
services.72 As noted earlier, the CDC laid out 10 essential
public health services (see Box 1-1) that help guide all
public health organizations in the United States.9 These

7711_Ch01_001-022 23/08/19 10:19 AM Page 18

functions and services directly relate to the ability of
a public health department to address CDs, eliminate
environmental hazards, prevent injuries, promote
healthy behaviors, respond to disasters, and assure qual-
ity and accessibility of health services.72 The CDC col-
laborates with state and local health departments, as well
as public health entities across the world, especially the
WHO. Globally it has personnel stationed in 25 foreign
countries.

State Public Health Departments
States independently decide how they will structure their
local and state health departments (see Chapter 13). Vari-
ations exist across states in relation to the organization
and management of formal public health systems. The
variation stems, in part, from how the state government
has directed the establishment of public health boards or
departments and from the variation in state jurisdictional
structure. For example, some states such as Pennsylvania
use a town/city (municipality), township, or county sys-
tem, and other states such as Massachusetts divide their
entire state into municipalities. Finally, some states such
as Alaska have territories as well as municipalities because
they have smaller populations spread across a larger land

mass. States with sovereign Native American nations
within their borders add an additional layer to the struc-
turing of their state level public health department.

Local Public Health Departments
The basic mandate of the local public health department
is to protect the health of the citizens residing in their
county, municipality, township, or territory. However,
how public health departments implement this protec-
tion varies across states (see Chapter 13). This results in
variability in the services offered and the public health
activities of the local health departments. As a result of
federal mandates, public health departments uniformly
perform certain activities. These include surveillance,
outbreak investigation, and quarantine as well as man-
dated reporting of specific diseases and cause of death to
state health departments and the CDC. This allows the
federal government to track the incidence and prevalence
of disease from a national perspective. Local health de-
partments are essential to the health of communities and
provide the day-to-day services required to assure safe
environments and the provision of essential public health
services (see Chapter 13) with state departments and fed-
eral health organizations.

C H A P T E R 1 n Public Health and Nursing Practice 19

Overarching Goals
• Attain healthy, thriving lives and well-being, free of pre-

ventable disease, disability, injury, and premature death.
• Eliminate health disparities, achieve health equity, and

attain health literacy to improve the health and well-
being of all.

• Create social, physical, and economic environments that
promote attaining full potential for health and well-being
for all.

• Promote healthy development, healthy behaviors, and
well-being across all life stages.

• Engage leadership, key constituents, and the public
across multiple sectors to take action and design
policies that improve the health and well-being of all.

Plan of Action
• Set national goals and measurable objectives to guide

evidence-based policies, programs, and other actions to
improve health and well-being.

• Provide data that is accurate, timely, accessible, and
can drive targeted actions to address regions and

populations with poor health or at high risk for poor
health in the future.

• Foster impact through public and private efforts to im-
prove health and well-being for people of all ages and
the communities in which they live.

• Provide tools for the public, programs, policy makers,
and others to evaluate progress toward improving health
and well-being.

• Share and support the implementation of evidence-
based programs and policies that are replicable, scalable,
and sustainable.

• Report biennially on progress throughout the decade
from 2020 to 2030.

• Stimulate research and innovation toward meeting
Healthy People 2030 goals and highlight critical research,
data, and evaluation needs.

• Facilitate development and availability of affordable
means of health promotion, disease prevention, and
treatment.

BOX 1–11 n Healthy People 2030 Goals and Action Plan

7711_Ch01_001-022 23/08/19 10:19 AM Page 19

n Summary Points
• Public health is a core component of nursing knowl-

edge and competency across settings and specialties.
• The goal of nursing is to help people achieve optimal

health, which ultimately requires understanding the
health of populations and communities due to the
intricate interplay between individuals, families, and
the communities in which they live.

• Public health science encompasses efforts to improve
the health of populations from the cellular to the
global level.

• Public health provides us with the means to build a
healthy environment and respond to threats to our
health from nature and from humans.

• Public Health Nursing is a recognized specialty at the
generalist and advanced level with specific scope and
standards of practice.

• Formal structures from the global to local level exist
to promote health, reduce risk, and protect popula-
tions from threats to health.

REFERENCES

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20 U N I T I n Basis for Public Health Nursing Knowledge and Skills

t THE CASE OF THE PARASITE ON
THE PLAYGROUND

In 2018, the New York Times published an article
related to roundworms, genus Toxocara, found in the
intestines of cats and dogs that are shed in the feces.1
The CDC estimated that about 5% of the U.S. popula-
tion has been exposed based on positive blood tests
for Toxocara antibodies. The rate is higher in those
who live below the poverty line (10%) and for African
Americans (7%).1,2 The difference in prevalence appears
to be based on economic status due to the higher num-
ber of strays in poorer neighborhoods versus pets with
regular veterinary care. Based on a recent survey of
pediatricians conducted by the CDC, a little less than
half of the doctors correctly diagnosed it.3 Cognitive
development is one of the long-term consequences
associated with exposure to the worm.4

Suggested prompts for discussion:

1. Review the CDC Web site on Toxocara. What
interventions are needed at the individual level
versus the community level?

2. What knowledge does a nurse need to set up
interventions to prevent this disease?

3. What is the role of individual health care providers,
health care organizations, and public health depart-
ments. Who else might play a role?

4. How does this issue depict the role of the social
determinants of health in the spread of disease?

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22 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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23

KEY TERMS

Attributable risk
Behavioral prevention
Clinical prevention
Downstream approach
Ecological determinants of

health
Environmental prevention
Health education
Health literacy

Health prevention
Health promotion
Health protection
Indicated prevention
Intervention Wheel
Multiphasic screening
Natural history of disease
Population attributable

risk (PAR)

Prevalence
Prevalence pot
Prevented fraction
Prevention
Primary prevention
Reliability
Risk reduction
Secondary prevention
Selective prevention

Sensitivity
Social determinants of

health
Specificity
Tertiary prevention
Universal prevention
Upstream approach
Validity
Yield

n Introduction
The proposed vision of Healthy People 2030 (HP 2030)
is that of “A society in which all people achieve their
full potential for health and well-being across the life
span.” The mission is “To promote and evaluate the
nation’s efforts to improve the health and well-being of
its people.”1 Thus, the health of populations takes center
stage in the effort to achieve the vision of reaching the
full health potential for all. The major objective of nurs-
ing practice is to provide interventions to individuals,
families, communities, and populations aimed at ad-
dressing disease and optimizing health. This requires
implementing multiple levels of prevention along the
entire spectrum of health and disease. To provide the
best possible care requires not only an understanding of
the pathophysiology of disease but also of the concepts
of health promotion, risk reduction, and the underlying

frameworks of prevention that help guide nursing inter-
ventions. These frameworks are not unique to nursing
and, for the most part, come from the public health
sciences.

In 2018, the New York Times published an op-ed
article by Pagan Kennedy who explained that, although
there are things individuals can do to improve their
health, there are things that remain outside of our control
such as bad genes, unintentional injuries, and environ-
mental risk factors. She stated that, “It’s the decisions that
we make as a collective that matter more than any choice
we make on our own.”2 In other words, the effects of
the environment and genes can override what we do at
the individual behavioral level. Making our collective de-
cisions as a society about our environment is perhaps
more important than our individual decisions about our
behavior. Kennedy uses examples of experts in healthy
living who nevertheless died early despite adherence to

Chapter 2

Optimizing Population Health
Christine Savage and Sara Groves

LEARNING OUTCOMES

After reading the chapter, the student will be able to:
1. Apply the concept of population health to nursing

practice.
2. Describe current public health frameworks that guide

prevention efforts from a local to a global perspective.
3. Apply public health prevention frameworks to specific

diseases.
4. Compare and contrast different levels of health

promotion, protection, and risk reduction interventions.

5. Identify health education strategies and chronic disease
self-management within the context of prevention
frameworks.

6. Describe components of screening from a population
and individual perspective.

7. Identify public health methods used to evaluate the
outcome and impact of population-based prevention
interventions.

7711_Ch02_023-054 23/08/19 10:21 AM Page 23

a healthy diet and exercise. It is often factors outside our
individual control that contribute to early death.

To be effective as nurses, with the understanding that
our collective decisions as a society impact our health, we
need basic knowledge and skills at the population health
level as well as at the individual level to provide expert
care to individuals and their families. As evidenced by the
launch of the Nursing Now campaign in February of
2018, nurses are key to reaching the goals set by the World
Health Organization (WHO) as well as the proposed
HP 2030 goals. Nursing Now represents a collaborative
effort by the WHO and the International Council of
Nurses “… to improve health globally by raising the pro-
file and status of nurses worldwide – influencing policy-
makers and supporting nurses themselves to lead, learn,
and build a global movement.”3

As a profession, nursing contributes substantially to
the health of populations. In turn, healthier populations
lead to more robust communities and societies. To achieve
the proposed HP 2030 overarching goals (see Chapter 1),
HP published the proposed framework for these goals
that includes foundational principles that clearly link the
health of populations to a well-functioning society.

The proposed goals and foundational framework for
HP 2030 align well with those of the United Nations’
(UN) Sustainable Development Goals (SDGs) (Box 2-1)
that focus on sustaining and developing healthy
environments. In particular, goal three of the SDGs is
to “… ensure healthy lives and promote well-being
for all at all ages.”4 All of this requires a population
level perspective and encompasses more than treating
or preventing disease. It requires promotion of a healthy

24 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Goal 1. End poverty in all its forms everywhere.
Goal 2. End hunger, achieve food security and improved

nutrition, and promote sustainable agriculture.
Goal 3. Ensure healthy lives and promote well-being for

all at all ages.
Goal 4. Ensure inclusive and equitable quality education

and promote lifelong learning opportunities for all.
Goal 5. Achieve gender equality and empower all

women and girls.
Goal 6. Ensure availability and sustainable management of

water and sanitation for all.
Goal 7. Ensure access to affordable, reliable, sustainable,

and modern energy for all.
Goal 8. Promote sustained, inclusive, and sustainable

economic growth, full and productive employment,
and decent work for all.

Goal 9. Build resilient infrastructure, promote inclusive
and sustainable industrialization, and foster innovation.

Goal 10. Reduce inequality within and among countries.
Goal 11. Make cities and human settlements inclusive,

safe, resilient, and sustainable.
Goal 12. Ensure sustainable consumption and production

patterns.
Goal 13. Take urgent action to combat climate change

and its impacts.*
Goal 14. Conserve and sustainably use the oceans, seas,

and marine resources for sustainable development.
Goal 15. Protect, restore and promote sustainable use

of terrestrial ecosystems, sustainably manage forests,
combat desertification, and halt and reverse land
degradation and biodiversity loss.

Goal 16. Promote peaceful and inclusive societies for
sustainable development, provide access to justice
for all, and build effective, accountable, and inclusive
institutions at all levels.

Goal 17. Strengthen the means of implementation and
revitalize the Global Partnership for Sustainable
Development.

BOX 2–1 n Sustainable Developmental Goals

Source: (4)
*Acknowledging that the UN’s Framework Convention on Climate Change is

the primary international, intergovernmental forum for negotiating the global
response to climate change.

n HEALTHY PEOPLE 2030
Foundational Principles: “What Guides
Our Actions”

Note: Foundational Principles explain the thinking that
guides decisions about Healthy People 2030.

• Health and well-being of the population and communi-
ties are essential to a fully functioning, equitable society.

• Achieving the full potential for health and well-being
for all provides valuable benefits to society, including
lower health-care costs and more prosperous and
engaged individuals and communities.

• Achieving health and well-being requires eliminating
health disparities, achieving health equity, and
attaining health literacy.

• Healthy physical, social, and economic environments
strengthen the potential to achieve health and
well-being.

• Promoting and achieving the nation’s health and well-
being is a shared responsibility distributed among all
stakeholders at the national, state, and local levels,
including the public, profit, and not-for-profit sectors.

• Working to attain the full potential for health and well-
being of the population is a component of decision
making and policy formulation across all sectors.

• Investing to maximize health and well-being for the
nation is a critical and efficient use of resources.1

7711_Ch02_023-054 23/08/19 10:21 AM Page 24

access to healthier foods in 2014.6 Although this initiative
is not currently active, the framework provides a way to
visualize the interaction between the elements that con-
tribute to the health of populations.

Increasing the number of healthy persons at all stages
of their life across the globe requires purposeful and well-
planned prevention on the part of nurses across the con-
tinuum of prevention. The full scope of interventions
includes those aimed at health promotion, risk reduc-
tion, and disease prevention. Specific population health
interventions done routinely by nurses include screen-
ing, health education, and evaluation of the effectiveness
of disease and injury prevention programs.

Population Health Promotion, Health
Protection, and Risk Reduction
The social ecological model of health has been used in
the public health field for the last 3 decades and clearly
demonstrates that health occurs from the cellular to
global level (Chapter 1, Fig. 1-1). It provides a basis for
understanding health promotion and prevention efforts
key to the achievement of the HP Goals and the SDGs
through an inclusion of both the physical and social
environments as key components of health.7,8 More
recently some authors have suggested turning the model
inside out, “… placing health-related and other social
policies and environments at the center.”9 Turning it
inside out places the focus on community context as
a means for fostering health policy and environmental
development.9 Either way, the model emphasizes the
interaction among communities, policy, and environ-
ment and their role in the health of individuals and their
families.

The social environmental determinants of health are
different from the individual-level biological and behav-
ioral determinants of health that are the usual focus of
health prevention interventions. The use of the ecological
model within the context of health promotion, health
protection, and risk reduction requires the inclusion
of social relations, neighborhoods and communities, in-
stitutions, and social and economic policies in the devel-
opment of prevention strategies.

Health Promotion, Risk Reduction,
and Health Protection
Health promotion-related interventions are an essential
component of nursing practice and occur from the in-
dividual to the population level. Authors use various
terms in relation to reducing the occurrence or severity
of disease in a population and enhancing the capacity of

environment, ending poverty and hunger, and increas-
ing access to education.4 It also requires development
of partnerships within nations and across the globe to
promote a healthy world.

In the U.S., over the past 2 decades, health care has
taken on a central role at the federal policy level. Follow-
ing the passage of the Affordable Care Act (ACA), the
National Prevention Council released a comprehensive
plan, the purpose of which was to increase the number
of Americans who are healthy at every stage of life.5 It in-
cluded four broad strategic directions fundamental to
this prevention strategy: (1) building healthy and safe
community efforts; (2) expanding quality preventive
services in both clinical and community settings; (3) em-
powering people to make healthy choices; and (4) elim-
inating health disparities (Fig. 2-1). There were seven
priorities: (1) tobacco-free living, (2) preventing drug
abuse and excessive alcohol abuse, (3) healthy eating,
(4) active living, (5) injury- and violence-free living,
(6) reproductive and sexual health, and (7) mental and
emotional well-being.5 The National Prevention Council,
per the ACA, was required to provide the president with
an annual report until 2015. The last report covered ad-
vances made including increasing the number of colleges
with tobacco-free campuses, improving school nutrition,
increasing supports for breast feeding, and increasing

C H A P T E R 2 n Optimizing Population Health 25

Figure 2-1 National Prevention Strategy Priorities.
(From National Prevention Council, 2012.)

7711_Ch02_023-054 23/08/19 10:21 AM Page 25

a population to achieve optimal health. These terms
include health promotion, risk reduction, and health
protection. The WHO’s definition of health promotion
is: “… the process of enabling people to increase control
over, and to improve, their health. It moves beyond a
focus on individual behaviour towards a wide range of
social and environmental interventions.”10 Risk reduc-
tion refers to actions taken to reduce adverse outcomes
such as the use of a condom to reduce the risk of trans-
mission of a communicable disease (CD). Another term
used in conjunction with risk reduction is health pro-
tection, which puts the emphasis on increasing the per-
son’s ability to protect against disease. An example of a
health promotion intervention is the institution of an
exercise program in an elementary school; an example
of a health protection, risk reduction program is a
vaccination outreach program. The first intervention
promotes a healthy behavior and the second increases
the ability of the immune system to protect against a
communicable agent, thus reducing risk.

Health promotion often focuses on interventions
aimed at helping patients increase healthy behaviors,
such as a healthy diet and exercise, and reduce unhealthy
behaviors, such as tobacco use or at-risk alcohol use.
In 2008, Michael O’Donnell, editor-in-chief emeritus of
the Journal of Health Promotion, stated that health pro-
motion is both a science and an art that helps people
change their lifestyles to achieve optimal health.11 From
O’Donnell’s perspective, health promotion remains
rooted in individual behavioral change. However, exam-
ined from a broader perspective and following the
WHO definition, health promotion encompasses
activities taken to promote health that require changes
other than behavioral changes, such as facilitating the
individuals’ ability to improve the health of their envi-
ronment and increase their access to resources needed
to promote health, such as good nutrition or a safe place
to exercise.

The socioecological model provides the basis of eco-
logical health promotion that expands on O’Donnell’s
individual approach to health promotion by taking into
account social and ecological determinants of health
using an upstream approach. Ecological determinants
of health include “… potable water and sanitation, af-
fordable and clean energy, climate action, life below
water, and life on land.”12 Social determinants of health,
according to the WHO “… are the conditions in which
people are born, grow, live, work, and age. These circum-
stances are shaped by the distribution of money, power,
and resources at global, national, and local levels. The
social determinants of health are mostly responsible for

health inequities—the unfair and avoidable differences
in health status seen within and between countries.”13 To
achieve optimal health for all, educational, policy, eco-
nomic, and environmental strategies are used to increase
access to needed resources as well as interventions aimed
at health promotion and protection.14 Nurses support
this goal of achieving optimal health for all not only
through the delivery of care to individuals, families, and
communities but also through advocacy and active in-
volvement in policy development, implementation, and
evaluation (see Chapter 21).

Health Promotion
Health promotion at the individual and family level
helps people make lifestyle changes aimed at achieving
optimal health. These prevention interventions are
implemented in various ways and often focus on behav-
ioral change. In relation to obesity, health promotion ac-
tivities focus on diet and exercise. Health-care providers
deliver these interventions to individuals in their care.
These interventions are also delivered to populations via
health education programs, media campaigns, or in the
workplace. The goal of these health promotion programs
is to achieve change at the individual level based on the
biological and behavioral issues related to developing
disease due to obesity. The assumption is that the pro-
motion of healthy behaviors will reduce risk and thereby
reduce the prevalence of morbidity and mortality related
to obesity.

The ecological model allows us to expand on this
approach to health promotion by incorporating what is
referred to as an upstream approach in contrast to a
downstream approach to these efforts.14 An upstream
approach focuses on eliminating the factors that increase
risk to a population’s health. In contrast, a downstream
approach represents actions taken after disease or injury
has occurred. These two terms are important in under-
standing health promotion efforts today. Upstream rep-
resents a macro approach to addressing health whereas
downstream takes a more micro approach with a focus
on illness care. Both are needed to adequately address
health issues in the population.15 Take obesity as an ex-
ample. With a downstream approach, a health-care
provider may focus primarily on nutritional health
teaching based on nutritional patterns, portions, and
choices without taking into consideration the environ-
mental factors influencing choices within a community.
If there are no supermarkets within a community, it is
difficult to make healthy choices. In contrast to a down-
stream approach, an upstream approach to obesity might
include interventions focused on agriculture subsidies,

26 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch02_023-054 23/08/19 10:21 AM Page 26

transportation policies, and urban zoning. It might also
involve interventions restricting television advertising of
food to children, creating national nutrition standards
for meals served in childcare settings, or working with
the private sector to introduce healthier options in
restaurants and local markets

An upstream approach to health promotion related to
the obesity epidemic examines the environmental factors
that contribute to the epidemic and institutes prevention
interventions that target environmental change. Using
the first and third strategic directions of the National
Prevention Strategy as examples, this can occur through
empowering community members to initiate and imple-
ment the changes to create a healthy community. For
example, to promote healthy eating behaviors in chil-
dren, a school system in Kentucky took action and elim-
inated all fried foods that had been offered on the school
menu. Other communities have eliminated all vending
machines in schools that offer unhealthy beverages and
food. The National School Lunch Program supports in-
cluding larger portions of fruits and vegetables, less
sodium, and no trans fats. It also places a cap on the num-
ber of calories for the school lunch at 650 for grades K
through 5, 700 calories for grades 6 through 8, and
850 calories for grades 9 through 12. Milk can be at most
1% fat, and flavored milk must be fat-free although there
are flexibilities allowed to help provide more local con-
trol.16,17 Such an approach to health promotion requires
that the planners for the health promotion intervention
take into account the context of the healthy behavior they
hope the population will adopt. If the focus is only on
having the schoolchildren change their eating habits
without taking into account the food available to them
in their total environment, then that kind of health
promotion program will likely fail.

Health Protection and Risk Reduction
In contrast to health promotion, which focuses on the
promotion of a healthy lifestyle and environment,
health protection/risk reduction interventions protect
the individual from disease by reducing risk. These
terms are often used interchangeably, but are in actu-
ality distinct. A good example of health protection is
the use of vaccines. When an individual is vaccinated,
the body develops immunity to the infectious agent and
is therefore protected from the disease. The use of a
vaccine has reduced the risk of developing disease. Risk
reduction, conversely, encompasses more than biolog-
ical protection. It can involve removing risk from the
environment or reducing the level of risk, for example,
by reducing hazardous chemical emissions produced at

industrial plants. Health protection and risk reduction
activities are an important component of our national
effort to prevent disease.

Much of the health protection and risk reduction
activities currently used in our health-care system focus
on influencing behavioral change at the individual level.
The focus is to have individuals adopt protective health
activities, even if the prevention program is offered to
groups or populations. For example, policies related to
the recommended childhood vaccines are population
based and aimed at reducing risk for the development
of childhood CDs. However, the actual delivery of the
vaccine requires an individual response.

Risk reduction and health promotion must take into
account the broader concept of risk for development of
disease by incorporating environmental and social risk
factors associated with the development of disease that
may not be amenable through individual-level interven-
tions. For example, protection from lead poisoning re-
quires an environmental approach aimed at eradicating
lead paint in the environment. The risk factor, lead paint,
cannot be eliminated solely at the individual level and
often requires a system or community approach related
to allocation of funds, development of public policy, and
follow-through with the removal of lead paint from older
buildings in the community.

Prevention Frameworks
Prevention is a word used often in health care, but what
does it mean and how does it work? From a simplistic
standpoint, prevention refers to stopping something from
happening. From a health perspective, health prevention
refers to the prevention not only of disease and injury
but also to the slowing of the progression of the disease.
It also refers to the prevention of the sequelae of diseases
and injury, such as the prevention of blindness related
to type 1 diabetes. Health prevention is accomplished
through the institution of public health policies, health
programs, and practices with the goal of improving the
health of populations, thus reducing the risk for disease,
injury, and subsequent disability and/or premature death.

Health promotion and protection are fundamental
concepts for nursing practice and are based on preven-
tion frameworks in use in the public health field.18,19 Pre-
vention frameworks help nurses shape prevention
interventions within a particular context. In the summer
of 2016, a major public health issue was the Zika virus
epidemic. Preventing the spread of the disease was the
main focus of the public health interventions taken by
the Centers for Disease Control and Prevention (CDC)

C H A P T E R 2 n Optimizing Population Health 27

7711_Ch02_023-054 23/08/19 10:21 AM Page 27

and the WHO. These activities included behavioral,
environmental, and clinical interventions. People were
asked to modify their behavior by utilizing insect repellent
and avoiding unprotected sexual intercourse with a
person who had been exposed. Governments worked to
reduce the mosquito population through sprays, and
travel alerts were put in place. How do these interventions
relate to the natural history of disease, and how do they
fit into current public health prevention frameworks?

Natural History of Disease
An understanding of the natural history of disease is an
essential basis for the discussion of current prevention
frameworks that follows. The natural history of disease
provides the foundation for the public health frameworks
currently in use, especially the most widely used frame-
work of primary, secondary, and tertiary prevention.
The natural history of disease depicts the continuum of
disease from the disease-free state to resolution. The four
stages are (1) susceptibility; (2) the subclinical phase after
exposure when pathological changes are occurring with-
out the person being aware of them; (3) clinical disease
with the development of symptoms; and (4) the resolu-
tion phase in which the final outcomes are cure, disability,
or death.20,21 The subclinical phase is also sometimes
referred to as the incubation period for CDs and latency
period for noncommunicable illness (Fig. 2-2).

This traditional presentation of the natural history of
disease with four stages initially appears linear. For some
diseases such as influenza, this linear model works well.
In some disease processes, an individual may go from a
subclinical stage to a clinical stage and then back to a sub-
clinical stage. For example, in human immunodeficiency
virus (HIV) infection, during the initial subclinical stage
an infected individual has no clinical symptoms that meet
the criteria for a diagnosis of acquired immunodeficiency

syndrome (AIDS). As the infection progresses, the person
may develop one or more clinical diagnoses, thus placing
the individual in the clinical stage of the disease. However,
with the treatments now available for treating AIDS, an
individual may recover from a clinical episode and return
to being asymptomatic, but there has been no resolution
of the disease; instead, that individual has reverted to a
subclinical stage.

Figure 2-2 also depicts the outcome of a particular
disease. Following the development of clinical disease, an
individual recovers completely (cure), is disabled by the
disease (disability), or dies. Some diseases, both commu-
nicable and noncommunicable, have no endpoint except
death. HIV/AIDS is an example of a CD with no cure.
Those who become infected will remain infected for the
rest of their lives. An example of a noncommunicable
disease (NCD) without a cure is type 1 diabetes. A person
diagnosed with this type of diabetes does not at some point
in time revert to producing insulin at normal levels.

To further illustrate, examine the prevalence of a
disease and the prevalence pot. Prevalence is basically
the number of total cases of disease (numerator) divided
by the total number of people in the population (denom-
inator) and reflects the total number of cases of a disease
in a given population. A prevalence pot is a way of
depicting the total number of cases of the disease in
the population that takes into account issues related to
duration of the disease and the incidence of the disease
(Fig. 2-3). For some CDs with a short incubation period
such as influenza, cases rapidly move in and out of the
prevalence pot, but for long-term chronic diseases with
no known cure, the prevalence pot can grow over time
(e.g., HIV infection). If the definition of a case is infection
with the HIV virus, then individuals who are subclinical
and those who have evidence of clinical illness that meets
the criteria for an AIDS diagnosis would all be in the

28 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Stage of Recovery,
Disability, or Death

Stage of
Clinical Disease

Stage of
Subclinical Disease

Stage of
Susceptibility

Pathological
ChangesExposure

Onset of
Symptoms

Usual Time
of Diagnosis

Figure 2-2 The natural
history of disease timeline.
(From Centers for Disease
Control and Prevention. (1992).
Principles of epidemiology (2nd ed.).
Atlanta, GA: U.S. Department
of Health and Human Services.
Retrieved from http://www.cdc.
gov/osels/scientific_edu/ss1978/
lesson1/Section9.html.)

7711_Ch02_023-054 23/08/19 10:21 AM Page 28

prevalence pot. During the early years of the AIDS epi-
demic, there were few treatment options. Once diag-
nosed, an individual often died within a short period of
time. As treatment has improved and the survival rate
for those infected with HIV has greatly increased, the
number of AIDS-associated deaths has declined. How-
ever, the HIV/AIDS prevalence pot has grown, because
the only way out of the prevalence pot is through death.
In developing countries where treatment for HIV/AIDS
is less available, the prevalence pot has not grown as rap-
idly, even with a higher number of cases, because the life
span of those with HIV/AIDS remains short.

Mapping out a disease using the natural history of dis-
ease model helps to identify where on the continuum
prevention efforts are needed. The prevalence pot helps
identify those health conditions that may have an in-
creasing number of cases over time if the development
of new cases is not prevented. In the case of seasonal flu,
laying out the natural history of the strain of flu appear-
ing in a given year helps to determine where the primary
focus should be. In the beginning of the fall in most years,
the majority of the U.S. population does not have in-
fluenza. As the next few months progress, more and
more people usually become infected, and some die.
Based on the severity of the flu epidemic nationwide,
large-scale prevention efforts may be instituted. In 2009,
during the H1N1 flu outbreak, efforts focused on vacci-
nating populations at greatest risk, in that case pregnant
women, children, and older adults, resulting in a focus
on those without disease at highest risk for mortality.22

This was important due to the shortage of vaccines avail-
able. Those who were most vulnerable got priority for
receiving the vaccine. The H1N1 virus is now a regular

human flu virus. Based on the 2009 pandemic and data
from subsequent years, the CDC updated its warnings
related to populations that were most vulnerable.
The most vulnerable populations now include children
under the age of 5, pregnant women, older adults, Native
Americans, and Native Alaskans. 23

How does the natural history of the disease and the
prevalence pot help public health officials focus on inter-
ventions? In the case of flu epidemics, the incubation
period, that is, the time interval between infection and
the first clinical signs of disease (Chapter 8), is short, with
those infected rapidly developing symptoms. In addition,
the course of the disease is also short. People with in-
fluenza are able to infect others from 1 day before getting
sick to 5 to 7 days after getting sick. Those who become
infected with a flu virus rapidly develop clinical symp-
toms including fever, cough, and in some cases gastroin-
testinal symptoms. New cases that enter the prevalence
pot usually leave the pot within 7 days. Most recover
completely, some experience long-term effects such as
coma and/or respiratory problems, and some die.

Using the natural history of disease model, the nurse
can lay out the progression of influenza (see Fig. 2-2).
The preclinical phase is very short (1 to 2 days), and there
are no interventions available that would prevent the
progression from this phase to clinical disease. Once the
patient is in the clinical phase, there are limited options
for intervention because the causative agent, the flu virus,
does not respond to antibiotics. However, early recogni-
tion in vulnerable patients, such as older adults, and
treatment with antiviral medication may help to reduce
the risk of complications and adverse consequences.

Because of the limited ability of antiviral medication
to prevent adverse consequences in at-risk populations
and the short period of time between phases, the best
approach is to focus on preventing disease from occur-
ring in the first place. The natural history of influenza
provides the basis for the nationwide public focus on pri-
mary prevention through the development, distribution,
and administration of flu vaccines with the hope of keep-
ing the majority of the population disease-free because
of the limited ability to provide effective secondary or
tertiary prevention interventions.

The natural history of a disease also allows the nurse
to identify who is at greatest risk for developing the
disease. For influenza, early evaluation of the prevalence
of the disease by age groups helps to establish who is
most likely to become ill. In the case of the 2009 H1N1
flu pandemic, the CDC concluded that there was a
greater disease burden on those under the age of 25.22

Unlike in other flu outbreaks, those who were younger,

C H A P T E R 2 n Optimizing Population Health 29

Figure 2-3 The prevalence pot.

Death

Leaving the pot

New Cases
People newly

diagnosed

The
Prevalence Pot:

Total Current
Cases

All people with
the disease

Entering the pot

Disability

Cure

7711_Ch02_023-054 23/08/19 10:21 AM Page 29

immune compromised, or pregnant were at increased
risk of death. This led to the speculation that the virus
was related to earlier strains, and those in late adulthood
had immunity due to earlier exposure. Thus, the older
members of the population had natural biological pro-
tection, whereas those under the age of 60 did not. With
limited vaccine available in the fall of 2009, decisions
were made to provide the vaccine to those at highest
risk. This included pregnant women, household and
caregiver contacts of children younger than 6 months of
age, health-care and emergency medical services person-
nel, people from 6 months through 24 years of age,
and people aged 25 through 64 years who had medical
conditions associated with a higher risk of influenza
complications.

The natural history of disease for type 1 diabetes is quite
different from H1N1 flu. The etiology, or cause, of type 1
diabetes is genetic rather than infectious. Although there
is no known prevention for type 1 diabetes, early detection
during stage one can lead to early diagnosis and treatment.
However, identifying the disease early will not prevent the
development of clinical disease, which lasts for a lifetime
because the body is unable to produce insulin. There is no
cure. This puts the majority of the focus on treatment of
the patient in the clinical stage to prevent premature death
and disability. Another key distinction between the natural
history of these two diseases is that influenza is population
based, that is, the disease spreads from one person to
another. Interventions are required to protect the entire
population at risk. By contrast, a disease such as type 1
diabetes is individual based, and the risk is usually tied to
a genetic trait passed down in families.

Public Health Prevention Frameworks
The natural history of a disease and the difference be-
tween population-based risks and individual-based risks
form the basis for two main prevention frameworks used
in public health science. The first framework is the tra-
ditional public health prevention model of primary, sec-
ondary, and tertiary prevention.21 The second is the
framework of universal, selected, and indicated preven-
tion based on work done by Gordon and put forth by the
Health and Medicine Division (HMD) of the National
Academies of Sciences, Engineering, and Medicine (for-
merly known as the IOM). 24 Both use a health promotion
and health protection approach, and employ the three
types of interventions—clinical, behavioral, and environ-
mental. The best place to start is with the traditional pri-
mary, secondary, and tertiary prevention model, because
it has been in use since the 1950s, and the newer IOM
framework was not used widely until it was mandated by

the Centers for Substance Abuse Prevention (CSAP), a
branch of the U.S. Federal Substance Abuse and Mental
Health Service Administration (SAMHSA), in 2004.25

Levels of Prevention
The traditional public health approach to prevention
focuses on health prevention based on the natural his-
tory of disease and includes three levels of prevention—
primary, secondary, and tertiary. Primary prevention
interventions are conducted to prevent development of
disease or injury in those who are currently healthy.21

The focus is usually on people at risk for developing the
disease or injury but may take a population approach
such as recommendations that all persons be vaccinated
against the flu. Activities include promoting healthy
behaviors and building the ability of populations and
individuals within that population to protect themselves
against disease. Many health policies are aimed at
primary prevention such as banning smoking in public
places, which is aimed at reducing the development of
diseases secondary to exposure to second-hand smoke.
The goal is to reduce risk factors for a health problem.
If the risk for developing disease or sustaining an injury
can be reduced, then the incidence (occurrence of new
cases) of a disease will be reduced. Secondary preven-
tion interventions include those aimed at early detection
and initiation of treatment for disease, thus reducing
disease-associated morbidity and mortality.21 If early
intervention results in cure from the disease, with or
without disability, screening can contribute to the reduc-
tion of the prevalence of a disease (total number of new
and old cases), thereby reducing the size of the preva-
lence pot. Secondary prevention can include screening
or case finding in CD outbreaks by seeking contacts of
people already ill. The focus of tertiary prevention is the
prevention of disability and premature death and, when
indicated, the initiation of rehabilitation for those diag-
nosed with disease.21 It includes interventions aimed at
preventing secondary complications related to disease
such as the prevention of bedsores.

Primary Prevention: Primary prevention is a central
part of nursing practice. Nurses engage in the delivery of
primary prevention across settings, including the acute
care setting where, on first glance, it looks as though the
nurse is only providing tertiary prevention interventions.
Because this approach is based on the natural history of
disease, what types of primary prevention does a nurse
provide in an acute care setting when every patient ad-
mitted has a diagnosis of clinical disease? A prime exam-
ple is the activities nurses do to prevent hospital-acquired
infections. All nurses must follow hospital policy related

30 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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to the use of personal protective equipment, isolation
precautions, and personal hygiene. These activities pre-
vent the spread of infection from a patient with disease
to patients or health-care workers without disease.
Nurses also participate in primary prevention from a
health protection perspective. All nurses must comply
with hospital policy related to vaccinations. In this way
the members of the health-care workforce who are free
of disease take steps to build their immunity to disease,
thus preventing the spread of disease to patients and
fellow workers who are free of disease. All these activities
are population based.

Nurses also apply the principles of primary prevention
on an individual level through health education, vacci-
nation, and other activities aimed at promoting and
protecting the health of their patients and increasing
the patients’ ability to protect themselves from disease.
Patients receiving nursing care in acute care settings
who are receiving care for one clinical disease may be at
increased risk for other disease or injury. Nurses often
include primary prevention in their plan of care, such as
altering the environment to prevent falls and teaching
basic fall prevention strategies to patients and their
families that can be implemented on discharge. Health
education begins with primary prevention, teaching
patients to reduce risk for disease (e.g., teaching patients
to increase exercise, reduce caloric intake, and perform
proper hand hygiene). Nurses working in the community
provide primary prevention by providing health educa-
tion, promoting breastfeeding, and working with com-
munities to reduce hazards such as lead paint.

During epidemics and pandemics, countries depend
on nurses as frontline workers in nationwide primary
prevention efforts to reduce the incidence of the disease
and prevent premature death. Public health departments
across the country often mobilize nurses and student
nurses to administer the vaccines at schools, health clin-
ics, and other community settings. Because of the need
for nurses to deliver the vaccine to large groups of at-risk
individuals, nurses and other health-care providers are
often the first to receive the vaccine when it becomes
available. Primary prevention is an essential part of pro-
viding nursing care to individuals and populations across
all settings.

Secondary Prevention: Nurses also regularly partic-
ipate in secondary prevention interventions in all set-
tings. Screening is one aspect of secondary prevention
and is an essential component of the nursing assessment
focused on early detection of problems in asymptomatic
individuals who already have certain risk factors. Screen-
ing also targets conditions that are not yet clinically

apparent for purposes of earlier detection. Early treat-
ment reduces risk for further morbidity and for mortal-
ity. In acute, community, and long-term care settings,
nurses regularly screen patients of all ages for the possible
existence of a number of conditions. Screening for
developmental delays is an example of secondary pre-
vention in children, whereas encouraging mammograms
is an example of a secondary prevention intervention for
adults. The goal of mammograms is to detect early stage
breast cancer. Some activities done by nurses can serve
as both secondary prevention and tertiary prevention.
For example, the simple taking of blood pressures at a
blood pressure clinic held in a local senior center is a type
of screening when conducted with older adults who have
not been identified previously as having hypertension.
At the same clinic, taking an individual’s blood pressure
reading may function as a method for monitoring the
health status of an older person who has already been
diagnosed with hypertension.

Through early detection, nurses can implement
interventions that will alter the natural history of the
disease. For example, on admission to long-term care
facilities, elderly patients are routinely screened for skin
integrity. If there is any evidence of skin breakdown,
nursing interventions are immediately put in place to
halt the progression of a stage 1 pressure ulcer (bed sore)
to a stage 2. In stage 1, the skin is reddened, but there is
no break in the skin. Without intervention, the patient
is at greatly increased risk for skin breakdown and rapid
development of a stage 2 to a stage 3 pressure ulcer.

There are many circumstances when early detection
and initiation of treatment prior to the development
of clinical disease can improve outcomes. Public health
efforts to prevent premature death due to cancer include
media campaigns for mammography screening, colono-
scopies, and prostate screening. Screening is also con-
ducted for behavioral health issues such as at-risk alcohol
use (see Chapter 11). Screening for syphilis and early
treatment can prevent serious disability, reduce the in-
cidence of syphilis infection in newborns, and prevent
premature death. Nurses participate in these efforts
by conducting screenings and by educating patients to
encourage their participation in screening.

Health education is done with a secondary prevention
focus. For example, a nurse participating in a blood pres-
sure screening health fair will include secondary preven-
tion health education for adults with a blood pressure
reading greater than or equal to 130/80. Adults with a
blood pressure reading between 130/80 and 139/89 are
considered to have stage 1 hypertension, and those with
a blood pressure reading greater than 140/90 have stage

C H A P T E R 2 n Optimizing Population Health 31

7711_Ch02_023-054 23/08/19 10:21 AM Page 31

2 hypertension. It is recommended that the diagnosis of
hypertension be based on the average of ≥2 readings ob-
tained on ≥2 occasions.26 Thus, it is important to refer
persons with blood pressures greater than 130/80 to a
primary care physician for follow-up. Early intervention
through lifestyle changes and medical intervention can
reduce the development of life-threatening conditions
such as stroke or myocardial infarction.

Tertiary Prevention: The primary focus of nursing
interventions in most acute care settings is tertiary pre-
vention. Once an individual has been diagnosed with
clinical disease, prevention aims at reducing disability,
promoting the possibility of cure when possible, and pre-
venting death. Efforts are made to interrupt the natural
progression of the disease or to reduce the impact of the
injury through multiple strategies including medical, en-
vironmental, and psychosocial.

Health education is a key tertiary prevention activity
for the nurse. For those with chronic diseases, a disease
self-management approach is often used. This approach
puts the individual in charge of managing his or her
disease with the goal of reducing disability and prevent-
ing premature death. The nurse serves as the teacher/
facilitator by helping the individual to identify the key
strategies needed to manage disease, such as regular foot
care and blood sugar monitoring in patients with
diabetes. The use of chronic disease self-management is
effective in reducing health-care utilization in general
populations, improving perceived self-efficacy, and
improving perception of health status for various non-
communicable chronic diseases.27,28,29

Universal, Selected, and Indicated Prevention
Models
The traditional public health framework consisting of
levels of prevention was introduced in the 1950s and

still has utility today, especially for diseases in which the
natural history and causal pathways for development of
the disease are well understood. It is also useful when
the early clinical and subclinical signs of the disease
are known and the disease is actually preventable. On the
flip side, the framework has limitations because of the
underlying linear approach to diseases with a clear etiol-
ogy. The framework is difficult to adapt to diseases or
disorders (see Chapters 10 and 11) with complex risk
factors; a curvilinear progression; and broad health
outcomes that encompass not only physical outcomes
but also psychological, social, and economic outcomes.
It also limits the majority of the prevention efforts to in-
terventions conducted by health-care providers and is
not as readily applicable to the broader interdisciplinary
field of public health.

An alternate approach using a continuum-of-health
framework was proposed by the IOM in the 1990s and
has been adopted by the Substance Abuse and Mental
Health Services Administration (SAMHSA).25 This model
divides the continuum of care into three parts: preven-
tion, treatment, and maintenance (Fig. 2-4). Under pre-
vention there are three categories: universal, selected, and
indicated. This model was first adopted by the behavioral
health field because there is less distinction in mental
disorders and substance use disorders between the tradi-
tional levels of prevention that were developed based
on the natural history of disease—primary (stage of sus-
ceptibility), secondary (subclinical stage), and tertiary
(clinical stage).24

A universal prevention intervention is one that is
applicable to the whole population and is not based on
individual risk. The intervention is aimed at the general
population. The purpose is to deter the onset of a health
issue within the population. Public health media cam-
paigns use a universal approach by targeting everyone

32 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Compliance
With Long-term

Treatment
(Goal: Reduction
in Relapse and

Recurrence)

Standard
Treatment
for Known
Disorders

Case
Identification

Indicated

Selective

Universal

Aftercare
(Including

Rehabilitation)

Maintenance

Treatment

P
re

ve
nt

io

n

Figure 2-4 Continuum-of-Care
Prevention Model. (From the Substance
Abuse and Mental Health Services Admin-
istration. [2004]. Clinical preventive
services in substance abuse and mental
health update: From science to services
[DHHS Publication No. (SMA) 04-3906].)

7711_Ch02_023-054 23/08/19 10:21 AM Page 32

in the population with such things as a billboard anti-
smoking campaign or TV ads aimed at preventing
drunk driving. All individuals in the population are
provided with the information and/or skills necessary
to prevent disease regardless of risk. Often the interven-
tion is passive, as in media campaigns, in that nearly all
of the population is exposed to the intervention. The
intervention often does not include participation on an
individual level. However, universal vaccination pro-
grams are not passive and require active participation
by individuals. This is an appropriate approach when
the entire population is at risk and would benefit from
prevention programs.

Selective prevention interventions are aimed at a
subset of the population that has an increased level of
risk for developing disease. This can be based on demo-
graphic variables such as age, gender, or race, or it can be
based on other risk factors such as genetic, environmen-
tal, or socioeconomic risk factors. Examples of selective
prevention interventions include: efforts to screen
women for breast cancer who have a known family
history of breast cancer, or providing community edu-
cation programs to prevent lead poisoning in older
urban neighborhoods. This level of prevention targets
everyone in the subgroup regardless of risk. For exam-
ple, everyone in a neighborhood with older buildings is
included in the selective lead poisoning intervention
whether or not they have already removed the lead
from their own residence. Once again, a selective inter-
vention can be passive or have an active component on
the individual level.

Indicated prevention interventions are provided to
populations with a high probability of developing
disease. Like secondary prevention, the purpose of indi-
cated interventions is to intervene with individuals with
early signs of disease or subclinical disease to prevent the
development of a more severe disease. The difference is
that the individuals included in the intervention have
already been identified as being at greater risk for the
disease whereas in secondary prevention the effort is to
identify those with the disease among an apparently
healthy population. The indicated prevention approach is
used in the substance abuse field to develop programs for
individuals with early warning signs of increased potential
for developing a substance use disorder, such as falling
grades or at-risk alcohol use. Only those individuals with
specific risk factors for developing the disease but who do
not yet meet the diagnostic criteria for the disease are
included in the intervention. The purpose is to reduce
behavioral risk factors that contribute to the develop-
ment of disease and to delay onset of disease or severity

of disease. The level of intervention provided is more
intensive and often multilevel. It always requires individ-
ual participation. An example of an indicated prevention
program is that of a weight-loss program for adolescents
who are obese and are showing signs of hyperglycemia
but who have not been diagnosed with type 2 diabetes.
Such an intervention would probably include case man-
agement, health education, nutritional counseling, and
an individualized exercise plan. If the program is effec-
tive, participants may not only delay the onset of type 2
diabetes but may also reverse the hyperglycemia and not
develop the disease.

Delivery of Public Health Prevention Strategies
The delivery of prevention services includes the use of
three basic strategies—clinical, behavioral, and environ-
mental. Clinical prevention strategies are those that
use a one-to-one delivery method between the health-
care provider and the patient, and usually occur in tra-
ditional health-care settings. These can include health
protection activities such as vaccinations, as well as
screening, and early detection of disease. Behavioral
prevention, often focused on health promotion strate-
gies, is aimed at changing individual behavior such
as exercise promotion, smoking cessation, or responsi-
ble drinking. Environmental prevention focuses on
health protection by improving the safety of the envi-
ronment such as fluoridating water, banning smoking
in public places, enacting laws against drunk driving,
enforcing clean air acts, and building green spaces for
recreation.21

In an effort to standardize clinical prevention strate-
gies through the application of evidence-based preven-
tion practices, the Agency for Healthcare Research and
Quality (AHRQ) created the U.S. Preventive Services
Task Force.30 This task force is made up of a panel of
experts in primary care and prevention. These experts
systematically review the evidence found in published
research related to the effectiveness of prevention strate-
gies and then develop recommendations for clinical
interventions. These recommendations are helpful in the
development of a clinical prevention program.

The earlier example of type 2 diabetes illustrates how
to apply both frameworks to a serious national health
issue. Globally, many health issues contribute to prema-
ture death. The CDC provides yearly updates on the
top 10 causes of death in the United States (Box 2-2).31,32

This is based on the classification of the death or injury
using accepted codes entered in the death registry for
each death. This information is sent to the U.S. Depart-
ment of Health and Human Services, which then sends

C H A P T E R 2 n Optimizing Population Health 33

7711_Ch02_023-054 23/08/19 10:21 AM Page 33

the information to the CDC. The cause of death listed on
the death certificates at the local level is the basis for the
aggregate statistics related to mortality rates at the state
and national levels. Though this provides important in-
formation, the underlying risk factors provide the infor-
mation needed to build health promotion, protection,
and risk-reduction interventions.

Not only is cause of death classified by disease or
injury, it is also further classified by risk factor, that
is, the underlying cause of death. Four health at-risk
behaviors—lack of exercise or physical activity, poor
nutrition, tobacco use, and drinking too much alcohol—
are underlying causes for illness and premature death.33

In other words, it is important not only to track the
causes of actual deaths but also to track the occurrence
of preventable risk factors to help predict whether efforts
to prevent these deaths are working. This information
helps to guide major prevention efforts aimed at reduc-
ing both morbidity and mortality in populations.

Each death can also be classified in quantitative terms
using attributable risk and prevented fraction. Attribut-
able risk is the measure of the proportion of the cases or
injuries that would be eliminated if a risk factor was not
present. Epidemiologists begin by determining the the-
oretical limit of the impact of prevention aimed at re-
moving the risk factor. That is, if the risk factor did not
exist, how many cases would be eliminated? For example,
if no one smoked, how many cases of lung cancer would
be eliminated, or if no one drove while intoxicated, how
many motor vehicle crashes (MVCs) would not occur?
It is calculated using the population attributable risk
(PAR), which is based on the strength of the risk factor
and the prevalence of the risk factor in the population.
To determine the strength of the risk factor, epidemiol-
ogists calculate what is referred to as the relative risk (RR)
(Chapter 3). If these pieces of the equation are known,

that is, the RR and the prevalence, then the PAR can be
calculated.21

Those who wish to implement a prevention program
can use the PAR to calculate the cost benefit and cost effec-
tiveness of the prevention program. However, the PAR is
population based and operates on the assumption that the
risk factor is removed from the entire population being
targeted. The prevented fraction provides the information
on what can be accomplished based on the intervention
actually being delivered at the community level. The
prevented fraction is defined as a measure of what can
actually be achieved in a community setting. It includes
the proportion of the population at risk that actually
participates and the number of cases prevented. This
approach takes into account the number of participants in
a program who will actually succeed in eliminating the risk
factor. For example, how many obese children participat-
ing in an after-school activity program will actually reduce
their weight to a normal body mass index?

Prior to implementing an intervention aimed at
prevention, it is important to understand the underly-
ing risk factors. The top four risk factors for preventable
death in the United States—tobacco use, improper
diet, physical inactivity, and alcohol use—relate to
behaviors.33 At first glance, it appears that a behavioral
intervention is the best approach. However, other in-
terventions are also helpful, including environmental
and policy-based interventions. For example, alcohol-
related MVCs can occur with just one episode of heavy
episodic drinking. The teenage driver who has con-
sumed alcohol for the first time at high levels and then
drives home may become involved in an MVC that
results in the death of people who are not consuming
alcohol. The teen did not have an alcohol use disorder
but instead had engaged in at-risk alcohol use. The nat-
ural history of disease does not fit this health-related
issue, yet prevention of alcohol-related MVCs is an
important issue. The questions become:

• What types of interventions will work to prevent dis-
ease or injuries?

• Is it primary, secondary, or tertiary prevention?
• Can it occur using a clinical, behavioral, or environ-

mental approach?
• In designing this approach, should it be addressed

as a universal, selected, or indicated preventive
intervention?

In answering these questions, it is important to have
a better understanding of some potential public health
nursing interventions and a framework that guides
public health nursing practice.

34 U N I T I n Basis for Public Health Nursing Knowledge and Skills

• Heart disease: 635,260
• Cancer: 598,038
• Accidents (unintentional injuries): 161,374
• Chronic lower respiratory diseases: 154,596
• Stroke (cerebrovascular diseases): 142,142
• Alzheimer’s disease: 116,103
• Diabetes: 80,058
• Influenza and pneumonia: 51,537
• Nephritis, nephrotic syndrome, and nephrosis: 50,046
• Intentional self-harm (suicide): 44,965

BOX 2–2 n Number of Deaths for Top 10 Leading
Causes of Death, 2017

Source: (31)

7711_Ch02_023-054 23/08/19 10:21 AM Page 34

A Public Health Nursing Framework
Conceptual frameworks and models guide the practice
of public health nurses (PHNs). One of the models im-
plemented by the Minnesota State Department of Health
in 2001 is the Intervention Wheel, which illustrates how
PHNs can improve the health of the individuals, families,
communities, and systems34,35 (Fig. 2-5). The model
evolved from the practice of PHNs in Minnesota and

consists of several components. The first component is
the population basis of all interventions. This component
illustrates that the focus of all interventions is population
health. The second component consists of the three levels
of care: individual/family, community, and systems. Care
can be provided at all three levels of working with indi-
viduals, the community as a whole, or with systems. In-
dividual level practice focuses on knowledge, attitudes,
practices, beliefs, and behaviors of individuals. A PHN’s

C H A P T E R 2 n Optimizing Population Health 35

Public Health Interventions
Applications for Public Health Nursing Practice

March 2001

Minnesota Department of Health
Division of Community Health Services
Public Health Nursing Section

Figure 2-5 Components of
the Intervention Wheel. (From
Minnesota Department of Health,
Division of Community Health
Services, Public Health Section.
[2001]. Public health interventions:
Applications for public health
nursing practice.)

7711_Ch02_023-054 23/08/19 10:21 AM Page 35

home visit to a new mother is an example of individual-
level practice. During the visit, the PHN provides antic-
ipatory guidance about the value of breastfeeding.

Community-level practice is focused on changing
norms, attitudes, practices, awareness, and behaviors. An
example of community-level practice is the development
of a faith-based program focused on smoking cessation.
Systems-level practice is concerned with policies, laws,
organization, and power structures within communities.
For example, a coalition of several senior housing sites
could be formed to address pest control and improve-
ment of overall environmental conditions, or a group of
parents could come together to build a safe playground
for the children.

The third component consists of 17 public health
interventions (Box 2-3). Three of these interventions—
health education, screening, and case management—are
discussed in this chapter as they relate to levels of pre-
vention, and the other interventions are discussed in
other chapters.

A Primary Prevention Approach:
Health Education
The purpose of health education is to positively change be-
havior by increasing knowledge about health and disease.
Health education is an important nursing intervention,

36 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Advocacy pleads someone’s cause or act on someone’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.

Case finding locates individuals and families with identified
risk factors and connects them with resources.

Case management optimizes self-care capabilities of indi-
viduals and families and the capacity of systems and
communities to coordinate and provide services.

Coalition building promotes and develops alliances among
organizations or constituencies for a common purpose.
It builds linkages, solves problems, and/or enhances
local leadership to address health concerns.

Collaboration commits two or more people or organiza-
tions to achieve a common goal through enhancing the
capacity of one or more of the members to promote
and protect health. (Henneman, Lee, & Cohen. [1995].
Collaboration: A concept analysis. Journal of Advanced
Nursing, 21, 103-109.)

Community organizing helps community groups to iden-
tify common problems or goals, mobilize resources, and
develop and implement strategies for reaching the goals
they collectively have set. (Minkler, M. [Ed.]. [1997].
Community organizing and community building for health
[p 30]. New Brunswick, NJ: Rutgers University Press.)
Delegated functions are direct care tasks that a regis-
tered professional nurse carries out under the authority
of a health-care practitioner as allowed by law. Dele-
gated functions also include any direct care tasks that a
professional registered nurse entrusts to other appro-
priate personnel to perform.

Consultation seeks information and generates optional
solutions to perceived problems or issues through in-
teractive problem-solving with a community, system,
family, or an individual. The community, system, family,

or individual selects and acts on the option best meet-
ing the circumstances.

Counseling establishes an interpersonal relationship with
the community, a system, the family, or an individual
intended to increase or enhance their capacity for self-
care and coping. Counseling engages the community, a
system, family, or an individual at an emotional level.

Disease and other health event investigation systemati-
cally gathers and analyzes data regarding threats to
the health of populations, ascertains the source of
the threat, identifies cases and others at risk, and
determines control measures.

Health teaching communicates facts, ideas, and skills that
change knowledge, attitudes, values, beliefs, behaviors,
and practices of individuals, families, systems, and/or
communities. (Adapted from American Nurses Associa-
tion [2010]. Nursing’s social policy statement: The essence
of the profession. [2010]. Silver Springs, MD; American
Nurses Publishing.)

Outreach locates populations-of-interest or populations-
at-risk and provides information about the nature of the
concern, what can be done about it, and how services
can be obtained.

Policy development places health issues on decision mak-
ers’ agendas, acquires a plan of resolution, and deter-
mines needed resources. Policy development results in
laws, rules and regulations, ordinances, and policies.

Policy enforcement compels others to comply with the
laws, rules, regulations, ordinances, and policies created
in conjunction with policy development. (Minnesota
Department of Health, Division of Community Health
Services, Public Health Section. [2001]. Public health in-
terventions: Applications for public health nursing practice.
Retrieved from http://www.health.state.mn.us/
divs/opi/cd/phn/docs/0301wheel_manual.pdf.).

BOX 2–3 n Public Health Interventions

7711_Ch02_023-054 23/08/19 10:21 AM Page 36

and it is important in changing behavior at all levels of
prevention. The Joint Committee on Health Education
and Promotion Terminology defined health education
as learning aimed at acquiring information and skills
related to making health decisions.36 The WHO defines
health education as “… any combination of learning
experiences designed to help individuals and communi-
ties improve their health, by increasing their knowledge
or influencing their attitudes…”37 Health education in-
volves not just teaching but also encouraging and giving
confidence to people to take the necessary action to im-
prove health, which includes making changes in social,
economic, and environmental determinants of health.

Theories of Education
Because health education involves teaching, understand-
ing how people learn is essential to effective teaching.
There are a number of learning theories that help us
understand how learning occurs from both a physiolog-
ical and social basis. The main theories come under four
categories: behaviorism, cognitivism, constructivism,
and humanism.

Behaviorism is the theory of classical conditioning. In
this framework, the behavior change is what is impor-
tant, and it is achieved with an environmental stimulus
that results in a response. The focus is only on the
observed behavior change and not on the mental activity.
Learning is based on reward and punishment by condi-
tioning (e.g., when a monkey learns to push a button for
a reward of food).38

The cognitive framework focuses more strongly on
inner mental activity. It is more rational than it is on re-
flexively responding to an external stimulus. There is be-
havior change as a result of knowledge that has changed
thought patterns. It frequently occurs as a result of varied
sensory inputs with repetition. The social learning theory

of Bandura is rooted in both the behavior and cognitive
frameworks, emphasizing that understanding, in addition
to behavior and environment, are all interrelated. He
stresses imitation of a behavior and reinforcement in
learning.39 An example of Bandura’s theory of social
learning is television commercials. An action is portrayed,
eating a certain food or using a certain cleaning product,
and the audience, seeing it as desirable, is encouraged to
model or imitate that behavior.

Constructivism is a learning theory that reflects on
our own experiences.40 We actively construct our own
world as we increase our experience and knowledge. It
is a process that builds knowledge within our own
unique framework. A good example is problem-solving
learning. To learn, students are actively involved in in-
tegrating new knowledge in their own frameworks with
guidance from the teacher. For example, children can
learn about what happens to their heart rate with exercise
by experimenting with different types of exercise and
counting pulse rates. They experience the concept of a
heart rate rather than merely having it verbally explained
to them.

Humanism learning uses feelings and relationships,
encouraging the development of personal actions to
fulfill one’s potential and achieve self-actualization.38

It is self-directed learning, examining personal motiva-
tion and goals. This is also a theory of adult learning.40

As an example, an individual diagnosed with elevated
cholesterol purchases books, seeks out articles, talks with
knowledgeable people, and in general informs him- or
herself about the problem and actions to take to solve the
problem then self-initiates these activities to improve
health.

All learning theories influence how we teach. The
identified teaching methods based on these theories
are varied but include the need to be developmentally

C H A P T E R 2 n Optimizing Population Health 37

Source: (34)

Referral and follow-up assist individuals, families, groups,
organizations, and/or communities to identify and
access necessary resources to prevent or resolve
problems or concerns.

Screening identifies individuals with unrecognized health
risk factors or asymptomatic disease conditions in
populations.

Social marketing uses commercial marketing principles and
technologies for programs designed to influence the
knowledge, attitudes, values, beliefs, behaviors, and
practices of the population-of-interest.

Surveillance describes and monitors health events
through ongoing and systematic collection, analysis,
and interpretation of health data for the purpose of
planning, implementing, and evaluating public health
interventions (Centers for Disease Control and
Prevention. [2012]. CDC’s vision for public health
surveillance in the 21st century. Morbidity and Mortality
Weekly Report, S61).

BOX 2–3 n Public Health Interventions—cont’d

7711_Ch02_023-054 23/08/19 10:21 AM Page 37

appropriate with children and with adults with varying
levels of education. Many of the more recent theories
provide a more balanced learning; encourage experien-
tial learning; and solve real problems in real places
by using role playing, visual stimuli, service learning,
interpersonal learning, and the promotion of complex
higher-order thinking.

Adult Learning
Pedagogy (pedagogical learning) is the correct use of
teaching strategies to provide the best learning. Andra-
gogy is similar but is specifically the art and science of
helping adults learn using the correct strategies.40 In
nursing, we are often teaching adults, as it is adults who
generally develop chronic diseases, are in a position to
promote health, and care for children. In the 1950s
Malcolm Knowles, using humanism learning theory,
suggested that adults learn differently from children and
that the role of the instructor is quite different. Adults
bring a great deal of experience to the learning situation,
and this experience influences what education they
receive and how they receive it.41 They are active learners
and need to see applications for the new learning.
Knowles identified six suppositions for adult learning:

1. The adult needs to know why he or she is learning
something.

2. The adult’s own experiences are an important part
of the learning process.

3. Adults need to participate in the planning and eval-
uation of their learning.

4. Adults learn better if the information has immediate
relevance.

5. Adults like problem-centered approaches to learning.
6. Adults respond better to internal rather than to

external motivation.

The role of the teacher in this situation is to direct the
learner.41

To be an effective educator the nurse needs to be flex-
ible. Nurses organize the learning experience by first as-
sessing the individual’s or population’s learning needs.
They then select the best learning format, create the best
possible learning environment, and send a clear message.
The learning should be participatory and include evalu-
ation and feedback.

Health Literacy
One of the first considerations before planning health
education is to consider the health literacy of the indi-
vidual client, the group, or the population. In conjunc-
tion with literacy, culture and language should also be

included. Health literacy is defined as “the degree to
which individuals have the capacity to obtain, process,
and understand basic health information and services
needed to make appropriate health decisions.”42 The
HMD division of the National Academies of Sciences,
Engineering, and Medicine built on this definition and
added key issues related to the individual receiving in-
formation. They stated that health literacy is something
that “emerges when the expectations, preferences, and
skills of individuals seeking health information and serv-
ices meet the expectations, preferences, and skills of those
providing information and services. Health literacy arises
from a convergence of education, health services, and
social and cultural factors.”42

Assessing literacy levels is currently done based on
levels, with levels 4 and 5 representing the top level and
level 1 and below representing the lowest literacy level.
According to the National Center for Education Statis-
tics, 18% of U.S. adults scored at or below level 1.43

They reported an association between age and literacy
with a greater percentage of those between the ages
of 25 and 44 scoring at the top level. For those who
were unemployed, 75% had 12 years of education or
less and approximately a third scored at level 1 or
below.44 There is evidence of a causal relationship
between health literacy and health outcomes. Those in-
dividuals with basic health literacy had a higher level
of health-care utilization and higher expenditures for
prescriptions.45 To address the problem of health liter-
acy the CDC put together five talking points about
health literacy that can be adapted to a specific organ-
ization as a means to advocate for promotion of heath
literacy (Box 2-4).46

Shame and stigma of having low health literacy have
been found to be major barriers to seeking care. The IOM
committee found that health education occurred in most
primary and secondary schools, but there was no univer-
sal sequencing, and only about 10% of teachers were qual-
ified health educators. One of the most telling of the IOM
findings was that health professionals had limited training
in patient/population education and had few opportuni-
ties to develop skills to improve a patient’s health literacy.
The IOM gave multiple suggestions on how to improve
health literacy, and points of intervention (Fig. 2-6). Some
of the most relevant to nursing included:

• Improve K through 12 basic health education.
• Help individuals learn how to assess the credibility of

what they see and read about health.
• Provide clear communication, allow ample time to

give this information, and encourage questions from
the patient.42

38 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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In the past few years, considerable research has been
done that brings better understanding to the magnitude
and consequences of the health literacy problem. One of
the issues is how to assess correctly and rapidly the level
of health literacy in a patient/population. Though there
are tools to screen for health literacy, they were developed
primarily for research purposes and are not currently rec-
ommended for routine use. Instead the recommendation
is to use universal health literacy precautions, which
translates into providing patients with information both
oral and written that is understandable and easily acces-
sible to persons across all education levels.47 The AHRQ
recommends use of universal health literacy precautions
and lays out what needs to be done (Box 2-5). The AHRQ
developed an evidenced-based toolkit for health-care

providers to help implement universal health literacy
precautions within a health-care setting. The goal is to
increase the health literacy of all patients, not just those
that appear to need assistance.48

Develop a Teaching Plan
Writing a teaching plan for individuals or populations
provides a means to lay out what will be taught, using
what methods, as well as a method for evaluating the
effectiveness of the teaching plan (Box 2-6). The teaching
begins with the assessment of the health education need.
What does this individual or population need to learn, or
what would they benefit from learning, to promote
health, prevent disease, or help manage an identified
health problem? Next, the nurse assesses the type of
learner or learners who will receive the education. For
example, what is their level of health literacy? Also, what
is the cultural context for the population? What is their

C H A P T E R 2 n Optimizing Population Health 39

Potential Intervention Points

Health
System

Culture
and

Society

Health
Outcomes
and Costs

Education
System

Health
Literacy

3

1

2

Figure 2-6 Potential points for intervention in the
health literacy framework. (From Nielsen-Bohlman, L.,
Panzer, A., Kindig, D. [2004]. Health literacy: A prescription to
end confusion [IOM Report].)

You are a health literacy ambassador. It is up to you to
make sure your colleagues, staff, leadership, and commu-
nity are aware of the issues. Whether to review for
yourself, present to others, or convince your leadership,
the following resources may help you talk about health
literacy.

Five Talking Points on Health Literacy: These brief
talking points may be helpful if you need to tell someone
quickly what health literacy is and why it is important.
Add in talking points relevant to your organization.

1. Nine out of 10 adults struggle to understand and use
health information when it is unfamiliar, complex, or
jargon-filled.

2. Limited health literacy costs the health-care system
money and results in higher than necessary morbidity
and mortality.

3. Health literacy can be improved if we practice clear
communication strategies and techniques.

4. Clear communication means using familiar concepts,
words, numbers, and images presented in ways that
make sense to the people who need the information.

5. Testing information with the audience before it is
released and asking for feedback are the best ways
to know if we are communicating clearly. We need
to test and ask for feedback every time information is
released to the general public.

BOX 2–4 n The CDC’s Five Talking Points on Health Literacy

Source: (45)

Health literacy universal precautions are the steps that
practices take when they assume that all patients may
have difficulty comprehending health information and
accessing health services. Health literacy universal precau-
tions are aimed at:

• Simplifying communication with and confirming
comprehension for all patients, so that the risk of
miscommunication is minimized.

• Making the office environment and health-care system
easier to navigate.

• Supporting patients’ efforts to improve their health.

BOX 2–5 n Health Literacy Universal Precautions

Source: (47)

7711_Ch02_023-054 23/08/19 10:21 AM Page 39

age, gender, and level of vulnerability? All of this infor-
mation will help drive how the information is provided.
Inclusion of the recipients in the planning process can be
an important strategy as can be the use of peer teachers.

Once the assessment has been completed, the next
step is to identify the goal(s) of the health education

program. Again, inclusion of the recipients in the pro-
gram will result in shared goals and greater engagement
of those receiving the program. For example, if from the
nurse’s perspective the goal of a proposed health educa-
tion program is to reduce premature births, including
women in the community who are pregnant or who may
become pregnant in the development of the program
may help shape the articulation of goals. What are the
immediate benefits to them for having a full-term baby?
What other issues are they concerned about related to
pregnancy and birth? This way specific objectives can be
written that truly meet the goals of the community.

To help frame learning objectives, Bloom identified
three learning domains: cognitive, affective, and psy-
chomotor.50 Identifying which learning domain is being
targeted is important when developing the plan. Within
the cognitive domain, Bloom identified six levels of cog-
nitive learning, from simple knowledge recall to more
abstract and higher-level synthesis and evaluation. Each
level, especially the first three, builds on the next. This is
referred to as Bloom’s Taxonomy, and this classification
is useful in looking at levels of learning, outcomes, and
the correct action verbs to be used when writing specific-
level learning objectives (Box 2-7). The first level of
learning is knowledge, which refers to remembering or
recalling specific information that has been taught. Com-
prehension is the second level and requires some demon-
stration of really understanding what was learned.
Application, the third level, requires using the knowledge
in real situations such as problem-solving. The next level
is analysis, wherein the acquired knowledge is broken
down by its organization and things such as making
inferences and looking for motives or causes. The last
two are synthesis and evaluation. In synthesis, the ac-
quired knowledge is used creatively to produce some-
thing new. Evaluation provides a way to judge the end
product. In addition to cognitive learning, Bloom also
identified affective and psychomotor learning. The affec-
tive domain looks at a growth in feelings, values, and at-
titudes. Psychomotor learning is the development of
manual or physical skills, a domain frequently taught by
nurses.

Once the plan is developed, the next step requires
identifying materials and resources needed for effective
teaching. Factors include the length of the lesson, where
it will be taught, what activities will promote the best
learning, and how much time will be needed to prepare
the lesson. It is helpful to write out a description of the
lesson including the key concepts and the learning do-
main of knowledge, attitude, and/or practice. The final
two steps are to write out the detailed procedure for the

40 U N I T I n Basis for Public Health Nursing Knowledge and Skills

1. Identify the health education need in the selected
population (individual/family/community).

2. Assess the learner; include health literacy, culture,
language, age, and learning style.

3. Write a goal for the teaching intervention.
4. Write specific, measurable objectives for the teaching

intervention (consider Bloom’s Taxonomy).
5. Identify materials and resources needed for the

teaching plan; include the appropriate teaching
environment and the length of the lesson.

6. Describe the lesson; include key concepts.
7. Write out the procedure step by step for teaching

the lesson using a variety of teaching methods.
8. Have a plan for the evaluation.

BOX 2–6 n Steps in Developing a Health Education
Teaching Plan

n CULTURAL CONTEXT
National Institutes of Health: Clear
Communication
The NIH Office of Communications and Public Liaison
(OCPL) established a “Clear Communication” initiative
related to health literacy with cultural respect as one of
the two foci of the initiative. Specifically:

• Cultural respect is a strategy that enables organizations
to work effectively in cross-cultural situations. Developing
and implementing a framework of cultural competence
in health systems is an extended process that ultimately
serves to reduce health disparities and improve access to
high-quality health care.

• Cultural respect benefits consumers, stakeholders, and
communities. Because a number of elements can influence
health communication—including behaviors, language,
customs, beliefs, and perspectives—cultural respect is also
critical for achieving accuracy in medical research. NIH
funds and works with researchers nationwide for the
development and dissemination of resources designed to
enhance cultural respect in health-care systems.49

Further resources are available through their Web site.

7711_Ch02_023-054 23/08/19 10:21 AM Page 40

teaching plan, carefully outlining each activity, and, if ap-
propriate, the follow-up for these activities. The final
component is to determine how an evaluation will meas-
ure whether or not the intended learning took place. The
evaluation plan should reflect the learning objectives and
be in place before teaching begins to anticipate how to
measure the outcomes.

Methods of Instruction
There are many ways to learn the same information, and
each of us has a preference for how we like to learn. There
are lists of different teaching methods that include formal
presentations, small-group work, field trips, role playing,
written assignments, and Internet activities, to identify a
few. Usually, experiential learning is most effective for
adults. Lecture format rarely appeals to an adult who
wants guided interactive learning. If people can feel it,
handle it, see it, taste it, smell it, and discuss it, they can
better integrate it into their own life experiences. A group
concerned with nutrition and being overweight may be
told that Ritz crackers, potato chips, corn chips, and
cheeseburgers are high in fat and also high in calories.
The group can be given numbers of calories and grams,
but it is not easily integrated into their life experiences.
However, if the portion size of four Ritz crackers, 10 po-
tato chips, and 1 ounce of corn chips, all having 8 to
9 grams of fat, are demonstrated, it is easier for people to
put it into the context of their own lives.

Using real-life scenarios to teach how to solve health
problems has also been quite effective. Giving new moth-
ers a vignette in which a family is having difficulty getting
adequate sleep at night because their 4-month-old
infant is awake all night allows for group discussion and
problem-solving that can be relevant at the moment. This
is information these women can take home and apply
immediately. Teaching children the importance of exer-
cise by using videos, Internet, and PowerPoint slides
can be entertaining and provide basic knowledge. Help-
ing children form walking groups and joining them for
their walks can help them apply this knowledge and start
to change behavior. Written material can help encourage
discussion, but the material must be appropriate for
literacy, content, culture, and language.

Regardless of the teaching method, it is always impor-
tant to emphasize the benefits of the proposed behavior
change and to personalize the message. A good strategy
is to apply the intended new behavior within the context
of the individual’s lifestyle and needs. Help clients weigh
the cost and benefit of the new health behavior. Key
points should be emphasized during teaching and new
information provided in small increments. Most people
can absorb only one or two new pieces of information in
an encounter. Learners are the best source of information
about what they want to learn and if the teaching method
is meeting their needs. Feedback should be frequently
sought from learners.

C H A P T E R 2 n Optimizing Population Health 41

Knowledge Comprehension Application Analysis Synthesis Evaluation
Define Discuss Interpret Distinguish Plan Judge
Repeat Recognize Apply Calculate Design Appraise
List Explain Use Test Assemble Value
Name Interpret Practice Compare Invent Assess
Tell Outline Demonstrate Question Compose Estimate
Describe Distinguish Solve Analyze Predict Select
Relate Predict Show Examine Construct Choose
Locate Restate Illustrate Compare Imagine Decide
Write Translate Construct Contrast Propose Justify
Find Compare Complete Investigate Devise Debate
State Describe Examine Categorize Formulate Verify
Arrange Classify Classify Identify Create Argue
Duplicate Express Choose Explain Organize Recommend
Memorize Identify Dramatize Separate Arrange Discuss
Order Indicate Employ Advertise Prepare Rate

Locate Practice Appraise Propose Prioritize
Determine

BOX 2–7 n Bloom’s Taxonomy of Learning*

Source: (49)
*Active verbs represent each level.

7711_Ch02_023-054 23/08/19 10:21 AM Page 41

The environment should not be neglected in a teach-
ing plan. The physical environment is important and
should be maximized as much as possible even when
many things in a community setting may be outside of
one’s control. A space should be the right size, have a
comfortable temperature, adequate places to sit, the nec-
essary resources for the planned lesson, and a place
where, as appropriate, the learners can receive and share
confidential information. However, one also needs to
create an environment conducive to learning in which
the learner has space to be an active learner and to learn
from real situations with someone to assist with guidance
and direction to master the material. It should be a place
in which individuals feel free to voice opinions, experi-
ment with new ideas, and identify what they do not
know; a place in which there is enthusiasm for learning
in a nonthreatening environment.

Evaluation
Successful learning changes behavior. Deciding how to
evaluate whether this learning has occurred requires re-
ferring back to the specific objectives for the level of
learning that was to take place and the specific outcomes
expected. If the first stage of teaching was to increase
knowledge, an appropriate method is needed to measure
whether the knowledge did increase. If the objective was
for the mother to explain how the different childhood
immunizations will keep her child healthy and prevent
disease, the mothers should be asked to repeat back the
information they have just received or play a game in
which they have to know the answers to specific factual
questions. If the objective was to help individuals apply
knowledge, the applied learning should be evaluated
in a different way. For application, one can provide a sce-
nario at the end of the teaching session and then note
how students solve the problems utilizing the informa-
tion just taught. A follow-up discussion with the group
may be held after they have had time to apply their new
knowledge. If the objective was for the mother to practice
primary prevention by having her child fully immunized
by 2 years of age, the mother’s behavior may be observed
after the teaching to determine whether the knowledge
has been applied and the child has been fully immunized.

There are several tools that can be used to evaluate
health education. It is always a good idea to ask for verbal
reaction to the teaching at the end of a teaching session.
This is useful in planning for future health education
sessions. To measure an increase in knowledge, a classic
pre- and post-test should be used, or a pre- and post-
interview/observation. Using a formal testing method is
frequently not well liked by adult learners, especially

those who have limited literacy skills. They respond
better to the oral interview, but this is more difficult to
carry out. To assess change, one can observe and inter-
view over a specific time period, especially to note the
sustainability of the change. These tools need to be
thoughtfully developed to provide objective, reliable
data. Likewise, long-term effects of the teaching may be
evaluated using objective predesigned tools (for more
complete discussion of evaluation, see Chapter 5).

Health education forms the basis for many health pre-
vention programs aimed at improving the health of in-
dividuals as well as of families. Nurses learn this skill first
with individuals, then families, and finally with popula-
tions and communities. Health education operates under
the assumption that improving health literacy is central
to improving health. In addition to health education,
other activities regularly performed by nurses, such as
screening, contribute to building the health of commu-
nities. Often these activities require the use of health
education as a strategy to improve full participation in
the prevention activity.

A Secondary Prevention Approach:
Screening and Early Identification
Just as health education is the basis of many primary
prevention programs, screening is central to secondary
prevention. The classic definition of screening is the
presumptive identification of unrecognized disease or
defect by the application of tests, examinations, or other
procedures that can be applied rapidly to sort out those
with a high probability of having the disease from a
large group of apparently well people.51 Screening is not
diagnostic and only indicates who may or may not have
a disease or a risk factor for disease.

Nurses routinely screen for health risks and disease
across health-care settings. This type of intervention
clearly fits within the secondary prevention phase of the
traditional public health prevention model. This allows
for early identification and treatment of disease as well
as the reduction of risk for those who are at greatest
risk for developing disease or sustaining injury. A good
example is blood pressure screening. If those with hyper-
tension are identified prior to development of clinical
symptoms, the institution of behavioral and clinical
interventions such as diet modification and the use of a
diuretic can bring the individual’s blood pressure back
to within the normal range and prevent adverse health
consequences associated with hypertension, such as
stroke. Screening conducted to detect risk factors in

42 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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people without disease includes screening for at-risk
drinking or fall risk. This type of screening is aimed at
distinguishing those with a higher risk for developing
disease or injury from those with low risk. For example,
screening for at-risk drinking not only identifies those
who may have an alcohol use disorder but also identifies
those with a current drinking pattern that puts them at
risk for developing an alcohol use disorder, developing
alcohol-related adverse consequences, or experiencing
alcohol-related injury (see Chapter 11).

When using the traditional public health model,
screening clearly falls into the category of secondary
prevention. The purpose is to identify within a group
of apparently well people those who probably have the
disease. For those with complex risk factors and a less
clear natural history of disease, the traditional model
has less utility. This is true with mental health, sub-
stance use disorders, and injury. In these cases, screen-
ing is done for the purpose of detecting risk for disease
or injury prior to the occurrence of disease as well as
the detection of disease in those who are apparently
well. It can be classified as both primary and secondary
prevention.

Using a continuum of health approach to prevention
provides a broader context for understanding the role of
screening as a prevention intervention. Screening in-
cludes identification of those with risk factors for disease
or injury as well as those with subclinical disease. In the
first case the assumption is that early detection of risk
and delivery of risk reduction interventions will reduce
disease or injury from occurring. In the second case,
the assumption is that early identification and treatment
of those with disease will result in reduction of the mor-
bidity and mortality associated with the disease. This
allows for screening to prevent disease or injury from
occurring in the first place (primary prevention) as well
as to prevent adverse health consequences that can be
avoided with early detection and treatment of disease
(secondary).

Most diseases are associated with a complex set of risk
factors and often do not progress in a linear fashion. In
addition, the broader continuum health model takes into
account not only adverse physical outcomes, but also
psychological, social, and economic outcomes. An exam-
ple of screening that reflects primary prevention is the
approach being used to prevent childhood obesity.
Screening for risk factors such as inactivity and high
caloric intake can help identify children without disease
who would most benefit from an intervention. Thus, the
screening process is conducted in a population without
disease to separate those with a high probability for

developing disease or sustaining an injury from those
with low or no risk factors for the disease or injury.

Diagnosis, Screening, and Monitoring
The difference between diagnosis, screening, and monitor-
ing is often blurred. For example, taking blood pressure
readings at a blood pressure screening event that only
includes people who have not been diagnosed with hyper-
tension is clearly screening, detecting probable disease in a
population of apparently well people. Taking a blood pres-
sure reading for a patient every 4 hours on a medical-surgi-
cal unit in the hospital is done to monitor the patient’s vital
signs and detect possible changes in the patient’s status,
and it is not a screening activity. Taking blood pressure
readings at a booth at a health fair where many of the par-
ticipants come to the booth and state that they have
hypertension and need to know how they are doing is a
combination of screening and monitoring, because many
of the participants have already been diagnosed. The nurse
practitioner or physician takes a blood pressure reading
during a physical work-up to assist in establishing a differ-
ential diagnosis for hypertension. The same activity is done
to screen, monitor, or assist in obtaining a diagnosis.

For each of these activities, there are set parameters
for the measure. In the case of monitoring the patient,
the nurse compares the most recent blood pressure read-
ing with the patient’s baseline reading and the readings
over the admission to determine whether there has been
a change in the patient’s status. The blood pressure read-
ing is part of a larger nursing assessment and, if the read-
ing reflects a change in the patient’s status, the nurse may
change the plan of care for either a positive or negative
change. When using the blood pressure reading from a
diagnostic standpoint, there are specific guidelines for
the clinician, and the blood pressure levels are based
on the average of two or more readings. These readings
are taken during the course of two or more visits.26 Using
the guidelines, the clinician can make a diagnosis of
stage 1 or stage 2 hypertension, or classify the patients as
prehypertensive. The guidelines have been revised based
on growing evidence related to both hypertension and
the development of a new category of risk, prehyperten-
sion, and are evidence based.26

The guidelines state that the process for diagnosing
hypertension occurs after an initial screening. So how
does the screening differ from the diagnostic stage be-
cause the same measurement is taken—a blood pressure
reading using standard equipment? In this case, the main
difference is that the screening is based on one reading
rather than two or more blood pressure readings over a
number of visits, and the purpose of taking the blood

C H A P T E R 2 n Optimizing Population Health 43

7711_Ch02_023-054 23/08/19 10:21 AM Page 43

pressure reading is to identify those who may be hyper-
tensive and are in need of further assessment and possi-
ble treatment. The clinician conducting the screening
will refer the individual whose blood pressure meets the
cutoff for probable hypertension to a clinician who is
qualified to conduct the needed assessment and is able
to make a differential diagnosis.

Sensitivity and Specificity
For all of these activities—screening, monitoring, and
diagnosis—the clinician must have a clear understanding
of the reliability and validity of the measure chosen to
screen for risk and/or probability of disease. Understand-
ing the reliability and validity of a screening tool provides
the clinician conducting the screening with the guide-
lines for deciding what is a positive screen and what is a
negative screen, that is, who most probably has the dis-
ease and who most probably does not. Or in the case of
screening for risk, it provides the guidelines for deciding
what is considered high risk and what is considered
low risk. In the case of blood pressure screening, the
screening is done for the most part using the same basic
instrument used to diagnose disease and monitor phys-
ical status, but for other health issues, the screening tool
is different from the diagnostic tool. Determining the
validity of the instrument for screening uses different
criteria than for diagnosis or for monitoring status.

In screening, the reliability and validity of the instru-
ment is crucial. Reliability is defined as the ability of the
instrument to give consistent results on repeated trials.
Validity is defined as the degree to which the instrument
measures what it is supposed to measure. For screening
instruments, the two aspects of validity that are the main
concerns are the sensitivity and the specificity of the in-
strument. Sensitivity is defined as the ability of the
screening test to give a positive finding when the person
truly has the disease, or true positive. Specificity is de-
fined as the ability of the screening test to give a negative
finding when the person truly does not have the disease,
or true negative.

44 U N I T I n Basis for Public Health Nursing Knowledge and Skills

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Silent Killer
Public Health Science Topics Covered:

• Screening
• Population assessment
• Health planning

Choosing a screening instrument requires under-
standing the importance of both sensitivity and

specificity. For example, in a hypothetical case a
team of nurses at a large urban hospital noticed that
there had been an increase in admissions of African
American men with a diagnosis of cardiovascular dis-
ease secondary to hypertension. They wanted to put
a large-scale blood pressure screening program in
place for the African American men in their city to
improve early detection of hypertension and poten-
tially reduce the need for hospitalization. Prior to
implementing the program, they wanted to make sure
that the method they used to screen for hypertension
was valid. This was important for two reasons. First,
they did not want to have too many false negatives. In
other words, they wanted to identify as many men as
possible with hypertension because there was such a
high morbidity and mortality rate for untreated hy-
pertension in the male African American population.
Second, they did not want too many false positives,
because this population had limited resources to pay
for care. Unnecessary visits to the physician could
result in reduced participation in the program, espe-
cially because an accurate diagnosis requires more
than one visit to a health-care provider. Too many
false positives could result in unnecessary utilization
of health-care resources.

Prior to initiating a full-scale screening program,
the nurses conducted a pilot with 250 African Ameri-
can men who had not been diagnosed with hyperten-
sion, who were not taking antihypertensive (blood
pressure–lowering) drugs, and who were not acutely
ill. To do the screening, they used a standard blood
pressure cuff and stethoscope and measured the
blood pressure in millimeters of mercury (mm Hg).
The nurses debated over the cutoff point. The 2017
guidelines for a diagnosis of stage one hypertension
is a blood pressure reading greater than or equal to
130 systolic (mm Hg) or greater than or equal to
80 diastolic was not yet released.26 Thus, they chose
the then-current diagnostic criteria of a blood pressure
reading greater than or equal to 140 systolic (mm Hg)
or greater than or equal to 90 diastolic. To evaluate the
sensitivity and specificity of the screening, all the partici-
pants were asked to complete three follow-up visits
with a primary care physician to establish whether or
not the participants had hypertension. Because this was
a pilot study, the nurses obtained written consent from
the participants and followed the Internal Review Board
process required by their institution.

Once they had obtained approval, the nurses con-
ducted the pilot study with 250 participants. First, the

7711_Ch02_023-054 23/08/19 10:21 AM Page 44

C H A P T E R 2 n Optimizing Population Health 45

A = True positives (screened positive and had the disease)

Screening for stage 1 or 2 hypertension with 250 persons

B = False positives (screened positive and did not have the disease)

C = False negatives (screened negative and had the disease)

D = True negatives (screened negative and did not have the disease)

Screening
Results Yes No Total

40

A

Yes 15 55

Disease (+ = BP �140/90)

B

C D

15No 180 195

55Total 195 250

Figure 2-7 Sensitivity and specificity matrix.

nurses screened the participants for possible hyperten-
sion by obtaining a blood pressure reading. They then
obtained follow-up data on all 250 in relation to
whether or not they were diagnosed with stage one or
stage two hypertension based on the current classifica-
tion of hypertension for adults age 18 years and older.
A diagnosis of hypertension is based on the average
of two readings greater than or equal to 130 systolic
(mm Hg) or greater than or equal to 80 diastolic.26 The
nurses then calculated basic frequencies on their data
and found that 55 of the participants screened positive
for hypertension and, on follow-up, 55 were diagnosed
with hypertension. On the surface, it looked as though
their screening instrument was 100% sensitive as they
correctly identified all who had the disease, but that
was not the case.

To determine the sensitivity and specificity of the
method they used to screen for hypertension, the
nurses constructed a two-by-two matrix using screen-
ing and diagnostic data (Fig. 2-7). They determined the
number of participants that belonged in each box of
the matrix. Each box of the matrix corresponds to four
different categories of participants: (1) those who were
true positives, that is, they screened positive and the
physician diagnosed them with hypertension, box A;

(2) those who were false negatives, that is, they
screened negative but the physician diagnosed them
with hypertension, box C; (3) those who were false
positives, that is, they screened positive and the physi-
cian did not diagnose them with hypertension, box B;
and (4) those who were true negatives, that is, they
screened negative and the physician did not diagnose
them with hypertension, box D.

Using these numbers, the nurses examined the sen-
sitivity of their instrument. They took the total of all
the persons who had positive screens and were subse-
quently diagnosed with either stage one or stage two
hypertension and divided it by the total number of peo-
ple diagnosed with the hypertension and multiplied this
by 100. Another way to express this formula is to use
the letters in the lower right-hand corner of two of the
boxes in the matrix, boxes A and C. The total number
of true positives, or A, is 40, and the total number
with disease (true positives plus false negatives)
equals 55, or A + C. Thus, the formula for sensitivity
is (A/(A + C)) × 100. In this example, the sensitivity is:
(40/55) × 100, or 72.7%

They then determined the specificity of their instru-
ment. To do this, they repeated what they had done
with sensitivity, but now they were concerned with
the relationship between those who were true nega-
tives and the total number who screened negative.
Again, the letters in the lower right-hand corner of
the boxes are used to construct the formula, but this
time the boxes of interest are boxes B and D. The
total number of participants who are true negatives,
or D, is 180, and the total number without disease
equals 195, or D + B. The formula for specificity is
(D/(B + D)) × 100. In this example, the specificity is:
(180/(15 + 180)) × 100 = 92.3%

In this example, the specificity of the screening
test was higher at 92.3% than the sensitivity that is
72.7%. More than 25% of the participants who had hy-
pertension would have been missed if the participants
relied on screening alone, but less than 10% of those
without disease were incorrectly identified as possibly
having hypertension when they actually did not have
the disease (see Fig. 2-5). The nurses had met one of
their requirements for the program (high specificity)
but not the other requirement of high sensitivity.
How could they address these issues?

First, they could look at the reliability of the instru-
ment they were using to obtain the blood pressure
reading. Because the method of measurement for
screening and diagnosis in this case is the same, the

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46 U N I T I n Basis for Public Health Nursing Knowledge and Skills

120/80

True negatives

False positive
and negative
screening

True positives

100/70 130/85 140/90 160/10 180/11 200/12

Figure 2-8 Distribution of blood pressure readings in
those with and without hypertension.

reliability could be a concern. There are two possible
issues: variation in the method and observer variation.
Observer variation has been known to happen when
taking blood pressures using the standard method
owing to observer variation in hearing acuity and expe-
rience in taking blood pressures. The nurses actually
addressed this issue prior to conducting the pilot
study. They did both inter-rater and intra-rater reliabil-
ity, testing at baseline for the nurses who would con-
duct the screening. For the inter-rater reliability, they
had different nurses take the blood pressure on the
same individual to determine the variation between
each rater’s blood pressure reading. For intra-rater
reliability, they compared one nurse or rater’s measure
of repeated blood pressures on the same person.
They initially found low inter- and intra-rater reliability
between the nurses. They then conducted a blood
pressure training workshop for all the nurses who
participated in the screening. Following training, the
reliability of the measure was high.

Because the nurses felt confident that they had
been using a reliable instrument, they considered ad-
justing their cutoff point. As they were working on the
project the 2017 Guideline for the Prevention, Detection,
Evaluation, and Management of High Blood Pressure in
Adults was released. They decided to reexamine the
sensitivity and reliability of their screening using the
new criteria for stage one hypertension of a blood
pressure reading greater than or equal to 130 systolic
(mm Hg) or greater than or equal to 80 diastolic.
Adjusting the cutoff point to a lower value could im-
prove the sensitivity of the screening process, but
would it result in reducing the specificity as they first
feared? Making this decision was done not only based
on the new guidelines, but also by comparing the con-
sequences of a false negative with the consequences
of a false positive. In this case, a false positive would
result in extra visits to the physician, whereas a false
negative would result in untreated disease. Missing
more than a quarter of the population being screened
was a serious problem. Hypertension is known as the
silent killer, that is, the disease has few if any clinical
symptoms until damage has occurred. A person with
the disease often does not know he or she has it until
damage has already occurred.

The nurses plotted the blood pressure readings on
a chart to help determine the cutoff point for 100%
sensitivity and 100% specificity to help decide whether
a lower cutoff point would increase sensitivity while
still maintaining adequate specificity. Plotting out the

normal distribution of the blood pressure values in
those with hypertension and those without hyperten-
sion helped to illustrate what would happen if they
changed the cutoff value (Fig. 2-8). If they changed
the value to 130/80, they would have 100% sensitivity,
but their specificity would drop to nearly 50%. If they
shifted the cutoff point to 145/95, they would achieve
100% specificity but decrease their sensitivity to less
than 70%. Choosing a cutoff value is always a compro-
mise. In this case, the nurses decided to use the diag-
nostic criteria for stage one hypertension as their
cutoff point. This increased their sensitivity to over
80% whereas the specificity decreased only a small
amount to a little less than 90%.

Armed with the information on the reliability and
validity of their screening method, the nurses were
ready to present a proposal to their hospital for
conducting the hypertension screening program as
a citywide outreach program for the hospital. They
approached the director of the community outreach
department with their information, sure that they
would be able to proceed. The director asked them
questions to which they could not respond, so they
went back to obtain more information.

The first question the director posed was, “What
is the expected yield of the screening program?” The
nurses were not sure what this meant. They found
that the yield is defined as the number of previously
undiagnosed cases of disease that result in treatment
following screening. They already had a crucial piece
of information, the sensitivity of the screening program
they proposed. The higher the sensitivity is, the greater
the potential yield will be. The next issue related to

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C H A P T E R 2 n Optimizing Population Health 47

yield is the prevalence of undetected disease. This
depends on the duration of the disease, the duration
of the subclinical phase of the disease, and the level
of available care. The natural history of disease (see
Fig. 2-2) was a helpful guide for the nurses. They went
back to their original literature review related to hy-
pertension and once again found clear evidence that
the duration of the subclinical phase (stage 1) can be
long, and early treatment can have significant effects on
reducing morbidity and mortality. They also reviewed
the statistics on access to care for the low-income
African American population with high levels of
poverty in their city. Owing to changes in the cutoff
for Medicaid eligibility in their state, access to care
was limited and African American males in the immedi-
ate area were less likely to have regular physical
checkups. The nurses also charted out the current
national estimates on the prevalence of undiagnosed
hypertension in African American males. They found
that more than 40% of African Americans have
hypertension, and hypertension was often not diag-
nosed in this population until individuals became
symptomatic.52,53

The nurses concluded that, because of the high
sensitivity of their screening method and the high
prevalence in the target population, the potential yield
was high. However, they had not reviewed the avail-
ability of medical care. Because they needed to deter-
mine whether treatment was available for those who
screened positive, they did a review of all the primary
care clinics in the area. They also reviewed their pilot
data on the resources used by the participants to iden-
tify which primary care clinics were most frequently
used. They then contacted these clinics to determine
whether the clinics would be able to handle a large
influx of potentially new clients following the screening.
The nurses were able to establish that the existing
primary care system was sufficient and that the major-
ity of clinics and primary care offices were willing to
put in writing their support for the project.

The second question the director asked had to do
with multiphasic screening, defined as administering
multiple tests to detect multiple conditions during the
same screening program. The nurses had not consid-
ered this idea, but felt it had merit and reviewed the
current information on health and African American
males. They found that colorectal cancer (CRC) and
high cholesterol were two other serious health prob-
lems for African American males. However, conducting
CRC screening would require a different approach

owing to the complexity of the screening procedure.
Although combining blood pressure screening with
screening for high cholesterol was promising, it was
more invasive and would require purchasing more
supplies, possibly using more personnel. The nurses
also did not have pilot data to provide information on
the sensitivity and specificity of screening with a sample
from the target population, so they would have to rely
on national data.

The director had also asked about the cost benefit
of the program. Because they were asking the hospital
to fund this program, the director wanted to know
the possible benefits of the program related to cost,
simplicity of administration, safety, and acceptability
of the population. The nurses mapped out the actual
budget of the proposed program. Because no new
equipment was needed, the majority of the cost was in
staff time. To reduce costs, the nurses collected a pool
of nurse volunteers willing to participate in the pro-
gram. The taking of blood pressures is safe and nonin-
vasive, and takes little time to complete. This helps
reduce cost because the time needed to conduct the
screening per individual is short.

When reviewing the acceptability of the program,
they were careful not to make the assumption that, be-
cause blood pressure clinics are common, the popula-
tion they wished to engage would come to theirs.
They had asked the participants in their pilot study for
feedback on the best site for conducting the screening
and they also enlisted the help of members of the
community in identifying the right sites and means of
advertising the program. They also reviewed the litera-
ture for evidence of other successful screening pro-
grams with African American males. Though some of
the participants had mentioned schools or churches as
good sites, the site that was mentioned most and also
supported in the literature was the local barbershop.

The nurses shared their data with the director
and reported that the blood pressure screening
program they proposed had a potentially high yield
and the cost would be low given the availability of vol-
unteers. They suggested that the screening program be
conducted in the local barbershops but recommended
that further work be done to develop a partnership
with the owners of these shops prior to implementing
the program. They then discussed the possibility of de-
veloping a multiphasic screening program by combining
blood pressure screening with other screenings such
as cholesterol but cautioned that this would require
additional funding and time investment.

7711_Ch02_023-054 23/08/19 10:21 AM Page 47

Criteria for Screening Programs and Ethical
Dilemmas
Screening is performed on a regular basis across popu-
lations and settings, and is often taken for granted as a
worthwhile endeavor. Prior to implementing a screening
program, it is important to determine whether the
screening program meets certain criteria. There are
serious ethical considerations that must be addressed.
For the majority of screening, the core assumption is that
the screening program will reduce disease-associated
morbidity and mortality due to early identification and
engagement in treatment. The other major assumption
is that all those who screen positive for probable disease
have access to appropriate assessment and treatment
services. These assumptions form the basis of the criteria
used to determine whether a screening program should
be implemented.

Criteria for Screening Programs
The first criterion is to be certain that the screening test
has high specificity and sensitivity. This is complex as
demonstrated in the previous case study. There is always
a trade-off between specificity and sensitivity. When
planning a screening program, it helps to review the im-
pact of missing true cases versus falsely identifying a per-
son with the disease as having the disease. For example,
if the disease being screened has a high mortality rate, it
may be more important to identify as many individuals
with the disease as possible; that is, it should have a high
sensitivity. That way there is a good chance of detecting
disease, even if the specificity is low and the percentage
without disease that ends up going through diagnostic
testing is high. However, those who screen positive and
do not have disease may unnecessarily experience a high
level of stress while waiting to find out whether they
do indeed have the disease. On the opposite end, if the
mortality for the disease is lower and the cost and incon-
venience of diagnostic testing is high, high specificity
may be more important than high sensitivity. The best-
case scenario is to have a test with both high specificity
and high sensitivity. There is always a trade-off.

The next important criterion is that the test needs to
be simple to administer, inexpensive, safe, rapid, and ac-
ceptable to patients. Screening that can be done quickly
with minimal time and effort has a higher likelihood
of success. It also needs to be safe. Some screening tests
are invasive and may carry some risk. For example, a
colonoscopy requires some anesthesia with its associ-
ated risk. A paper-and-pencil questionnaire is noninva-
sive and carries minimal risk. Also, a simple one-page

48 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 2-9 Blood pressure screening. (From Centers for
Disease Control and Prevention, James Gathany, 2005.)

The director then challenged them to describe how
they would evaluate the success of the program. In
response they shared with him the hospital discharge
data that had initially sparked their interest in doing
the screening. They felt that this would provide suffi-
cient baseline data to help evaluate the outcome of
the screening program. The director asked them to
clarify what their programmatic outcome would be.
They were not sure, so the director asked them to
come back when they had a clear idea of how they
would evaluate the success of the program (for more
on evaluation, see Chapter 5). After reviewing basic
models for program evaluation, they decided on a
short time span for their evaluation and chose simple
measures to evaluate the impact of the program. They
chose to measure the number of people who attended
the program, the number of positive screens, and the
number of positive screens who accepted information
related to referral for treatment. They went back to
the director and stated that, owing to the limited re-
sources for the targeted population, there were three
clinics that were most often used by residents in the
targeted community. The nurses felt it would be practi-
cal to track individuals postscreening. To do this, they
proposed to first keep a record of how many men
attended the screening. They then would contact each
of the clinics and ask them to track the number of men
who said they had been referred by the screening
program. Based on all the information provided, the
director finally approved their request, and the nurses
were able to institute the screening program (Fig. 2-9).

7711_Ch02_023-054 23/08/19 10:21 AM Page 48

paper-and-pencil screening tool is rapidly administered,
whereas a colonoscopy requires a minimum of 24 hours
including preparation for the test, the administration of
the test, and recovery from the test. Acceptability of the
screening test is often dependent on cost, time, safety,
and ease of administration, which are reasons that it is
harder to get individuals to have the recommended
colonoscopy screening than it is other screening tests.

Even paper-and-pencil tests should be reviewed for
simplicity. Many screening tests take too long to admin-
ister, decreasing the chance that a person will complete
a test. Consider the difference between screening for pos-
sible depression using a 10-item questionnaire that can
be inserted into a regular health assessment versus a
32-item questionnaire. A 10-item test is simpler. It is also
easier to learn and perform, and can be delivered by non-
medical personnel. A good example of a measurement
tool for depression with high sensitivity, specificity, and
reliability is the 10-item Center for Epidemiologic Stud-
ies Short Depression Scale (CES-D 10).54,55 The original
screening tool was 20 items long and took longer to learn
and administer. The shorter form is easier to administer
and more acceptable to patients.

The next criterion is that the disease be sufficiently se-
rious to warrant screening. The purpose is to prevent the
adverse consequences associated with the disease. In the
case of colonoscopy, the screening test does not meet the
rapid, simple, inexpensive, and acceptable criteria. How-
ever, the severity of the disease outweighs the inconven-
ience and cost of the screening test. CRC is the third
leading cause of cancer-related deaths in the United
States.54 Screening and early detection of CRC increase the
chance of a cure in a disease with a high mortality rate
when treated in its late stages. Screening often leads to the
identification of precancerous lesions (i.e., adenomas),
which can be removed, thus preventing CRC.56

The next criterion addresses the issue of whether the
treatment for disease is easier and more effective when
the disease is detected early. This is not the case for all
diseases and is the reason that there is ongoing scientific
inquiry into the utility of screening tests. If screening is
done, will it reduce the disease-associated morbidity and
mortality through initiation of early treatment and to
what extent? If there was a screening test for Parkinson’s
disease, what type of early treatment exists? Because
there is no known cure and treatment is confined to
reducing symptoms, early detection does not serve to
reduce the disability associated with the disease. Con-
versely, mammography has the potential of identifying
breast cancer in the early stages, thus increasing the
potential survival rate.

This then raises the issue of the acceptability of the
available diagnostic services and treatment. If screening is
done, will those who screen positive seek further assess-
ment? Will those with a positive diagnosis engage in treat-
ment? This issue was raised over the use of a reliable
instrument to screen for at-risk drug use. There is no evi-
dence that screening resulted in subsequent assessment
and treatment. Those who screened positive were not
likely to follow up with the next steps related to the screen-
ing. Based on this, the National Quality Forum’s (NQF)
publication on evidence-based treatment for substance use
disorders does not recommend that health-care providers
screen for at-risk drug use as a standard practice in general
populations.54 When screening will not result in the
needed follow-up, the screening program will not result
in reduced disease-related morbidity and mortality.

Another criterion for implementing a screening pro-
gram is to determine whether the prevalence of a disease
is high in the population to be screened. Despite the
NQF’s recommendation that screening for at-risk drug
abuse not be conducted in the general population, it is
applicable in a population in which the prevalence of
at-risk drug use is high, such as an inner-city program for
adolescent males with failing grades. The prevalence is
higher, and the program staff can be trained to provide
health education along with the screening, thus improving
the acceptability of subsequent referral and possible treat-
ment by the boys in the program who screen positive.

This criterion is also helpful when deciding whom to
target when putting together a screening program. The
IOM continuum health prevention model referenced
earlier30 provides a framework for deciding whom to in-
clude in the screening program. A universal approach
would include everyone in the population regardless of
age, gender, or other characteristic. A screening program
that uses a selected approach would focus on those at
higher risk. Making these decisions is based on preva-
lence and risk for disease. For example, breast cancer
screening through mammography is not done using a
universal approach. Instead, age, gender, and risk factors
are used to determine who should get a mammogram
and how often.

The final and ethically the most important criterion is
that resources are available for referral for diagnostic
evaluation and possible treatment. In our example of
putting together a screening program for hypertension
in African American men, the team first ascertained
whether there were available resources to handle those
with a positive screen. The main issues to address are
economic access, physical access, and capacity to treat.
Economic access refers to the ability to pay for care. Will

C H A P T E R 2 n Optimizing Population Health 49

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all those who attend the screening program be able to re-
ceive follow-up diagnostic services and possible treat-
ment? If the answer is yes, will they have physical access
to the clinics providing the care? For example, what type
of transportation is available to get to the clinics provid-
ing services, and will everyone who attends the screening
have adequate transportation in terms of time, utility,
and cost? Finally, if a large-scale screening program
is done, does the existing health-care system have the
capacity to provide diagnostic and treatment services for
the anticipated increase in individuals needing these
services? This last criterion is rarely addressed and can
result in serious consequences.

Ethical Considerations
The criteria discussed raise serious ethical questions
related to screening. It is unethical to conduct screening
if treatment is not available. Screening programs are
often done without thinking through the consequences.
A serious ethical question is, what will be done with the
positive screens? Availability of treatment is not just
related to the existence of health-care resources that pro-
vide the treatment but also to the ability of those partic-
ipating in the screening to access those resources. What
if nurses conducted blood pressure screening with a
homeless population in a neighborhood where the near-
est hospital was three bus rides away; the nearby clinics
required a minimal co-pay of $50.00; there were no
pharmacies in the area that provided medications to
those without the ability to pay; the soup kitchens in the
area served donated food that was high in salt, fat, and
sugar; and there were limited public toilets? What would
they do with the homeless persons who had a positive
screen? Even if they managed to see a physician who
then prescribed a salt-free diet and a powerful diuretic,
how would they be able to fill the prescription and fol-
low the diet? If they were able to fill the prescription,
how would they handle the frequent need to urinate
without getting arrested for urinating in public? The pri-
mary question is, did the screening program result in re-
duced morbidity and mortality in this population? Was
it ethical to conduct the screening without ensuring first
that a system was in place to provide the needed health-
care services?

Another example involves the American Cancer
Society’s eagerness to provide free breast exams and
mammography to low-income Hispanic and African
American women in a midwestern city. The organization
engaged several partners to provide the service (at a time
before most states provided free screening to low-income

women). The director of one of those clinics agreed to
see a specific number per week for free (one criterion was
no health insurance). However, the director insisted that
the clinic would do this only if the American Cancer
Society had a plan in place for diagnosing and treating
any woman who screened positive for the cancer. The
ethical and moral question that the planners then ad-
dressed was what to do if they told a participant in the
screening program that she had cancer and then had no
way for her to receive treatment. The planners were able
to contract with three physicians and two hospitals that
agreed to provide care. The screening program began and
the first woman screened was positive for breast cancer,
requiring major surgery. She had no insurance and no
resources to pay for the surgery. To be eligible for Med-
icaid, she would have had to give up her home, a resource
for which she had spent a lifetime saving. Because of the
preplanning, this woman and the four other women
participating in the program who were diagnosed with
cancer all received the needed surgery. Without the gen-
erosity of the physicians and hospitals, they would not
have been able to have the surgery, and the planners
of the screening program would have been left with a
serious ethical dilemma.

Another ethical issue has been raised by the possible
use of genetic screening as a means of identifying those
who are genetically at risk for developing disease. For ex-
ample, with our increased knowledge related to geneti-
cally linked disease, genetic screening can help determine
whether a well person without disease is at risk for de-
veloping disease. A woman’s risk of developing breast
and/or ovarian cancer is greatly increased if she inherits
a deleterious (harmful) BRCA1 or BRCA2 mutation.
Men with these mutations also have an increased risk of
breast cancer. Both men and women who have harmful
BRCA1 or BRCA2 mutations may be at increased risk of
other cancers. Should genetic screening be done and, if
so, what interventions should occur related to positive
results? There are no easy answers. Consider the woman
who screens positive for a BRCA1 or BRCA2 mutation.
Should she consider removing her healthy breasts prior
to the development of disease?

Tertiary Prevention and
Noncommunicable Disease
Secondary prevention attempts to reduce morbidity and
mortality through early detection and treatment. Tertiary
prevention is another powerful prevention approach that

50 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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can also reduce the burden of disease. During the past
100 years, as the life span of populations has increased,
the prevalence of NCD (Chapter 9), also referred to as
chronic diseases, increased, creating a growing burden
of noncommunicable chronic disease in the United
States and across the world.57 According to the WHO, in
contrast to CDs, NCDs are defined as disease that are not
passed from person to person, they have a long duration
and usually a slow progression. There are four main
categories of NCDs: cardiovascular diseases, cancers,
chronic respiratory diseases, and diabetes.55 Almost half
of the population in the United States has been diagnosed
with at least one noncommunicable chronic disease, and
four in every five health-care dollars are spent on the care
of NCD. Although the U.S. health system is built on an
acute care model, the vast majority of the care provided
is for the management of noncommunicable chronic
diseases.56

Once it has been identified, how do NCDs fit into
the prevention frameworks previously presented? Using
the traditional public health model, tertiary prevention
is the logical choice. The goal of tertiary prevention in-
terventions is to prevent premature mortality and ad-
verse health consequences related to an NCD. For some
diseases, such as hypertension, tertiary prevention efforts
can result in the person returning to a normal state; that
is, a combination of behavioral changes and pharmaceu-
tical interventions can result in the patient’s blood pres-
sure returning to normal limits. In other diseases, the
prevention strategies are aimed at slowing the progres-
sion of the disease and reducing the likelihood of adverse
consequences related to the disease. With pharmaceuti-
cal interventions, patients with Parkinson’s disease can
improve their gait and reduce the tremors. This reduces
their risk of falls and other injuries while improving their
ability to perform ADLs, but they are not returned to a
normal state.

Tertiary prevention appears at first glance to be indi-
vidual based rather than population based. However, the
burden of NCDs affects the whole population, and move-
ment toward more population-level interventions is gain-
ing momentum. In 2009, the WHO released a report
calling for “urgent action to halt and turn back the growing
threat of chronic diseases.”56 In that report, the WHO
stressed that population interventions can be done related
to reducing the burden of already diagnosed chronic dis-
eases. In the 2014 WHO report on NCDs, the Director
General released a statement that: “WHO Member States
have agreed on a time-bound set of nine voluntary global
targets to be attained by 2025. There are targets to reduce

harmful use of alcohol, increase physical activity, reduce
salt/sodium intake, reduce tobacco use and hypertension,
halt the rise in diabetes and of obesity, and to improve cov-
erage of treatment for prevention of heart attacks and
strokes. There is also a target to improve availability and
affordability of technologies and essential medicines to
manage NCDs. Countries need to make progress on all
these targets to attain the overarching target of a 25%
reduction of premature mortality from the four major
NCDs by 2025.”57

Tertiary care also occurs with CDs during both the
acute and recovery stages of infection. For many CDs,
tertiary care focuses on provision of acute care, that is,
treatment of the disease to prevent further morbidity
and mortality, such is the case of treatment for influenza
or measles. For some CDs such as HIV, there is no cure
and the infection requires long term care to prevent
and/or treat AIDS. Other CDs require long-term care to
bring about a disease-free state such as tuberculosis. Due
to the long-term duration of AIDS and other CDs, the
preferred term NCD helps to distinguish between dis-
eases based on the ability of a disease to be transmitted
from one human to another. In addition, with CDs part
of tertiary prevention becomes primary prevention, that
is, the prevention of transmission to other persons (see
Chapter 8).

n Summary Points
• Health promotion and protection are major

emphases of national and global health
organizations.

• The socioecological model of health promotion
uses an upstream approach that includes the social,
environmental, and economic contexts of healthy
populations.

• The health of a population is greater than the
sum of the health of each individual in the
population.

• Health prevention frameworks provide
guidance for the development of prevention
interventions.

• Health education and health literacy are keys
to improving the health of populations.

• Screening for possible disease has the potential
to reduce disease-related morbidity and mortality
but has serious ethical issues that must be
addressed.

• Tertiary prevention can help to reduce the burden
of chronic diseases.

C H A P T E R 2 n Optimizing Population Health 51

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Public Health, 32, 381-398.

15. Martins, D.C., & Burbank, P.M. (2011). Critical interaction-
ism: an upstream-downstream approach to health care
reform. Advances In Nursing Science, 34(4), 315-329.
doi:10.1097/ANS.0b013e3182356c19.

16. U.S. Department of Agriculture. (2018). National school
lunch program. Retrieved from https://www.fns.usda.gov/
nslp/national-school-lunch-program-nslp.

17. U.S. Department of Agriculture. (2018). Interim final rule:
child nutrition program flexibilities for milk, whole grains,
and sodium requirements. Retrieved from https://
www.fns.usda.gov/school-meals/fr-113017.

18. Morgan I.S., & Marsh, G.W. (1998). Historic and future
health promotion contexts for nursing. Journal of Nursing
Scholarship, 30(4), 379-383.

19. Pender, N., Murdaugh, C.L., & Poarsons, M.A. (2014).
Health promotion in nursing practice (7th ed.). Upper Saddle
River, NJ: Prentice Hall.

20. Dicker, R., Coronado, F., Koo, D., & Parish, G. (2012).
Principles of epidemiology in public health practice (3rd ed.).
Atlanta, GA, Centers for Disease Control and Prevention.

21. Centers for Disease Control and Prevention. (1992). A
framework for assessing the effectiveness of disease and
injury prevention. Morbidity and Mortality Weekly Report,
41(RR-3).

22. Centers for Disease Control and Prevention. (2009).
Novel H1N1 flu facts and figures. Retrieved from http://
www.cdc.gov/h1n1flu/surveillanceqa.htm.

23. Centers for Disease Control and Prevention. (2018). People
at high risk of developing flu complications. Retrieved from
https://www.cdc.gov/flu/about/disease/high_risk.htm.

52 U N I T I n Basis for Public Health Nursing Knowledge and Skills

t CASE STUDY
The Centers for Disease
Control and Prevention Asks
the Question: “Should I Get
Screened for Prostate Cancer?”

The CDC follows the U.S. Preventive Services Task
Force recommendations that the prostate specific anti-
gen (PSA)-based screening should not be done for men
who do not have symptoms.58 Other organizations
have made different recommendations. Based on your
review, answer the following questions:

1. What is the sensitivity and specificity of PSA tests?
2. The CDC states that one of the reasons is “… the

PSA test may have false positive or false negative
results. This can mean that men without cancer
may have abnormal results and get tests that are
not necessary.” What is the biggest issue?

3. How well does a PSA differentiate between
non-aggressive and aggressive prostate cancer?

4. Review the information on PSA screening and the
criteria and ethical guidelines for conducting a
screening program on pages 48-50. Of the list of
criteria and ethical issues listed in this chapter,
which ones are a concern related to PSA
screening?

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2. Kennedy, P. (2018, March 9). The secret to a longer life?
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6. U.S. Department of Health and Human Services, Office of
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24. Gordon, R. (1987). An operational classification of disease
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25. Substance Abuse and Mental Health Services Administra-
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27. Havas, K., Bonner, A., & Douglas, C. (2016). Self-manage-
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28. Enworom, C.D., & Tabi, M. (2015). Evaluation of kidney
disease education on clinical outcomes and knowledge of
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29. Salvatore, A. L., SangNam, A., Luohua, J., Lorig, K.,
Ory, M. G., Ahn, S., & Jiang, L. (2015). National study of
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Psycho-Oncology, 24(12), 1714-1722. doi:10.1002/pon.3783.

30. U.S. Preventive Health Services Task Force. (2017). Home. Re-
trieved from https://www.uspreventiveservicestaskforce.org/
Page/Name/about-the-uspstf.

31. Centers for Disease Control and Prevention. (2017).
Faststats: leading causes of death. Retrieved from https://
www.cdc.gov/nchs/fastats/leading-causes-of-death.htm.

32. National Center for Health Statistics. (2017). Health,
United States, 2016: With chartbook on long-term trends
in health. Hyattsville, MD: National Center for Health
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33. Institute of Medicine and National Research Council.
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34. Keller, L.O., Strohschien, S., Lia-Hoagberg, B., & Schaffer, M.
(2004). Population-based public health interventions:
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35. Minnesota Department of Health, Division of Community
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interventions: Applications for public health nursing practice.
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36. Joint Committee on Health Education and Promotion
Terminology. (2014). Report of the 2011 Joint Committee
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37. World Health Organization. (2018). Health education.
Retrieved from http://www.who.int/topics/health_
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38. Shunk, D.H. (2012). Learning theories: An educational per-
spective (6th ed.). Boston: Pearson.

39. Bandura, A. (1977). Social learning theory. New York:
General Learning Press.

40. Hughes, N., & Schwab, I. (2010). Teaching adult health
literacy: principles and practice. Berkshire, England:
McGraw Hill.

41. Knowles, M.S. (1990). The adult learner: A neglected species
(4th ed.). Houston, TX: Gulf.

42. The Institute of Medicine, Committee on Health Literacy,
Board on Neuroscience and Behavioral Health. (2004).
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DC: The National Academies Press.

43. U.S .Department of Education, National Center for
Education Statistics. (2016). Skills of U.S. unemployed,
young, and older adults in sharper focus: results from the
program for the international assessment of adult competen-
cies (PIAAC) 2012/2014. Retrieved from https://nces.ed.gov/
pubs2016/2016039rev.pdf.

44. Rasu, R.S., Bawa, W.A., Suminski, R., Snella, K., & Warady,
B. (2015). Health literacy impact on national healthcare
utilization and expenditure. International Journal of
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ijhpm.2015.151.

45. Centers for Disease Control and Prevention. (2016).
Talking points about health literacy. Retrieved from
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TellOthers.html.

46. Hersh, L., Salzman, B., & Snyderman, D. (2015). Health
literacy in primary care practice. American Family Physician,
92(2), 118-124.

47. Agency for Health Care Research and Quality. (2015). AHRQ
Health Literacy Universal Precautions Toolkit (2nd ed.).
Rockville, MD: Author.

48. National Institutes of Health. (2017). Clear communica-
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cultural-respect.

49. Bloom, B.S. (1956). Taxonomy of educational objectives:
Handbook 1. The cognitive domain. New York, NY: David
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50. Commission on Chronic Illness. (1951). Chronic illness
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51. American Heart Association. (2016). High blood pressure
and African Americans. Retrieved from http://www.heart.
org/HEARTORG/Conditions/HighBloodPressure/
UnderstandSymptomsRisks/High-Blood-Pressure-
and-African-Americans_UCM_301832_Article.jsp#.
Wxly1fZFw2w.

52. Centers for Disease Control and Prevention. (2016). High
blood pressure facts. Retrieved from https://www.cdc.gov/
bloodpressure/facts.htm.

53. Radloff, L.S. (1977). The CES-D scale: A self-report depres-
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54. Andresen, E.M., Malmgren, J.A., Carter, W.B., & Patrick,
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adults: Evaluation of a short form of the CES-D (Center for
Epidemiologic Studies Depression Scale). American Journal
of Preventive Medicine, 10, 77-84.

55. Centers for Disease Control and Prevention. (2017). Colorec-
tal cancer statistics. Retrieved from https://www.cdc.gov/
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56. Centers for Disease Control and Prevention. (2017). Chronic
disease prevention and health promotion: National Center for

Chronic Disease Prevention and Health Promotion. Retrieved
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publications/aag/NCCDPHP.htm.

57. World Health Organization. (2009). Preventing chronic
diseases: A vital investment. Retrieved from http://www.
who.int/chp/chronic_disease_report/en/.

58. World Health Organization. (2014). Global status report
on noncommunicable diseases 2014. Geneva: Author.

54 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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55

KEY TERMS

Active surveillance
Agent
Analytical epidemiology
Attack rate
Biostatistics
Causality

Demography
Descriptive epidemiology
Environment
Epidemiology
Host
Incidence

Infectivity
Life expectancy
Morbidity
Mortality
Passive surveillance
Percent change

Prevalence
Prospective
Rate
Retrospective
Secondary attack rate
Web of causation

n Introduction
In 2017, a National Public Radio headline reported “U.S.
has the worst rate of maternal deaths in the developed
world,” based on a recent study of global levels of maternal
mortality.1 Information from the Centers for Disease Con-
trol and Prevention (CDC) also confirms that pregnancy-
related deaths, defined as the death of a woman during or
within 1 year of the end of pregnancy, have been increas-
ing in the United States since 1987 when this information
was collected.2 A headline like this inspires many ques-
tions: Why is the mortality rate increasing? What factors
are influencing this disparity between the U.S. and other
developed countries? Is a particular population affected
more by high rates of maternal mortality? How was this
information collected? Is this an accurate headline based
on the information?

As nurses, if we were to investigate these data
further we would discover that there are great disparities
in the pregnancy-related mortality within the U.S.
According to the CDC, for example, black women have a
much higher rate of pregnancy-related deaths compared

with white women (12.7 deaths per 100,000 live births for
white women vs. 43.5 deaths per 100,000 live births for
black women).2 However, for a public health nurse, this
suggests the need for further inquiry into what factors
might be driving this difference: poverty, urban/rural
differences, racial stigma, or differing access to care. See
Chapter 17 for more details specific to maternal child
health, and maternal mortality and public health.

Collecting, analyzing, and synthesizing data to under-
stand public health questions such as disparities in mater-
nal mortality is the heart of epidemiology. Epidemiology,
the combination of three Greek words: epi, translated
as “upon”; demos, translated as “people”; and logy, or
“the study of something”, is broadly defined as the study
of factors that influence health and disease in populations.3
Epidemiology is a natural fit for the nursing profession
because nursing, unlike many of the health-related pro-
fessions, extends well beyond one-on-one patient-clinician
interactions to engaging groups of people where they live,
work, and play. Public health nursing has traditionally
blended health promotion, disease prevention, health
education, and population-based initiatives in an effort to

Chapter 3

Epidemiology and Nursing Practice
Erin Rachel Whitehouse and William A. Mase

LEARNING OUTCOMES

After reading the chapter, the student will be able to:
1. Describe aspects of person, place, and time as they

relate to epidemiological investigation.
2. Explain the epidemiological triangle.
3. Apply the epidemiological constants to an investigation.
4. Identify sources of epidemiological data.
5. Apply basic biostatistical methods to analyze

epidemiological data.

6. Differentiate cohort and case-control study design and
select appropriate measures of effect.

7. Explain surveillance and the difference between active
and passive surveillance.

7711_Ch03_055-076 21/08/19 11:06 AM Page 55

maximize the health and wellness of individuals through
population-level strategies. As 21st-century health profes-
sionals, nurses are now more than ever required to
demonstrate both competency and proficiency in the prin-
ciples of epidemiology.

Today the curriculum in accredited colleges of nurs-
ing is shifting toward the inclusion of epidemiology as
core content. The historical development of epidemiol-
ogy is replete with references to the same women who
carved out the nursing profession. Public health nursing
and population-based health and wellness are evident in
the pioneering efforts of Florence Nightingale, Lillian
Wald, Clara Barton, Mary Breckinridge, and Dorothea
Dix. Each of these legendary women initiated public
health efforts from a population health perspective
toward the reduction of disease and promotion of health
within populations.

What Is Epidemiology?
Epidemiology has been defined many ways. Tradition-
ally, it is the study of the distribution of disease and
injury in human populations. More recently, broader

56 U N I T I n Basis for Public Health Nursing Knowledge and Skills

n CELLULAR TO GLOBAL
Epidemiology and biostatistics are critical fields to
understand health outcomes from a cellular to global
level. Mycobacterium tuberculosis (TB), the leading
cause of communicable disease deaths globally, is an
example of a disease that affects health on a cellular,
individual, community, and global level.4 Diabetes, smok-
ing, and HIV infection are leading risk factors both for
the development of TB and for poorer treatment
outcomes through mechanisms such as increased
inflammation, decreased immunity, and structural lung
damage. TB is also related to community factors such
as poverty because risk factors like overcrowded
housing increase the risk of exposure and subsequent
development of TB. Drug-resistant TB, which is resist-
ant to the first-line TB antibiotics, is an increasing
challenge in part due to insufficient health systems
that do not have the appropriate resources to treat it.
Finally, preventing and treating TB is a global challenge
given the movement of populations due to migration,
war, famine, natural disasters, and even tourism.
Epidemiological principles are one tool to understand
how risk factors on cellular, local, national, and global
levels impact population health outcomes like mortality
from TB.

definitions of the term move beyond the study of disease
and include the examination of factors that affect the
health and illness of populations, thus providing the basis
for interventions aimed at improving the health and
well-being of populations. The focus of epidemiology is
on populations rather than on individuals. Epidemiology
takes an analytical investigative approach to this study of
health and disease, and is built on three central elements:

• Person: Which groups of individuals are affected?
• Place: Where does the health issue occur, i.e., what

geographically defined region?
• Time: Over what specified period of time does the

health issue occur?

These three elements of person, place, and time are
the bricks of epidemiology. The mortar cementing these
bricks is made up of the methods of quantitative com-
parison used by epidemiologists when studying patterns
of disease and health. The tools used by epidemiologists
are best described as comparative, numeric, and analyt-
ical. To effectively quantify illness and disease, accurate
data are required. Epidemiological data sources vary
widely. Some of the more frequently used data sources
include hospitals, community-based clinical practices,
health departments, workplaces, schools, and health
insurance reimbursement claims. The capacity for an
epidemiologist to effectively analyze and present data is
inextricably linked to the network of health-care–related
workers throughout an array of health and human
service–related industries. Nurses are pivotal to the ac-
curate assessment and timely reporting of health-related
data upon which epidemiology is grounded.

Historical Beginnings
John Snow is celebrated as the founder of modern epi-
demiology just as Florence Nightingale is recognized
as the founder of modern nursing (see Chapter 1). John
Snow’s watershed work, Snow on Cholera, introduced
methods of epidemiological investigation and methods
upon which contemporary epidemiological methods are
founded.5 His use of the epidemiological strategy, now
defined as disease mapping, to study the incidence of
cholera deaths reported in London, England, laid the
foundation for investigation of disease in populations.
The Lambeth Company provided residents of London
with drinking water collected from the Thames River.6
Snow’s enumeration and subsequent investigation of
cholera deaths reported for residents living near the
Lambert Company’s Broad Street water pump is her-
alded as the defining event upon which all future
epidemiological methods are based. Snow developed a

7711_Ch03_055-076 21/08/19 11:06 AM Page 56

timely measures for disease investigation using contem-
porary 21st-century methods. The three elements of per-
son, place, and time are as central to an epidemiological
investigation now as they were in the time of Snow, and
they form the building blocks for modern-day epidemi-
ological investigations.

Since the time of Snow’s work, epidemiology has gone
through various phases. The first phase is referred to as
the sanitary phase. It was based on the miasma theory
that illness was related to poisoning by foul emanations
from soil, air, and water. During this phase, public health
efforts focused on improving sanitation. This approach
to illness prevailed until the discovery of microscopic
organisms that were linked to disease, which led to the
germ theory and the communicable disease phase of epi-
demiology. This phase led to the examination of single
causes for a disease and worked well in a world where com-
municable diseases were the number one killers. With the
emergence of antibiotics and the reduction of communicable
disease, the life expectancy of populations increased,

frequency distribution of the number of human deaths
by placing a hash mark on a city street map. Upon visual
inspection of the map it became clear to Snow that there
were residential patterns of deaths. He demonstrated that
greater numbers of cholera deaths were clustered within
the vicinity of a specific public water source, the Broad
Street water pump. The number of cholera deaths near
the Broad Street pump far exceeded the deaths in other
areas of London (Fig. 3-1).

Snow’s work illustrated the three central elements re-
lated to his investigation: person, place, and time. The
person variable can be defined as the number of human
cholera deaths. Place is visually demonstrated by the
street mapping method Snow used to count human
deaths by street of residence. Finally, the time variable in
Snow’s study was the 5-year period between 1849 and
1854 when the Lambeth Company drew community
water from the contaminated source, the Thames River.
In the 150 years since Snow’s community disease map-
ping, epidemiologists have developed more effective and

C H A P T E R 3 n Epidemiology and Nursing Practice 57

Figure 3-1 Snow map.
(Published by C.F. Cheffins,
Lith, Southhampton Buildings,
London, England, 1854, in Snow, J.
[1885]. On the mode of commu-
nication of cholera (2nd Ed.).
John Churchill, New Burlington
Street, London, England. http://
www.ph.ucla.edu/epi/snow/
snowmap1_1854_lge.htm)

7711_Ch03_055-076 21/08/19 11:06 AM Page 57

especially those in developed countries. This resulted in
the emergence of noncommunicable diseases and a new
phase in epidemiology, the risk factor phase. This phase
of study is still a mainstay of epidemiological investiga-
tions. It relies on the linking of exposures to the occur-
rence of injury or disease and helps us identify risk
factors that, when reduced, may result in a subsequent
reduction in morbidity and mortality. The most recent
phase in epidemiology is the ecological model as pro-
posed by Susser and Susser in the 1990s.7,8 This helps
move the science of epidemiology to a broader perspec-
tive and, as explained in Chapter 1, reflects not only
the biological and behavioral influences on health but
also a deeper understanding of the role of the physical
environment and the underlying conditions in the social
environment that create poor health.

Risk Factors
Risk factors are a foundational concept in epidemiology.
The World Health Organization (WHO) defines a risk
factor as “any attribute, characteristic, or exposure of an
individual that increases the likelihood of developing a
disease or injury.”9 Although there are several ways to
classify risk factors, we will explore three major categories
of risk factors: behavioral, environmental, and genetic.

Behavioral Risk Factors
The CDC began the now nationwide Behavioral Risk
Factor Surveillance System (BRFSS) in 1984.10 They in-
tended to study the way that human behavior influences
health and wellness, and identify behaviors that might
influence health conditions, such as the impact of under-
age drinking on the risk of unprotected sex. This human
health behavioral survey is the largest telephone survey
assessment in the world. The BRFSS provides timely
health behavior data for policy makers in all 50 states as
well as the District of Columbia, Puerto Rico, U.S. Virgin
Islands, and Guam. These data are effective in providing
health-related trend analysis and serve to guide and direct
local, state, and national pro-health initiatives. Figure 3-2
presents national-level trended data on tobacco use.11 It is
exciting to see that the Healthy People 2020 goal for ado-
lescent smoking has been reached! The BRFSS can be used
to present population-level trend data related to many
behavioral risk factors. For community-based health
educators, these data are an effective resource to assist in
planning community health interventions.

Environmental Risk Factors
Is it possible that the community in which one lives
and/or works puts one at an increased or decreased risk

for developing a given illness or disease? Yes, it does. The
Agency for Toxic Substances and Disease Registry
(ATSDR) Web site provides useful information on ad-
verse health effects linked to health-related environmental
risk from exposure ranging from arsenic to zinc and
everything in between (see Web Resources on DavisPlus).
Often, increased environmental risk for residents of com-
munities is related to specific industries located in and
around the community. By mapping industries related to
hazardous waste, it is possible to identify populations at
greater risk for disease at the local and state levels. The
federal government has set aside funds referred to as the
Superfund to clean up uncontrolled hazardous waste sites
across the country through the Environmental Protection
Agency (EPA). The states with the greatest number of
Superfund clean-up sites include New Jersey, Pennsylvania,
and New York, with more than 100 Superfund sites per
state. The EPA Web site at http://www.epa.gov/superfund/
provides information on identifying possible industry-
related environmental hazards.

Public health professionals working in environmental
health often focus on three critical areas in assuring the
health of the public: safe air quality conditions, safe water
supplies, and safe soils throughout the nation’s agricul-
tural industry. The majority of the human health risks

58 U N I T I n Basis for Public Health Nursing Knowledge and Skills

40

35

30

25

20

15

10

5

0

19
97

19
99

20
01

20
03

20
05

20
07

20
09

20
11

20
13

20
15

20
17

Adults (%)**

Percentage of high school students who smoked cigarettes on at least 1
day during the 30 days before the survey (i.e., current cigarette use).
(Youth Risk Behavior Survey 1997-2017)

Percentage of adults who were current past 30-day cigarette smokers
(National Health Interview Survey 1997-2017)

*

**

P
er

ce
nt

ag
e

(%
)

Students (%)*

Figure 3-2 Trends in Current Cigarette Smoking by
High School Students* and Adults** United States 1997
to 2017. (Source: 11a, 11b.)

7711_Ch03_055-076 21/08/19 11:06 AM Page 58

are associated with what we breathe and ingest. It is
important to keep in mind that the environmental risks
affecting humans are indeed vast, including automobile
safety, seatbelt use, and safe conditions throughout pub-
lic recreational facilities. Public health professionals use
a combination of education, engineering, and enforce-
ment to achieve our mandated goals and objectives.
There are more details about the role of public health
science and environmental health in Chapter 6.

Genetic Risk Factors (Genomics)
The field of genetic epidemiology otherwise known as
genomics seeks to understand and explain heritability
of factors that have an impact on the development of
illness and disease. The past 2 decades have witnessed the
expansion of research into genetic markers for disease.
We will likely see a transformation in the evaluation,
assessment, and tools surrounding genetically relevant
strategies at the population level because of emerging
individual-level genetic knowledge.

Application of genomics to population health poses
some practical and ethical dilemmas. First, at the pop-
ulation level, the purpose is to develop interventions
relevant to the population that will result in a general
improvement of health at the population level. Genetic
testing is done at the individual level and usually results
in individual decision making related to potential risk
for development of disease. For diseases such as cystic
fibrosis that are related to one gene, genetic testing can
help with early identification and treatment for those
born with the disease and may assist parents make
childbearing decisions prior to conception. However,
most diseases occur due to multiple factors and are
linked to more than one gene as well as numerous other
risk factors. Evidence on the benefit of genetic screen-
ing for most diseases is limited. In addition, genetic
testing can be costly.

A good example of the controversy over the benefits
of genetic testing is the issue of BRCA1 and BRCA2. These
human genes are referred to as tumor suppressors. Based
on recent research, it is apparent that mutation of these
genes is associated with hereditary breast and ovarian
cancers.12 The company that developed the screening test
for BRCA1 and BRACA2 initiated an advertising campaign
encouraging women to have the genetic screen. Though
the National Cancer Institute lists possible options for
managing cancer risk for those with a positive screen, it
acknowledges that the evidence concerning the effective-
ness of these strategies is limited. Testing can cost up to
$3,000 for those who do not know their family history.
The high cost raises the ethical question of taking a

universal approach to screening all women for this
genetic risk factor, especially as less than 10% of all breast
cancers are genetically related and the direct benefit of the
testing in reducing cancer rates is not known. Genomics
is a growing field with the potential benefit of better
understanding the role individual genetic makeup plays
in an individual’s health. However, as the BRCA1 and
BRCA2 screening example illustrates, the applicability of
genomics to population-level interventions from a prac-
tical and ethical standpoint has still not been determined.

Epidemiological Frameworks
There are several frameworks guiding the field of epi-
demiology such as the epidemiological triangle, the web
of causation, and the ecological model. The latter two
frameworks evolved from the epidemiological triangle
framework. Public health professionals continue to use
these and other frameworks to assist in a better under-
standing of health phenomena.

The Epidemiological Triangle
The classic model used in epidemiology to explain the
occurrence of disease is referred to as the epidemiological
triangle. There are three main components to the trian-
gle: agent, host, and environment (Fig. 3-3). In commu-
nicable diseases, the model helps the epidemiologist map
out the relationship between the agent or the organism
responsible for the disease and the host (person) as well
as the environmental factors that enhance or impede
transmission of the agent to the host.

Although this model is ideally suited for explaining
the transmission of an infectious agent to a human host,

C H A P T E R 3 n Epidemiology and Nursing Practice 59

Figure 3-3 Epidemiological triangle.

Environment

Agent Host

7711_Ch03_055-076 21/08/19 11:06 AM Page 59

it is now applied to noncommunicable diseases, such as
lung cancer, with a specific exposure, such as cigarette
smoke, representing the agent or causative factor. The
agent can be viewed as the causative factor contributing
to noninfectious health problems or conditions. The
agent may be biological (organism), chemical (liquids,
gases), nutritive (dietary components or lack of dietary
components), physical (mechanical force, atmospheric
such as an earthquake), or psychological (stress). The
host is the susceptible human or animal, whereas the
environment is all of the external factors that can influ-
ence the host’s vulnerability to the risk factors related to
the disease.

The value of this model lies in the fact that it helps in
the development of interventions. For example, in the
case of the H1N1 outbreak, epidemiologists first worked
at isolating the agent. Based on the type of agent, a
flu virus, it was clear that the environment needed for
transmission was both the breathing in of air droplets
that contained the virus and coming in contact with the
virus via a fomite, that is, an inanimate object such as a
water faucet. Based on this information, three prevention
interventions were instituted. The initial approach
focused on the environment. To reduce exposure of
people to the virus in the environment, all those with
signs and symptoms of H1N1 were asked to stay home
and to cough into their arms rather than their hands.
Uninfected individuals were also instructed to use hand
sanitizers. The second approach was aimed at protect-
ing the host (person) through the development and
distribution of the H1N1 vaccine. The use of a vaccine
reduced the susceptibility of hosts to the agent, which,
in turn, reduced further introduction of the virus into
the environment. In this example, no interventions were
aimed at the agent because no viable options were avail-
able to directly eradicate the agent.

The Epidemiological Constants of Person,
Place, and Time
In addition to the epidemiological triangle, there are three
constants that are the foundation for any epidemiological
investigation: person, place, and time (Fig. 3-4). The
person aspect typically includes demographic variables
including age, gender, and ethnicity. Place considerations
include such variables as city resident, office building user,
or downhill skier. Finally, the third constant, time, is a
critical dimension of consideration. Conditions in one lo-
cation with the same subset of individuals can change
substantially as a product of the passage of time. It is
important to keep in mind that this model is the founda-
tion upon which our understanding of illness and disease

are built and can help guide investigations into a health
issue in a population.

Who, What, When, Where, Why, How, and How
Long: To further understand the use of the epidemio-
logical triangle and the constants of person, place, and
time, seven questions have been used to conduct an
epidemiological investigation. These questions have most
often been used to examine the epidemiology of commu-
nicable diseases. The who question relates to the person,
the place question to where, the when and how long ques-
tions to time, the what to the causative agent, and the
why and how to the mechanism for acquiring disease,
such as the mode of transmission in communicable dis-
eases. These seven questions provide an effective model
by which illness can be analyzed at the population level in
order to develop interventions that will improve health
and/or prevent disease. This approach is an example of nat-
uralistic experimentation, a study that occurs in the natural
world and not in a controlled laboratory environment.

60 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Person

Place Time

Figure 3-4 Epidemiological constants.

n CULTURAL CONTEXT
Epidemiology is rooted in asking questions, collecting
and analyzing data, and making informed decisions to
influence policy or practice. Understanding the cultural
context of a given population is critical in all steps of the
process. Differences across ethnicity, geography, race,
nationality, or religion can potentially affect risk factors
or perceptions of health and risk. Are you asking the

7711_Ch03_055-076 21/08/19 11:06 AM Page 60

Causality
Although the seven questions help the investigator learn
about the occurrence of disease, that knowledge only
begins to provide a broader understanding of the mul-
tiple factors that could be related to the occurrence of
the disease. Epidemiologists investigate possible causes
of disease to better understand how to prevent and treat
disease. The term cause is traditionally used to indicate
that a stimulus or action results in an effect or outcome.
For example, if you turn on a light switch, the observed
effect is that the light bulb lights up. When it comes to
epidemiology, causality refers to determining whether
a cause-and-effect relationship exists between a risk
factor and a health effect. In health, causes can include
a number of things related to person, place, and time.
Using the light switch example again, it may be first
assumed that the singular cause for lighting the bulb is
the physical act of flipping the switch. In actuality, there
are other factors involved, including the presence of
a source of electrical energy, a working electrical con-
nection between the switch and the light, and a light
bulb that is not burned out.

As presented throughout this chapter, epidemiologi-
cal studies typically report measures of associations based
on population-based correlations; that is, an increase
or decrease in the amount of the risk factor and the fre-
quency of the risk factor are parallel to the increase or
decrease of the incidence of the health issue. It is always
important to keep in mind that correlation, the fact that
two variables are correlated with one another, does not
necessarily mean that one factor causes the other. For ex-
ample, heavy smokers often have a yellow stain on the

fingers that hold the cigarette. Although the presence of
yellow stains on the fingers may be correlated with lung
cancer, the yellow stain is not the cause of lung cancer.

To examine the possibility of causality, the first step
is to determine whether there is a statistical relationship
between the risk factor and the health issue. In other
words, can the association between the two be attributed
to chance alone—does the association between the
two occur at a frequency higher than what could be
attributed to chance? After determining that the relation-
ship does not occur by chance alone, the next step is to
determine whether the relationship is causal. In some
cases, the relationship between two variables is statisti-
cally significant, but the relationship is noncausal.
For example, in a group of schoolchildren, height may
be statistically correlated with grade level; that is, the
higher the grade level, the taller the children, but grade
level is not the causal factor for the increase in height.

A causal relationship is present when there is a direct
or indirect relationship between the two factors. If it
is a direct relationship, then the factor causes the disease.
For example, the mumps virus directly causes mumps.
A nondirect relationship exists when the factor con-
tributes to the development of the disease through its ef-
fect on other variables. Being overweight does not
directly cause disease, but it adversely affects the body,
thus increasing the risk of cardiovascular disease and
diabetes, for example.

Results from studies conducted in the field can be
limited because sources of error might be present. These
errors most likely relate to assumptions of causality. For
example, error can occur when deciding who was actu-
ally exposed to a potential risk factor and who was not.
There can be errors in how some important variable was
measured and errors relating to who received a vaccine
and who did not.

C H A P T E R 3 n Epidemiology and Nursing Practice 61

right questions to understand risk factors that might be
particular to the population? Are you using the correct
terminology so that the population of people under-
stands the question in the way that it is being asked?
One of the best ways to ensure that a survey or out-
break investigation is conducted in a way that respects
the cultural context is to involve people from the
population in creating and executing the research or
investigation. This can provide critical information for
access to key informants, asking appropriate and rele-
vant questions, and understanding the data within the
perspective of the population. Thus, although epidemio-
logic principles are broad and apply locally to globally,
it is important to always frame epidemiology questions
and investigations within the appropriate cultural
context.

l APPLYING PUBLIC HEALTH SCIENCE
Public Health Science Topics Covered:
• Applied Epidemiology
• Health Promotion

Smoking and tobacco use are considered by the
WHO to be among the biggest public health threats
because they kill up to half of the people who use to-
bacco.13 Smoking increases the risk for noncommunica-
ble diseases like cardiovascular disease or lung cancer
and also increases the risk for communicable diseases
like tuberculosis as described in the cellular to global
section of this chapter. However, smoking’s influence is

7711_Ch03_055-076 21/08/19 11:06 AM Page 61

62 U N I T I n Basis for Public Health Nursing Knowledge and Skills

not limited to people who use tobacco; it also affects
children, families, and communities through second-hand
smoke exposure. In addition, 80% of the 1.1 billion
smokers globally live in low- and middle-income coun-
tries where the burden of disease for tobacco-related
conditions and premature death is high.13

To think about how to understand the impact of
smoking within a specific population, an epidemiologist
can explore who is smoking within their community
and who might be exposed to smoke (person), where
the sources of smoke or tobacco exposure are within
a community (place), and how the population of smok-
ers has changed (time). This information is then used
to develop community-specific health improvement
initiatives that target those populations at greatest risk
for harm from smoking or tobacco use. The first
step in the investigation of any illness is to begin with
inquiry. Ask questions across the seven areas of who,
what, when, where, why, how, and how long.

Jane Paterson is a public health nurse employed by
the City Health Department of River City, a hypothetical
midwestern city with a population of 75,000 and a mix
of urban and suburban residents. One of the primary
objectives of Jane’s job is to develop community-based
health promotion and disease prevention initiatives tar-
geting smoking with a focus on youth. According to the
most recent U.S. Census data available, there are
3,000 urban and 7,000 suburban River City residents
aged birth to 18 years. Of the 3,000 urban residents in
this age group, 1,500 have used some form of tobacco
product. Of the 7,000 nonurban residents in this
age group, 1,000 have used some form of tobacco
product.

To understand the smoking data among youth in
River City, Jane considers the tools in her epidemio-
logic toolbox. She needs to ask questions to under-
stand who smokes, why they smoke, what risk factors
influence their decision to smoke, how youth are
obtaining cigarettes, how much they cost, and what
factors might influence their decision to quit. She also
needs to look at the data to explore what common
risk factors for smoking, such as poverty or parents
who are smokers, might be influencing the youth of
River City. She needs to understand who already
smokes and who is at risk for future smoking to de-
velop an evidence-based intervention that targets these
specific populations. The data from the U.S. Census
informed Jane that there was a higher percentage of
youth who smoked from the urban areas of River City,
but do these percentage differences suggest an actual

difference in the risk of smoking between urban and
nonurban youth? See Box 3-5 later in the chapter to
look at the calculation of odds ratio to explore the
difference in smokers from urban and nonurban
areas and an explanation of odds ratios further in
this chapter.

In addition, Jane needs to understand the risk fac-
tors within River City and what community factors
might influence youth smoking. Jane explored legisla-
tion regarding smoking and found that River City has a
low tax on cigarettes compared with other cities and
counties in the area. She also noted that the public
schools were not smoke-free zones and, although
restaurants were supposed to be smoke-free, there
was minimal enforcement of these regulations espe-
cially in places where older adolescents tended to
congregate. Thus, on a community level, risk factors
for smoking influenced the relatively low cost of
tobacco products and the limited bans on public
smoking.

Finally, Jane wanted to explore trends over time
to understand how smoking had changed over the
past 10 years in the community. Jane had previous
data from community assessments that documented
smoking in River City, and she found that there was
an overall decrease in the percentage of adults who
smoked, but that the smoking rates for youth remained
largely unchanged. Jane realized that, to develop a
more thorough understanding of youth smoking, she
needed a bit more data about smoking. So, she used
the CDC Web site and the Youth Risk Behavioral
Survey to understand the specific risk factors related
to youth smoking.14 She was also able to access infor-
mation from her state to compare the smoking rates
in River City to state levels.

Once Jane had looked at the data on smoking, she
reported to her supervisor at the Health Department
that she felt that a multiprong intervention was needed
to prevent smoking, to provide smoking cessation
incentive for youths that smoked, and to advocate
for policy-level interventions such as proposing an
increased tax on tobacco products and extending the
smoke-free zones in the community. She was able to
advocate for her programming because she had data
that demonstrated that River City had higher smoking
rates compared with other cities in her region and
fewer community-based interventions, such as smoke-
free schools and high tobacco taxes. Jane also pro-
posed conducting a survey of high school students
in the schools within River City, selecting some

7711_Ch03_055-076 21/08/19 11:06 AM Page 62

Web of Causation
One difficulty for Jane is determining which risk factors
for youth smoking are priority concerns for River
City. Multiple factors are correlated with smoking
among youth including environmental risk factors both
internal and external, parental smoking habits, gender,
race, poverty, and educational status of the youth
and their parents. Untangling the risk factors to deter-
mine what type of intervention should be developed is
a challenge. To help understand the multiple factors
that contribute to the development of disease, epidemi-
ologists use a framework called the web of causation.
This framework or model can be used to illustrate the
complexity of how illness, injury, and disease are deter-
mined by multiple causes and are at the same time af-
fected by a complex interaction of biological and
sociobehavioral determinants of health (Fig. 3-5).15,16,17

It helps health-care providers develop more compre-
hensive strategies to reduce disease- and injury-related
morbidity and mortality through primary and second-
ary prevention measures.

The term web is used because the model acknowledges
the complexity related to occurrence of disease.15 Simply
stated, the spider is the reason the fly is caught in the web.
What are the factors that converged, resulting in the
ill-fated fly being caught in the web? The fly selected
the path that led him to the web, he was ill equipped to
extract himself from the web once entangled, the spider
selected that specific location to construct his web, etc.
The list of predetermining factors is endless. The fact is,
for both the fly caught in the spider’s web as well as for
humans, there is frequently no one single cause for an
undesirable outcome but a convergence of circum-
stances, actions, inactions, and behaviors.

Ecological Model
The ecological model has been used in recent years to
design health promotion efforts and understand health
behavior. The terms health promotion and health behav-
ior have been used during the past 25 years to help
understand the interventions that can be done to help
maintain and improve health (health promotion), and the
behaviors that contribute either positively or negatively
to overall health (health behaviors). The ecological model
provides a formal theoretical foundation on which public
health nursing has established a professional identity and
knowledge base.

Ecological studies use groups, not individuals, as the
unit of analysis.18 Conclusions from ecological studies
should be considered with caution. The classic notion
of the stork bringing the baby to new parents is a con-
temporary manifestation of what one might suggest
could have been an ecological study, demonstrating
the ecological fallacy discussed later in this chapter.
Anchored in the pagan belief that storks brought babies
to expecting mothers, the arrival of storks in northern
Germany coincided with the storks’ spring and the
increase in the number of human births. The increased
birth rates in spring might have something to do with
the 9-month elapsed time between summer and normal
human gestation. Analyses of health-related behaviors
at the group level are carried out by epidemiologists,
providing the evidence by which practice-based health-
care providers can begin the development of interven-
tions using the ecological model approach. An effective
ecological model defines, understands, changes behav-
ior, and ultimately promotes population-level health
and wellness.

C H A P T E R 3 n Epidemiology and Nursing Practice 63

urban and some nonurban schools, to better understand
why students start smoking and what might motivate
them to quit to develop an effective school-based
intervention to reduce youth smoking. Jane used her
epidemiology skills to understand the existing data and
how that might inform smoking reduction efforts but
also to help her understand gaps in the data so that she
could plan the next steps for developing an effective,
tailored public health intervention.

Endocarditis

Bacteria
(External

Environment)

Bacteria
Reservoir
(Human)

Hereditary
(Genetics)

Bacteremia
(Human)

Antibiotic
Prophylaxis

Cardiac
Abnormalities

Oral/Dental

Figure 3-5 Web of causation and endocarditis.

7711_Ch03_055-076 21/08/19 11:06 AM Page 63

Tools of Epidemiology: Demography
and Biostatistics
The science of epidemiology requires the use of particu-
lar tools to help epidemiologists study health and
wellness as well as determine which interventions will
help improve the health of populations. Among these
tools are demography and biostatistics. Understanding
how to apply demography and biostatistics helps nurses
in all settings to provide better care and promote the
health of the populations they serve.

Demography
Demography is the population-level study of person-
related variables or factors. The field of demography
has been around since the early 20th century. Warren
Thompson, an early pioneer, developed the demographic
transition model used today to explain the shift from
high birth and death rates to low birth and death rates
within populations.19 Warren Thompson is to the field
of demography as Florence Nightingale is to nursing and
John Snow is to epidemiology. Establishing methods for
tracking populations over time adds to the methods of
tracking disease established by John Snow. Public health
and health-related disciplines use demography and asso-
ciated methods to better understand population-level
patterns related to health phenomena.

Typically, person-related variables are compared over
two or more time periods to establish trends within
the population of interest. Comparing demographic
data from time 1 to time 2 is fundamental to the promo-
tion and establishment of relevant prohealth environ-
ments, policies, and behaviors across time. For example,
comparing the percentage of the population below the
poverty level in a particular community from 2010 to
2020 can help identify changes in the population that
may affect access to health care. Another example is to
put together a visual depiction of demographic data
using the demographic transition model (Fig. 3-6). This
model refers to population change over time, especially
in relation to birth and death rates.

One measure of the health of populations used to
compare populations from a global perspective is life ex-
pectancy. Life expectancy is the average number of years
a person born in a given country would live if mortality
rates at each age were to remain constant in the future.20

Based on 2015 estimates worldwide, there is a wide
range among countries in relation to the average life ex-
pectancy at birth (50.1 years in Sierra Leone to 83.7 years
in Japan).20 One of the reasons for lower life expectancy

in low- and middle-income countries is that they expe-
rience more difficulty with control and eradication
of communicable diseases and the illnesses associated
with maternal, child, and women’s health. Also, many of
these countries lack the health benefits of more stable
economies with advanced industrial and technological
developments. The study of trends across time results in
interventions including policy reform, re-engineering,
educational initiatives, and enforcement of standards
and laws to assure the health of the public. Public health
is a dynamic interdisciplinary field associated with other
fields such as political science, sociology, criminology,
and psychology. Ultimately, the sociobehavioral determi-
nants of health contributing to the health of individuals
are affected substantially by subsystems such as political,
social, and environmental factors.21

Obtaining Population Data
A challenge for public health professionals is obtaining
current and accurate population data. There are various
sources of data from the local to the international level.
Data are obtained initially through various routes
including surveys, mandatory health data reports, inde-
pendent research, and hospital data, to name a few.
Some of the data are available on the Internet, whereas
other data are protected and special permission is
needed to obtain them.

Census Data: Census data are extremely useful
sources of demographic data. These public domain data
are available on the official U.S. Census Bureau Web site
(see Web Resources on DavisPlus) as well as in multiple
formats upon special request. It is advised that public
health researchers, health promotion planners, and other

64 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 3-6 Demographic transition.

1 2

Time

Total Population

Birth Rate

Death Rate

3 54

B
ir

th
s/

D
ea

th
s

pe
r

1,
00

0

7711_Ch03_055-076 21/08/19 11:06 AM Page 64

professionals charged with developing and implement-
ing health promotion and disease prevention initiatives
access and review local, regional, and state-level
data provided in the U.S. Census. Accessing U.S. Census
data related to a population located in a specific geo-
graphical area is a very effective starting point when
seeking to quantify a health-related phenomenon.
Demographic variables include gender, race, housing,
economic level, age, and other relevant data. However,
census data reflect populations within a specific geo-
graphical area. The census data are available from
the national level down to the neighborhood or census
block level and are useful if the population of interest is
defined based on a geographical community. The data
can be viewed based on ZIP code, town, county, or state.
Accessing the Web site provides a mechanism for
exploring a town or county to determine what the pop-
ulation is, how many housing units are rented or owned,
and how many people living in the town or county have
an income below the poverty level.

Community Data: More typically, public health pro-
fessionals are asked to address community-level health
issues. Community data are valuable resources with both
strengths and limitations. Before addressing sources of
community data, it would be useful to review the discus-
sion of community in Chapter 1. Which of the following
is representative of a community—residents in Portland,
Oregon, diabetics in the tri-state area, women above age
65 years, or gay men in Houston, Texas? An answer of
“all of the above” would be correct. Community data are
not limited to simply a geographical location but can
take on additional characteristics such as disease status
(diabetes), sexual orientation (gay, lesbian, bisexual), and
demographics (race, ethnicity, and age). Examples of
typical opportunities for public health nurses and other
health-related professionals to use community data
include hospital-based initiatives, health plan initiatives,
nonprofit agency initiatives, special interest groups, and
local/state/federal initiatives.

One example of community data relating to the health
of residents in cities, states, and territories is the Behav-
ioral Risk Factor Surveillance Study (BRFSS) found at the
CDC Behavioral Risk Factor Surveillance System Fre-
quently Asked Questions section of its Web site. Disease-
specific data and health-planning and education resource
materials can be found at the American Diabetes Asso-
ciation Web site as well as at local area health-care agen-
cies (see Web Resources on DavisPlus). As previously
mentioned, if the community is a geographical commu-
nity, the U.S. Census data can be used to focus on demo-
graphic information such as the number of women older

than age 65 years. More challenging might be tapping
community-level data on variables such as sexual orien-
tation. Challenges in estimating these variables (e.g.,
number of gay men living in Houston, Texas) are diffi-
cult to overcome as there is a lack of accurate and reliable
data sources. Data relating to these more complex vari-
ables can be, and often are, generated through original
data collection at the community level.

The Nurses’ Health Study, now more than 30 years
old, is of special interest to nursing professionals.
Information on this study can be found on a Harvard
University Web site (see Web Resources on DavisPlus).
This study provides community-level data that have been
generalized to women’s health in the general population.
By seeking to better understand community-level data,
such as women’s health, a more complete understanding
of the factors influencing health and appropriate proac-
tive measures toward the improvement of women’s
health can be successfully achieved. Community data can
relate to person, place, and time variables and a myriad
of interactions between these three broad categories.
Responsible investigators should always take a critical
look at the sources of data and remain cognizant that
errors likely exist within any data to be used in the
development of community health programming. Poten-
tial sources of error should not halt efforts to promote the
health of the public but should be carefully considered
and reported openly.

Biostatistics
Biostatistics reflects the analysis of data related to
human organisms and is used in public health science
and other biological sciences. It examines variations
among biological organisms (people, mice, cells). Thus,
it is a core part of public health science.

Mean, Median, and Mode
Demographers use descriptive statistics as well as ad-
vanced inferential statistical methods to describe the size,
structure, and distribution patterns of populations and
subpopulations within geographically defined regions.
These measures include the computation of the mean,
median, mode, quartiles, and interquartile ranges. De-
mographers also compute the percent change in popu-
lations over time as well as estimate population counts
for the future. These come under the umbrella of descrip-
tive data analysis.

Most epidemiologists regard descriptive data analysis
as the initial step in analysis of demographic data. How-
ever, the analysis of data at the descriptive or inferential
level of analysis is only as good as the accuracy of the data

C H A P T E R 3 n Epidemiology and Nursing Practice 65

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being used. Though the accuracy of data and the methods
by which data are gathered go beyond the scope of this
text, public health scientists should ensure that they de-
velop thoughtful and evidenced-based original data col-
lection protocols and review published science carefully
to evaluate whether data were collected in an accurate
and meaningful way.

Determining the mean, the median, and the mode
uses basic math skills. All three are measures of central
tendency. The mean is what is commonly considered the
average, as it is the mathematical average of a set of num-
bers. The mean is calculated by summing the total of all
values and dividing by the total number of values in the
set. The median is the middle value in a set of values. For
example, if you have 20 individual patient blood pres-
sures, the 10th occurrence in an ordered set from lowest
to highest is the median. The mode is the value that oc-
curs more times within a data set than any other occur-
rence. To help you understand these basic concepts,
complete the question in Box 3-1.

Percent Change
It is useful to have a time 1 and a time 2 measurement to
determine a percent change related to a demographic
variable or health statistic. The time 1 measure is often
referred to as the baseline and can be used to establish
the proportion or percentage of illness or disease within
the population. This is often used to evaluate changes in
a population over time and is calculated by taking the
new number (B) and subtracting the original number
(A) then dividing the resulting number by the original
number A (Box 3-2). This information is quite valuable
when completing community assessments (see Chapter 4),
because it explains shifts in population that may have an
impact on the health of the community or the type of
interventions needed. For example, if there has been a
positive 20% change in the population who are over the
age of 85, then the community may have increased health
needs related to aging, but if the opposite has occurred,
a 20% decrease in those over the age of 85 and a 20% in-
crease in those aged 1 to 5 years, there may be less need
for interventions aimed at the very old and more inter-
ventions needed to support infant health.

Rates
To help in understanding the distribution of disease in a
population, epidemiologists calculate rates. In under-
standing the magnitude of a health-related phenomenon,
epidemiologists need both a numerator and a denomi-
nator. What does this statement mean? Imagine that a
health educator in Columbus, Ohio reports that there

66 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Methods Review
Mean, Median, Mode, Quartiles, and Interquartile Range
Twenty students have been admitted to the dual degree
MSN/MPH degree program. You have been asked by the
Dean of the College to report the average age of these
students.

Data Set [Not real persons]:
Name Gender Age in Years
1. Angela Jones F 23
2. Bill Baker M 32
3. Connie Clark F 22
4. Dennis Daniels M 24
5. Emily Edwards F 56
6. Frank Fitzgerald M 23
7. Georgia Grant F 24
8. Herald Hall M 22
9. Ingrid Israel F 22

10. James Jennings M 24
11. Kelly Karr F 22
12. Lawrence Lee M 35
13. Melissa Martin F 22
14. Nelson Newman M 21
15. Olivia Owen F 22
16. Paul Pierce M 31
17. Quinn Queen F 27
18. Robert Reynolds M 23
19. Sarah Salzman F 22
20. Timothy Tucker M 22
Q1: The mean, median, and mode are all measures of

central tendency—averages. You should report all
three.
A: Mean = 25.96
A: Median = 23
A: Mode = 22

BOX 3–1 n Calculating Population Mean, Median,
and Mode

Formula
(Time B–Time A)/Time A × 100 = percent change

Population 2010 2020 Percent
City A Time A Time B change
Hispanic 1,512 1,955 29.3%
85 years of age 215 92 –57.2%

or older

BOX 3–2 n Calculating Percent Change [Not from
an actual data set]

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are 12,500 smokers in his city and a health educator in
Columbus, Indiana reports that there are 11,800 smok-
ers in his city. Based on these two estimates, it is fair to
say that smoking is a greater problem in Columbus,
Ohio, than it is in Columbus, Indiana, correct? It is clear
that there are 700 more smokers in the Ohio city than
there are in the Indiana city. However, the denominator
is missing in this equation. By going to the U.S. Census
Bureau and learning what the city population estimate
was, we can effectively establish a denominator. It is
always advisable to use the same source if possible so that
comparable population estimates and associated collec-
tion methods are assured in establishing estimates. If the
estimated population for Columbus, Ohio is 730,657 and
for Columbus, Indiana, it is 39,059, then it is possible to
calculate the percentage. Now the facts are that 1.7% of
the population in Columbus, Ohio, smokes compared
with 30.2% in Columbus, Indiana!

Using these data from the two towns, we just calcu-
lated the rate of smoking in each population. To further
illustrate how a rate is determined, consider being the
health commissioner of Petersburg, Oregon, with a
population 5,000. Of the total population, 1,250 people
report that they are current cigarette smokers. The health
department receives a weekly report on the number of
influenza cases reported in the city in the month of
January (Table 3-1). One should assume that these data
are accurate and that no reporting error exists.

Given the data in Table 3-1 and the information on
how many people live in the city, we can construct pop-
ulation rates of influenza cases across the two classifica-
tions of smoker and nonsmoker. First, using the data in
the table, calculate the rate of influenza in smokers
during week 1. To do this, divide 50 by 1,250, which
illustrates a rate of 4%, or 4 in every 100 smokers came
down with the flu in week 1. In comparison, less than
1% of nonsmokers came down with the flu in week 1

(1 in 100). If one considers the total population percent-
ages by week, there was a spike in cases during the third
week of January. However, by breaking the data out by
smoking status, it is clear that there are variations in the
monthly pattern across the two groups. Therefore, a rate
represents the proportion of a disease or other health-
related event, such as mortality, within a population at a
certain point in time. It is the basic measure of disease
used by epidemiologists and other health professionals
to describe the risk of disease in a certain population over
a certain period of time.

How to Calculate: Calculating rates is a relatively
simple mathematical procedure, if one can secure an
accurate estimate of disease or illness in the population
to use as the numerator and an accurate total population
estimate to serve as the denominator (Box 3-3). Again,
using the data in Table 3-1, focus on the first cell
corresponding to week 1: smokers with influenza. The
numerator is 50 (week 1 influenza cases) and the denom-
inator is 1,250 (smokers residing in Petersburg, Oregon).
The number 100 represents a constant, in this case per
100 smokers. The constant could be 1,000 or 10,000 de-
pending on the frequency of the disease in the popula-
tion. This approach allows for the presentation of rates
based on various constants. One may express a rate in
terms of 1,000 or 10,000 rather than 100 if the number
of cases is small. For example, infant mortality rate is
expressed as the number of infant deaths for infants less
than age 1 year per 1,000 live births.

Types of Rates: Mortality and morbidity are two
commonly used rates in epidemiology as well as within
the health-care professions. Mortality refers to the num-
ber of deaths within a given population. To calculate
the mortality rate, take the number of deaths within a
specified time-period and divide it by the total number
of individuals within the same population during the
same time period. A commonly used mortality rate is the

C H A P T E R 3 n Epidemiology and Nursing Practice 67

TABLE 3–1 n Fabricated Data—Influenza in Anytown, USA

Week Influenza Smoker Influenza Nonsmoker Total Influenza

Number of New Cases Number of New Cases Number of New Cases

1 50 (4.0%) 20 (0.5%) 70 (1.4%)

2 40 (3.2%) 25 (6.8%) 65 (1.3%)

3 80 (6.4%) 50 (1.35%) 130 (2.6%)

4 700 (56.0%) 100 (2.7%) 800 (16.0%)

1,250 (Smokers) 3,700 (Nonsmokers) 5,000 (Total Population)

7711_Ch03_055-076 21/08/19 11:06 AM Page 67

infant mortality rate, as this measure is considered an
effective metric by which to gauge the health-care “sys-
tems” of a nation. To calculate the infant mortality rate,
take the number of infant deaths among those ages birth
to 365 days and divide by the total number of live births
during the same 365-day period. To establish a rate,
include a multiplier that represents the previously men-
tioned constant (e.g., × 1,000). Morbidity refers to the
number or proportion of individuals experiencing a
similar disability, illness, or disease. Examples of condi-
tions and diseases reported using morbidity are the num-
ber of infants within a county with pertussis (“whooping”
cough), the number of new mothers delivering at
St. Ann’s in 2020 experiencing postpartum depression,
the number of returning service men and women expe-
riencing post-traumatic stress disorder (PTSD), and
the number of adults in the United States living with
diabetes. Note that the challenge in reporting these con-
ditions as rates is in accurately establishing the denomi-
nator or the total number of individuals at risk for the
condition in question.

Attack rates are calculated by placing the number of
ill or diseased people in the numerator and dividing by
the total number of ill plus well people (in the susceptible
population) in the population of interest, then multiplying
by a given multiplier (e.g., 100,000). The secondary attack
rate can be calculated by taking the number of new cases
of a disease or illness among the contacts of the initial
(primary) cases, dividing by the number of people in the
population at risk, then multiplying by a given multiplier
(e.g., 100,000).

Prevalence, Incidence: Prevalence and incidence
rates are used by epidemiologists to demonstrate the
burden of disease or illness within the population of
interest. However, these practitioners must carefully
consider when and how to report these rates, as they can

be misleading. What is the difference between preva-
lence and incidence? Incidence can be best understood
as the number of new cases of a disease or illness at a
specific time or period of time. Prevalence is the total
number of accumulated cases of a disease or illness both
new and pre-existing at a given time.

Imagine that you are a public health official and that
you have been serving the people of New York City
for the past 25 years. In 1994, the total number of newly
diagnosed cases of HIV was 2,500 and the total number
of existing or prevalent cases in 1994 was 5,000. In 2014,
20 years later, the number of newly diagnosed cases of
HIV is 1,000 and the total number of existing or preva-
lent cases is 50,000. The change in annualized new HIV
cases went from 2,500 to 1,000 and the prevalence went
from 5,000 to 50,000 over the 15-year period. This
20-year change shows a decrease in new cases, whereas
the prevalence rate comparing the difference across
the 20-year period is a 10-fold increase. Given these data,
would it be fair for a reporter from the New York Times
to feature a headline of “HIV in New York City Drasti-
cally Increases 10-fold Since the Mid-1990s!” or “HIV in
NYC Decreases After 20 Years of Prevention Educa-
tion”? Both headlines are accurate, yet neither is a fair
nor accurate account of the state of HIV in the city.

A prevalence rate is basically the number of existing
cases (numerator) divided by the total number of persons
in the population (denominator). The rate calculated
using the information in Table 3-1 can be understood as
a point prevalence or the number of ill people divided by
the total number of people in the population “group” at
a specific point in time. An associated measure, referred
to as the period prevalence, is calculated as the number
of ill people divided by the estimate of the average num-
ber in the population during a specified time period. An
application of period prevalence might be the number of
people living with a chronic disease within a given pop-
ulation during a specified time, such as a year. Asthma is
a chronic disease that might be effectively presented
using a period prevalence.

In addition to prevalence, there are other rates
reported by epidemiologists that are important to under-
stand and use appropriately (Table 3-2). They are inci-
dence rate, attack rate, and secondary attack rate. An
incidence rate can be calculated by placing the number of
new cases diagnosed in a given period of time divided by
the total number at risk in the population over that same
time period and multiplying by a given multiplier (e.g.,
100,000). For example, the incidence of H1N1 in a school
during a specified period of time would be the number of
new cases of H1N1 divided by the denominator, those

68 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Using the data in Table 3-1, focus on the first cell corre-
sponding to week 1—smokers with influenza.

The rate of influenza was calculated using the follow-
ing formula:

(Number of cases [numerator] ÷ population
[denominator]) × a constant = rate per 100; 1,000;

10,000; or 100,000.

For this case:

(50 ÷ 1,250) × 100 = 4.0%

BOX 3–3 n Calculating Rates

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children in the school who had not had H1N1 in the
past. Those children who had had H1N1 would be re-
moved from the denominator to indicate those children
at risk.

A good way to examine the difference between the in-
cidence and prevalence rate is the prevalence pot (Fig. 3-7),
defined in Chapter 2. The prevalence pot represents all
the current cases of a disease in a population. Entering
into the pot are the new cases reflected by the incidence
rate. Exit from the prevalence pot occurs by one of three
events: death, cure, or disability. For some diseases such
as HIV/AIDS the only way a case leaves the prevalence
pot is through death. For other diseases such as polio, all
three options occur. The size of the prevalence pot de-
pends both on the incidence rate and on the duration of
the disease. Over time the prevalence pot for HIV/AIDS
in the United States has grown not because of dramatic
increases in the incidence of HIV/AIDS but because of
the pharmaceutical interventions that have extended
life expectancy. For other serious health threats such as
the 2017-2018 H3N3 virus, the prevalence pot grew
rapidly with the increase in incidence but dropped
rapidly once incidence rates dropped because of the
short duration of the disease.

The incidence and prevalence rates are affected by fac-
tors such as the number of people being screened for the
disease and the number of people surviving with a posi-
tive HIV status. During the early 1980s and into the
1990s, few people survived a positive diagnosis for more
than a few years. Thus, the absence of effective medical
treatment options would have resulted in higher death
rates and subsequently lower prevalence rates. As screen-
ing tests became more widely available and stigmatizing
labels began to be reduced, more people became willing
to be screened for HIV. What is missing from the pres-
entation is the number of people tested who were not
positive for HIV. The lesson to be learned is that data

reporting does not necessarily result in effective interpre-
tation. Careful, cautious, and intentional epidemiological
data reporting is a critical task of the public health infor-
mation officer.

Comparing Dependent and Independent Rates:
Data in Table 3-1 provide a useful illustration of inde-
pendent and dependent rates. The weekly influenza rates
independent of smoking status for the month of January
are 15.0, 12.5, 26.0, and 16.0 per 100 persons, respectively.
Simply stated, these weekly rates are independent of the
smoking status of the individuals within the population.
The converse is true for dependent rates where the rates
of influenza by smoking status by week range from
approximately 40% to 32%, spiking to 64%, and finally
dropping to 56%. The week 3 spike pattern is also
reflected in the nonsmoking population. However, the
proportion of nonsmokers with influenza is consistently
25% to 50% lower than that estimated for smokers. There-
fore, a public health official might accurately state that

C H A P T E R 3 n Epidemiology and Nursing Practice 69

Figure 3-7 Prevalence pot.

Death

Leaving the pot

New Cases
People newly

diagnosed

The
Prevalence Pot:

Total Current
Cases

All people with
the disease

Entering the pot

Disability

Cure

TABLE 3–2 n Differentiating Rates

Measure

Point prevalence

Incidence rate

Attack rate

Secondary attack rate

Multiplier

e.g., 100,000

e.g., 100,000

e.g., 1,000

e.g., 1,000

Numerator

Number ill

Number of new cases over
specified time

Number of new cases during
an epidemic period

Number of new cases among
contacts of known cases

Denominator

Population at risk at specific
point in time

Total number at risk during
time period

Total number in population
at start of epidemic period

Total number of population
at risk

7711_Ch03_055-076 21/08/19 11:06 AM Page 69

influenza rates (independent of smoking) for Petersburg,
Oregon, for January ranged between 12.5% and 26%. In
addition, dependent rates adjusted for smoking status for
the city and time-period demonstrated a substantially
greater proportion of influenza among smokers.

The terms independent rates and dependent rates
are also used to describe rates that are independent or
not independent of each other. For example, if you
were concerned with the infant mortality rate in city Y
compared with the infant mortality rate in city X, the
two rates would be independent of each other. By con-
trast, if you wanted to compare the rates between city
Y in state X and the rate in state X, the rates are
dependent; that is, all of the cases in city Y are included
in the count of cases in state X because the city is in
state X.

Descriptive and Analytical Epidemiology
Now that we have examined the basic demographics of
the population of interest, what else can be done to learn
about the specific health issue? There are three broad
categories of epidemiological studies that help to answer
questions about the health of populations: descriptive,
analytical, and experimental studies. The majority of
epidemiological investigations, particularly community-
based public health investigations, are defined as either
descriptive or analytical. In descriptive or observational
case control and cohort studies, the investigator has
no control over the exposure or nonexposure status of
subjects. By contrast, experimental epidemiology con-
sists of the research methodology whereby the investiga-
tor has direct control over the subject’s assignment to
exposure status. Clinical trials fall into the latter classifi-
cation. Experimental studies tend to fall under the
authority of clinical research scientists and are housed in
academic research centers, federal agencies, or private
research and development agencies, such as pharmaceu-
tical companies.

Descriptive Epidemiology
Descriptive epidemiology refers to the analysis of
population and health data that are already available. It
includes the calculation of rates (e.g., mortality) and an
examination of how they vary according to demographic
variables (e.g., gender, race, socioeconomic status).22

Similar to demography, descriptive epidemiology pro-
vides an understanding of the general features of
the population of interest. In contrast to demography,
the epidemiologist shifts from a broad population demo-
graphic representation to one that illustrates aspects

of health, wellness, and/or disease considerations within
the population.

Analytical Epidemiology
Analytical epidemiology involves examining health-
related data to determine the association between risk
factors and the occurrence of a health phenomenon. In
descriptive epidemiology, the epidemiologist can use the
findings to formulate a hypothesis about possible causes
for the health phenomenon. In analytical epidemiology,
the purpose is to test the hypothesis. There are three
basic types of studies that use analytical epidemiology
methods: the case-control study, the cohort study, and
the clinical trial. The study may use a cross-sectional
design that reports health-related information for a spe-
cific point in time. Or the study may use a prospective,
retrospective, or longitudinal design related to data
collected in more than one time period.

Cross-Sectional Studies
Cross-sectional studies or surveys examine risk factors
and disease using data collected at the same point in
time. It is easy to remember that a cross-sectional study
provides an estimate of the disease status or frequency
at one point in time; thus, it is truly a cross section of
the disease or illness within the population of interest
at a given moment in time. It is also called a prevalence
study. For example, numerous health surveys are
conducted by the National Center for Health Statistics
as a means of determining the prevalence of disease at
a given point in time. They are relatively easy to admin-
ister, and the data can be collected in a rather short pe-
riod of time. However, because they are cross-sectional,
they do not provide a temporal, or time-related, se-
quence of events. For example, if nurse Jane in River
City wanted to determine specific risk factors for smok-
ing among adolescents, she might conduct a survey of
the students through the school system to ask about
specific smoking habits and risk factors. Jane might
also ask whether any of the students’ parents smoked.
However, because Jane collected data at one point in
time, she cannot with confidence assert that parental
smoking preceded smoking initiation by the student.
However, the data can provide valuable information on
which risk factors might be related to smoking among
the youth in River City.

The cross-sectional design methods are not limited to
the study of disease or even illness factors. For example,
this research design methodology can be used to evaluate
satisfaction with health-care–related services within a
community.

70 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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Case-Control Studies and Odds Ratio
The case-control study design allows the epidemiologist
to compare the ratio of disease in those exposed to a risk
factor with those who were not exposed to the same risk
factor. Using the case-control method, the epidemiolo-
gist has a specified number of people with a disease or
illness. These individuals who are defined as diseased
or ill are the “cases.” The epidemiologist then must seek
to establish a representative group of people without the
disease or illness as the controls. Then both the cases and
controls are measured related to a specific exposure or
multiple exposures.

A standard two-by-two table is used to divide
individual-level or person-specific data into disease
status (yes/no) and exposure status (yes/no). The odds
ratio (OR) is defined as the odds of having a disease or
condition among the exposed in comparison with the
odds of those who were not exposed. The calculation of
the OR is a relatively simple mathematical procedure.
The OR is mathematically expressed as [OR = AD/BC]
(Box 3-4). The epidemiologist then determines whether
the OR for those with the disease who have experienced
exposure is significantly greater than the controls by
calculating confidence intervals and p-values for each OR
point estimate. This calculation goes beyond the intro-
ductory nature of this text. Intermediate and advanced
epidemiology textbooks can and should be consulted to
gain depth of understanding of these calculations.

Take, for example, individuals with oral cancer of the
gums. The researcher hypothesizes that people who use
or have a history of using smokeless tobacco (chewing
tobacco) are at greater risk of developing oral cancer. The
researcher now needs a group of individuals to serve as
the controls. To construct the two-by-two table and
establish the risk of oral cancer from chewing tobacco,
she needs a group of individuals who have not been ex-
posed to chewing tobacco. The cases are the individuals
with oral cancer who are asked to report on exposure
variable and use of chewing tobacco. The challenge is to
find a fair representative group that fits into the control
or “no disease” category. Often studies of this nature are
conducted using controls at the same health-care facility

with a different disease or illness. In this scenario, skin
cancer patients will be used as controls. The biological
plausibility of developing skin cancer as a result of
using chewing tobacco is unlikely but could indeed be a
confounder. A confounder is a studied variable that can cause
the disease that is also associated with the exposure of
interest. Confounders can make it difficult to establish a
clear causal link unless adjustments are made for their
effects. Confounders are potential limitations in all epidemi-
ological studies; methods of controlling for confounders are
addressed in advanced epidemiological textbooks.

Case-control studies have limitations. There can be
effects from multiple determinants of health, the com-
plexity of additive, and/or interactive exposures on
health. There are also potential problems related to the
representativeness of the cases and the controls, that is,
how well they reflect the target population. Another issue
is accurately determining exposure. Case-control studies
are done retrospectively; that is, disease has already
occurred in the cases. For both cases and controls, deter-
mining whether individuals have been exposed requires
obtaining a history from the individuals rather than
through direct observation of the exposure. See Box 3-5
for a case-control study of the smoking among youth in
River City.

Cohort Studies and Relative Risk
Cohort studies are studies that follow a specific popula-
tion, subset of the population, or group of people over a
specified period of time. Cohort studies can be effective
in generating a wealth of data relating to the population

C H A P T E R 3 n Epidemiology and Nursing Practice 71

Disease Disease
Status (Yes) Status (No)

Exposure status (Yes) A B
Exposure status (No) C D

BOX 3–4 n Calculating Odds Ratio

Set up a two-by-two table for children aged birth to
18 years with residency (urban/nonurban) on one axis
and smoking status (yes/no) on the other axis.

Answer:
Smoker Smoker
(Yes) (No) Totals

Urban 1,500 1,500 3,000
Non-urban 1,000 6,000 7,000
Totals 2,500 7,500 10,000

Calculate the appropriate measure of association.
HINT: Either relative risk or odds ratio.

Answer: Odds ratio — AD ÷ BC = 1,500 × 6,000 ÷
1,500 × 1,000 — [OR = 6.0] Interpretation: River City
youth between the ages of birth to 18 years living in
the urban district have six times the risk of smoking as
compared with nonurban youth.

BOX 3–5 n Case-Control Study for River City

7711_Ch03_055-076 21/08/19 11:06 AM Page 71

of interest. The epidemiologist has substantial control
over the data collection process; therefore, cohort studies
have strong validity. This validity comes with high costs
that include actual direct costs in personnel as well as
costs in time from data collection to the generation of
findings and conclusions. Two types of cohort studies are
found in application:

• Prospective
• Retrospective (also called historical)

Two Web links are provided in the following section.
The first directs you to the Fels Longitudinal Study
established in 1929, the longest-running continuous
human life span and development study in the world.
This longitudinal study is housed at the Wright State
University Boonshoft School of Medicine in Dayton,
Ohio, and can be accessed at https://medicine.wright.
edu/epidemiology-and-biostatistics/fels-longitudinal-
study-collection. The second is to the Framingham study,
a commonly referenced cardiovascular health study
established in 1948. Both studies are longitudinal and
provide useful data to researchers on human populations
over time. Information on the Framingham study can be
accessed at http://www.framinghamheartstudy.org.23

The relative risk is the measure of association used for
cohort studies. Relative risk is determined by comparing
the incidence rate in the exposed group with the inci-
dence rate in the non-exposed group. This measure is
calculated by dividing the number of people in the
yes/yes (cell A) divided by the row total (cells A+B)
divided by the number of people in the yes/no (cell C)
divided by that row total (cells C+D) (Box 3-6).

For example, if we were interested in exploring the
risks of using oral birth control pills and stroke (these are
fabricated data), we could follow 500 women from age
18 to 25 during a specific time period. We would divide
these women into two groups: those taking an oral birth
control pill (250) and those using alternative birth con-
trol or none (250). We find that after following these
500 women during the 32-year study, among those who
were taking the pill, 100 suffered a stroke and 150 had no
stroke, whereas among those not taking the pill, 24 had

a stroke and 225 had no stroke. How would the relative
risk be calculated?

Confounder WARNING
Of the 100 women taking oral contraception, 90 were
cigarette smokers. What additional information is needed
to establish a confounder effect based on tobacco use? As
explained earlier, a confounder is another variable that
may actually account in whole or in part for the relation-
ship between the observed variable (taking the pill) and
the outcome (stroke).

Most cohort studies use a prospective longitudinal
approach that requires following a group over a long
period of time, which can be 30 years or more. An exam-
ple is the Nurses’ Health Study that began in 1976.
The purpose of the study was to examine the long-term
effects of oral contraceptives.24 The researchers have
added to this important study with the Nurses’ Health
Study II in 1989 and the Nurses’ Health Study III in 2008.
Data are collected from participants every 2 years with a
sustained 90% response rate. Clearly, this type of design
is limited in application because waiting more than
30 years to establish conclusive results can be problem-
atic. In addition, the notion of confounders, or factors
affecting the outcome other than the factor of interest, is
a limitation. Despite these challenges, data from large co-
hort studies have contributed greatly to our understand-
ing of risk factors related to disease. The Framingham
heart study is still ongoing today, spanning three gener-
ations.23 Prior to the study, the common belief was that
cardiovascular disease was part of the aging process. The
information obtained in the study changed the approach
to the prevention and treatment of cardiovascular disease
and continues to contribute to our understanding of
cardiovascular disease today.

There are times when a cohort study is done retro-
spectively. Imagine a situation in which 500 women
today are asked to report on their past 32 years of history.
Specifically, data are collected on all 500 women relating
to oral contraception usage and stroke. Note: In this ret-
rospective study design, you can add a variable such as
cigarette smoking. This design methodology provides the
researcher with the opportunity to report findings in the
present relating to the variables of interest. Recall is often
a problem with any study design that seeks to collect data
from the subjects based on their recall regardless of the
recall period. Often an individual can’t remember what
he or she ate for breakfast a week ago, or what his or her
last fasting blood sugar was. Imagine how much error
might be present in collecting health behavior data from
the general population. Sources of error in this design

72 U N I T I n Basis for Public Health Nursing Knowledge and Skills

HINT: (A ÷ [A + B]) ÷ (C ÷ [C + D])

Stroke No Stroke Total
Oral pill 100 150 250
No oral pill 25 225 250

BOX 3–6 n Calculating Relative Risk

7711_Ch03_055-076 21/08/19 11:06 AM Page 72

also include subject attrition or discontinued participa-
tion, a concern known as right censoring, which is beyond
the scope of this introductory text; confounding; and
other issues related to following a large cohort over a
long period of time.

Clinical Trials and Causality
Clinical trials represent a special type of epidemiological
investigation and the related research methods are a spe-
cial subset. Clinical trials vary widely in their method, but
generally have a control and an experimental group, and
require random assignment to one of these groups. The
control group is not exposed to a treatment, medication,
or therapy, whereas the experimental group is exposed
to the treatment or intervention of interest. The two
groups are then compared to evaluate whether there are
statistically significant differences in outcomes between
the two groups. Clinical trials are more likely to result
in findings that lend themselves to causal statements
of relationships. Cohort and case-control studies can
demonstrate an association between two variables, but a
clinical trial gets much closer to establishing causality.
That said, causality is always a challenging goal to attain
and causal assumptions within clinical research trials
should be carefully considered.

Outbreak Investigations
Outbreak investigation is fundamental to field epidemi-
ology and pivotal to the role of epidemiologists, public
health nurses, and public health workers. As previously
confirmed, epidemiology is truly an applied science. Epi-
demiologists use quantitative data analysis methods at
the population level to better understand health-related
circumstances within communities. The unit of analysis
is groups of people, not the individual. It is critical to
remain cognizant of the risk of committing an ecological
fallacy. The fallacy refers to the erroneous assumption
that one can draw conclusions for individuals based on
group findings, which occurs when the researcher draws
conclusions at the individual level based solely on the
observations made at the group level. An example of an
ecological fallacy can be illustrated based on a study of
obesity in women in two cities. Consider that the women
in City A had a higher body mass index (BMI) on average
than the women in City B. It would be a fallacy to con-
clude, just based on these averages, that a randomly
selected woman from City A would have a higher BMI
than a randomly selected woman from City B. Because
the BMI reported in the study reflected an average
and not a median, there is no information about the

distribution of BMI values in the two cities, and a ran-
domly selected individual woman from City A may
have a lower BMI than a randomly selected woman from
City B.

Although much of the work of public health nurses
and public health workers is focused on implementing
initiatives that prevent disease or illness, the outbreak in-
vestigation is in response to elevated levels of a disease
or illness within the defined population. The outbreak
investigation is one of the more commonly recognized
applications of epidemiology by the general public.
Examples of commonly recognized outbreak investiga-
tions include foodborne illness investigations resulting
from salmonella; gastroenteritis illness investigations at
community daycare centers resulting from Shigella; com-
munities with elevated numbers of pediatric asthma
emergency room visits and subsequent hospitalization;
health-care providers with unusually high numbers of
patients with uncontrolled type 2 diabetes; employees
with elevated levels of asbestosis; communities with un-
expectedly high numbers of infants with elevated blood
lead level; and, on a global level, the Ebola outbreaks in
Africa. Outbreak investigations are an important appli-
cation of epidemiology because of the truly applied na-
ture of the inquiry. The investigation is not simply an
academic exercise but an opportunity to initiate disease
or illness investigation, analyze data collected within the
community or workplace, interpret data, implement
health promotion and risk reduction interventions, and
evaluate short- and long-term health and the effects of
wellness on the population. Precipitating factors relating
to person, place, and time are essential as is an awareness
of disease or illness etiology. Outbreak investigations
can occur in relation to communicable diseases, chronic
disease, and exposure to toxic agents.

Investigation strategies are dependent on the type of
agent resulting in illness, the communicability of the
illness, the virulence of the agent, and the infectivity of the
agent. The infectivity of the agent is defined as the propor-
tion of persons exposed to an infectious agent who become
infected by it and the specific route of infection. As pre-
sented earlier in this chapter, three key aspects of tracking
disease within a population and developing strategies to
reduce the spread and severity of outbreaks are contingent
on person, place, and time considerations. The importance
of effective surveillance of disease and illness is vital in es-
tablishing expected levels of illness within the population.
The CDC maintains publicly reportable data on a number
of diseases (see Web Resources on DavisPlus).

Illnesses such as influenza and pertussis have seasonal
variations and can be substantially reduced through

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preventive vaccination. The number of reported in-
fluenza cases typically spikes annually from December
through March. Public health community-wide vaccina-
tion campaigns are initiated in the autumn each year in
an attempt to prevent disease through targeted immu-
nization at the population level. A vaccine for the pre-
vention of pertussis was developed in the 1940s, and
aggressive public health childhood immunization initia-
tives resulted in a low number of reported cases nation-
ally in the mid-1970s. Unfortunately, the number of
pertussis cases has increased during the past 30 years
with an increasing proportion of cases among the adult
and older segments of the U.S. population.25

Communicable Disease Outbreaks
Communicable diseases can be the result of a point source
or a common source followed by secondary spread within
the population. Typically, person-to-person spread is
observed as with the case with the Ebola virus. However,
communicable diseases such as the West Nile virus are
spread through vectors, specifically insect to human. The
21st century has witnessed a substantial reduction of
diseases as a result of improved environmental condi-
tions and sanitation systems. Person-to-person spread
of communicable disease continues to present substan-
tial challenges to professions charged with promoting
health and reducing the burden of disease at the popu-
lation level. Unlike systems, which can be re-engineered
to eliminate risks of exposure, strategies addressing
person-to-person transmission of disease can be daunting.
Global public health and disease prevention initiatives
such as hand hygiene education and safe sex practices
are initiatives seeking to address person-to-person spread
of communicable diseases. See Chapter 8 for further in-
formation on how to investigate a communicable disease
outbreak.

Noncommunicable Disease Outbreaks
In the latter decades of the 20th century, chronic dis-
eases have replaced communicable diseases as the most
significant disease classification in high-income coun-
tries. Simply stated, as a result of aggressive interven-
tions during the past 100 years, the mortality rate from
communicable diseases has dramatically declined, con-
tributing to higher life expectancy. With this increased
life expectancy, more people are surviving long enough
to develop noncommunicable diseases that occur later
in life such as cardiovascular disease. Often referred to
as lifestyle diseases, illnesses related to poor diet, a lack
of exercise, and tobacco and alcohol use have become
epidemic. Some typically diagnosed noncommunicable

diseases include heart disease, type 2 diabetes, cancer,
and chronic obstructive pulmonary disorder (COPD).
Initiatives including tobacco cessation programs, bal-
anced nutrition education, and exercise/fitness programs
have been and continue to be developed to combat the
negative impact of noncommunicable diseases.

Although not necessarily demonstrative of traditional
outbreak investigation, noncommunicable diseases can
be studied with epidemiological methods comparing
risk factors such as tobacco use and BMI, and the pres-
ence or absence of disease states. Unlike communicable
diseases in which there exists a direct cause-and-effect
relationship between the exposure and the onset of dis-
ease, noncommunicable diseases are usually connected
to multiple risk factors, and it can be harder to demon-
strate a direct cause and effect. This presents challenges
in both demonstrating direct causes of disease and
changing destructive behaviors within the population
that compromise health.

Exposure to Toxins
Similar to noncommunicable diseases, exposure to toxins
has emerged as a substantial risk to human health and
wellness. As with noncommunicable diseases, a direct
cause-and-effect relationship is difficult to prove. In fact,
toxic substances often have thresholds below which
exposures do not present human health risks but above
which can prove to have adverse and at times fatal con-
sequences. The movement during the past 40 years has
been to advance the study of risk exposure to potentially
toxic substances. Organizations including the National
Institute for Occupational Safety and Health (NIOSH),
CDC, EPA, and ATSDR have made substantial gains
in research and policy to reduce toxic risks adversely
affecting the health of the public.

Surveillance
James Maxwell, a physician in the 1800s, once said
“We owe all the great advances in knowledge to those
who endeavor to find out how much there is of any-
thing.”26 This could be a summary of epidemiology but
also specifically of surveillance, which focuses on deter-
mining and monitoring “how much there is” of diseases,
health conditions, environmental disasters, or other risk
factors. The CDC defines public surveillance as “the on-
going, systematic collection, analysis, and interpretation
of health-related data essential to planning, implemen-
tation, and evaluation of public health practice.”27 Sur-
veillance principles are used when universities provide
information on interpersonal violence on campus, the CDC
reports on communicable disease outbreaks or changes

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to the rates of tobacco use, or the WHO provides
national and global level estimates on the prevalence of
tuberculosis infection. All these reports are based on col-
lecting and interpreting data to make practice or policy
recommendations.

There are two main types of surveillance: passive and
active. Passive surveillance is when data are collected
based on individuals or institutions that report on health
information either voluntarily or by mandate. The onus
for collecting and reporting of the data to public health
or governmental agencies is on health-care providers or
public health professions in the field. For example, day-
care centers are often required to report an increase in
the number of cases of communicable disease like hand
foot and mouth (caused by an enterovirus) to the local
or state health departments so that the health depart-
ments can report and monitor communicable diseases.
One of the challenges in passive surveillance is ensuring
that those reporting the data have adequate resources to
collect accurate data. If the data is inaccurate or only
some agencies are reporting the data then there is a risk
that the data will be biased or will not reflect the actual
conditions of the population. Surveillance in low- and
middle-income countries can be particularly challenging
where local and national governments may not have ad-
equate resources to accurately collect morbidity and
mortality data. The consequence of poor surveillance
data is that it can be difficult to accurately prioritize
health-care resources on a national and global level be-
cause the true levels of disease are poorly understood.

One example using the results of surveillance to
understand the impact of disease is the global burden of
disease. As will be discussed in more detail in Chapter 9,
the burden of disease is defined by the WHO as the dif-
ference between a population’s actual health status and
the “ideal” health status if everyone were to live to their
fullest potential and life span. It is measured in the years
of life lost to both premature mortality and disability.28,29

These data include information about the impact of a
health problem on a population using indicators such as
monetary cost, mortality, and morbidity, and refers to
this as the burden of disease. To help measure the burden
of disease, statisticians calculate the disability-adjusted
life years (DALY) that considers not only mortality
but also the morbidity and the disability associated with
a disease or risk factor. Such reports are compiled by
organizations like the WHO based on global surveillance
reports and other local and national data sources. These
data help researchers evaluate the impact of interven-
tions and identify areas for action (see Chapter 9 for
additional information and how to calculate DALY).

A second type of surveillance is active surveillance,
which involves the deployment of public health profes-
sionals including nurses to identify cases of a disease or
health condition under surveillance. This could involve
reviewing medical records, interviewing health-care
providers or hospital administrators, and surveying those
exposed to the condition. Active surveillance is typically
used in an outbreak where there is a sudden change in
the number of cases of a particular disease or condition.
The Ebola responses in Sierra Leone and Liberia provide
examples of active surveillance where multiple organiza-
tions including the CDC and WHO were involved
in finding cases, tracking the spread of disease, and
deploying staff to prevent further transmission.

C H A P T E R 3 n Epidemiology and Nursing Practice 75

t CASE STUDY
Investigating Motor Vehicle
Crashes using Epidemiology

Learning Outcomes
• Apply epidemiology methods to a public health

concern.
• Explore sources of epidemiologic data on a national,

state, and local level.

You are a public health nurse at your state’s health
department tasked with identifying one of the leading
causes of mortality and morbidity, and working with a
local university to design a study to further explore
risk factors related to the identified cause. After com-
paring state-level surveillance data to national data,
you realize that motor vehicle crashes (MVCs) are
a leading cause of death and injury in your state.

Discussion Points
• Using the seven questions for epidemiologic investi-

gations, list what type of information you would like
to gather about MVCs.

• Identify where you might find additional information
regarding MVCs on a local, state, or national level.

• If you were to design an epidemiologic study to
gather more data on MVCs in your state, what type
of study could you design? What are the pros and
cons to your study design?

n Summary Points
• Epidemiology provides the scientific basis for under-

standing the occurrence of health and disease.
• An epidemiological investigation revolves around

person, place, and time.

7711_Ch03_055-076 21/08/19 11:06 AM Page 75

• An understanding of risk factors for disease
from an individual and ecological perspective
is essential for the development of effective
interventions.

• The two-by-two table is a principle pertaining to
epidemiological investigation and analysis.

• Epidemiological investigations include descriptive
and analytical epidemiology.

• Surveillance, both passive and active, helps to
identify and respond to public health concerns
such as outbreaks of communicable diseases.

REFERENCES

1. Martin, N., & Montagne, R. (2017, May 12). U.S. has the
worst rate of maternal deaths in the developed world.
NPR. Retrieved from https://www.npr.org/2017/05/12/
528098789/u-s-has-the-worst-rate-of-maternal-deaths-
in-the-developed-world.

2. Centers for Disease Control and Prevention. (2017). Preg-
nancy mortality surveillance system. Retrieved from https://
www.cdc.gov/reproductivehealth/maternalinfanthealth/
pmss.html.

3. Friis, R.H., & Sellers, T.A. (2014). Epidemiology for public
health practice (5th ed.). Boston, MA: Jones & Bartlett.

4. World Health Organization. (2017). Global tuberculosis
report 2017. Retrieved from http://www.who.int/tb/
publications/global_report/en/.

5. Snow, J. (1965). Snow on cholera. Cambridge, MA: Harvard
University Press.

6. Lilienfeld, A.M., & Lilienfeld, D.E. (1980). Foundations of
epidemiology (2nd ed.). New York, NY: Oxford University
Press.

7. Susser, M., & Susser, E. (1996a). Choosing a future for
epidemiology: I. Eras and paradigms. American Journal
of Public Health, 86(5), 668-673.

8. Susser, M., & Susser, E. (1996b). Choosing a future for
epidemiology: II. From black boxes to Chinese boxes and
eco-epidemiology. American Journal of Public Health,
86(5), 674-677.

9. WHO. (n.d.). Risk factors. Retrieved from http://www.
who.int/topics/risk_factors/en/.

10. CDC. (2018). Behavioral risk factor surveillance system.
Retrieved from https://www.cdc.gov/brfss/index.html.

11a. CDC. (2017). Youth risk behavior survey 1997-2017. Data
retrieved from https://www.cdc.gov/healthyyouth/data/
yrbs/.

11b. CDC. (2017). National health interview survey 1997-2017.
Data retrieved from https://www.cdc.gov/nchs/nhis/
index.htm.

12. National Cancer Institute. (2018). BRCA mutations: cancer
risk and genetic testing. Retrieved from http://www.cancer.
gov/about-cancer/causes-prevention/genetics/brca-fact-sheet.

13. WHO. (2018). Tobacco. Retrieved from http://www.
who.int/mediacentre/factsheets/fs339/en/.

14. CDC. (2018). Youth and tobacco use. Retrieved from
https://www.cdc.gov/tobacco/data_statistics/fact_sheets/
youth_data/tobacco_use/index.htm.

15. Krieger, N. (1994). Epidemiology and the web of causation:
Has anyone seen the spider? Social Science Medicine, 39(7),
887-903.

16. Diez Roux, A.V. (2007). Integrating social and biological
factors in health research: A systems review. Annals of
Epidemiology, 17(7), 569-574.

17. Shapiro, S. (2008). Causation, bias and confounding: A
hitchhiker’s guide to the epidemiological galaxy, part 2.
Principles of causality in epidemiological research: Con-
founding, effect modification, and strength of association.
Journal of Family Planning and Reproductive Health Care,
34(3), 185-190.

18. Reifsnider, E., Gallagher, M., & Forgione, B. (2005). Using
ecological models in research on health disparities. Journal
of Professional Nursing, 21(4), 216-222.

19. Lee, P.R., & Estes. C.L. (2003). The nation’s health (7th ed.).
Burlington, MA: Jones & Bartlett.

20. WHO. (2016). Life expectancy increased by 5 years since
2000, but health inequalities persist. Retrieved from
http://www.who.int/mediacentre/news/releases/2016/
health-inequalities-persist/en/.

21. Szklo, M., & Nieto, F.J. (2012). Epidemiology: Beyond the
basics (3rd ed.). Boston, MA: Jones & Bartlett.

22. Babbie, E. (2016). The practice of social research (14th ed.).
New York, NY: Wadsworth.

23. National Heart, Lung and Blood Institute & Boston University.
(2018). Framingham heart study. Retrieved from http://
www.framinghamheartstudy.org/.

24. The Nurses’ Health Study. (n.d.). Retrieved from http://
www.nurseshealthstudy.org/

25. CDC. (2018). Pertussis (whooping cough). Retrieved from
https://www.cdc.gov/pertussis/surv-reporting.html.

26. Gordis, L. (2014). Epidemiology (5th ed.). Philadelphia, PA:
Elsevier Saunders.

27. Thacker, S.B., & Birkhead, G.S. (2008). Surveillance. In:
M.B. Gregg (Ed.), Field epidemiology. Oxford, England:
Oxford University Press.

28. Murray, C., & Lopez, A. (1996). The global burden of disease:
A comprehensive assessment of mortality and disability from
diseases, injuries, and risk factors in 1990 and projected to
2020. Cambridge, MA: Harvard University Press.

29. Murray, C., & Lopez, A. (2013). Measuring the global
burden of disease. The New England Journal of Medicine,
369, 448-457.

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77

KEY TERMS

Aggregate data
Assets
Census block
Census tract
Community
Community-based

participatory research
(CBPR)

Community Health
Assessment

Community Health
Assessment and
Group Evaluation
(CHANGE)

Comprehensive
community assessment

Deidentified data
Focus group
Geographic information

system (GIS)

Health impact assessment
Inventory of resources
Kinship/Economics/

Education/Political/
Religious/Associations
(KEEPRA)

Key informant
Mobilizing for Actions

Through Planning and
Partnerships (MAPP)

PhotoVoice
Population
Population pyramid
Primary data
Qualitative data
Quantitative data
Rapid needs assessment
Secondary data
Windshield survey

n Introduction
Assessment, the first step in the nursing process, is fo-
cused on determining the health status and needs of an
individual. In public health practice, a community
health assessment is a strategic plan that describes the
health of a community by collecting, analyzing, and
using data to educate and mobilize communities; de-
velop priorities; obtain resources; and plan actions to im-
prove health.1,2 Assessment is one of the three core public
health functions established by the Institute of Medicine
(IOM)3 in 1988 (see Chapter 1) and is critical to the work
of public health, especially as it relates to the other core
functions, policy development and assurance.3

Nurses conduct community assessments as the first step
in the development of health programs and interventions
aimed at optimizing the health of a community or popula-
tion. For example, Dulemba, Glazer, and Gregg (2017)
conducted a community assessment prior to developing an
action plan for persons with chronic obstructive pul-
monary disease (COPD) who were residing in east-central
Indiana and west-central Ohio.4 Other health-care profes-
sionals and community partners have come together and
used the principles of community health assessment to bet-
ter understand the health needs of vulnerable groups. For
example, a team in Chicago utilized a community partici-
patory method to do an assessment in a Mexican immi-
grant community.5 A thorough assessment prior to putting

Chapter 4

Introduction to Community Assessment
Christine Savage and Joan Kub

LEARNING OUTCOMES

After reading the chapter, the student will be able to:
1. Define community health assessment within the context

of population health.
2. Describe six approaches to conducting an assessment

(comprehensive community assessment, population
focused, setting specific, problem focused, health impact,
rapid needs assessments).

3. Describe two assessment frameworks (MAPP,
CHANGE).

4. Use secondary data to identify health characteristics of a
community.

5. Describe qualitative and quantitative methods to collect
primary data for conducting an assessment.

6. Describe the use of multiple techniques and tools
(geographic information system [GIS], PhotoVoice) to
conduct community assessments.

7. Discuss the usefulness of community assessments.
8. Use the frameworks in conducting a hypothetical

assessment of a community.
9. Analyze primary and secondary data to identify strengths

and needs of a community.

7711_Ch04_077-106 22/08/19 11:35 AM Page 77

in place community/population health interventions not
only provides needed information on risk factors within
the community, but also increases the understanding of the
complex interactions between multiple aspects of a com-
munity that impact health such as culture, environment,
infrastructure, and resources. It also provides a method of
assessing the resources of the community as well as the per-
spectives of those who live in the community. Conducting
assessments in partnership with the community is an es-
sential component and provides buy-in from the beginning
as evidenced by the assessments referenced earlier when
conducted in both an urban and a rural community.

Just as an individual nursing assessment requires
special skills, a community assessment also requires a
unique set of skills to systematically examine the health
status, needs, perceptions, and assets or resources of a
community. Some of the skills or competencies needed
to conduct such an assessment include selecting health
indicators, using appropriate methods for collecting data,
evaluating data, identifying gaps, and interpreting and
using data. Basic community health assessments skills for
frontline public health professionals, also referred to as
Tier 1 professionals, are set out by the Council on Link-
ages Between Academia and Public Health Practice
(Box 4-1).6 Note, of the eight competency domains for
public health professionals, assessment/analytical com-
petency is the first domain. As with the nursing process,
assessment is the first step in the process for achieving
optimal health in populations and communities.

Definitions of Community
and Community Health
Defining the concepts of community and community
health is critical in thinking about a community
assessment.

A community, as defined in Chapter 1, is a group of
individuals living within the same geographical area,
such as a town or a neighborhood, or a group of individ-
uals who share some other common denominator, such
as ethnicity or religious orientation. In contrast to aggre-
gates and population, individuals within the community
recognize their membership in the community based on
social interaction and establishment of ties to other
members in the community, and often participate in col-
lective decision making.

There is a great deal of media interest in the health of
communities. Media outlets often use various indices
such as mental wellness, lifestyle behaviors, fitness,
health status, and nutrition to identify the healthiest
cities in our country. Public health agencies also focus

78 U N I T I n Basis for Public Health Nursing Knowledge and Skills

on defining the health of a community. At the national
level there are programs with goals to improve the
health of communities such as the Centers for Disease
Control and Prevention’s past program Partnerships to
Improve Community Health (PICH).7

Three important characteristics help define the health
of a community: health status, structure, and competence.
Selected biostatistics provide vital information about lead-
ing health issues in a community. Statistics commonly
used when doing a community assessment related to
health and disease are covered in Chapter 3. These statis-
tics include indicators such as mortality rates and morbid-
ity rates (the incidence and prevalence of disease).
Mortality is often depicted by crude rates or age-adjusted
rates. Next there is the structure of a community, which
includes the demographics of the community as well as
the services and resources available in the community. The
demographic data include such indicators as age, gender,
socioeconomic indicators, racial/ethnic distributions, and
educational levels. The community health services and re-
sources include information about the resources available

Analytic/Assessment Skills—Tier 1
1. Describes factors affecting the health of a community
2. Identifies quantitative and qualitative data and

information
3. Applies ethical principles in accessing, collecting,

analyzing, using, maintaining, and disseminating data
and information

4. Uses information technology in accessing, collecting,
analyzing, using, maintaining, and disseminating data
and information

5. Selects valid and reliable data
6. Selects comparable data
7. Identifies gaps in data
8. Collects valid and reliable quantitative and

qualitative data
9. Describes public health applications of quantitative

and qualitative data
10. Uses quantitative and qualitative data
11. Describes assets and resources that can be used for

improving the health of a community
12. Contributes to assessments of community health

status and factors influencing health in a community
13. Explains how community health assessments use

information about health status, factors influencing
health, and assets and resources

14. Describes how evidence is used in decision making

BOX 4–1 n Core Assessment Competencies
for Public Health Professionals

Source: (6)

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Comprehensive Assessment
Since the 1988 IOM report, The Future of Public Health,
improving health in populations or communities has
been linked to performing comprehensive assessments.3
There is a mandate for public health agencies to regu-
larly and systematically collect, assemble, analyze, and
make available information on the health of the com-
munity, including statistics on health status, community
health needs, and epidemiological studies of health
problems.12 In addition, the Affordable Care Act re-
quires that nonprofit hospitals conduct community
health assessments.13 Data regarding demographic and
health characteristics of the entire population are col-
lected in these assessments. A comprehensive commu-
nity assessment is the collection of data about the
populations living within the community, an assessment
of the assets within a community such as the local health
department capacity, and identification of problems and
issues in the community (unmet needs, health disparity)
and opportunities for action.14

Since 1992, the CDC has guided communities in con-
ducting assessments, making health decisions, and de-
veloping policy. There are a number of tools available
for conducting community assessments such as the
Community Health Assessment and Group Evalua-
tion (CHANGE) tool that includes a process for con-
ducting a comprehensive assessment of a community.
Other tools are available such as Mobilizing for Actions
Through Planning and Partnerships (MAPP) as well
as some that are specific to a one aspect of community
health such as PACE-EH (Chapter 6), which targets
environmental health (Table 4-1).14

Population-Focused Assessment
A population, as defined in Chapter 1, is a larger group
whose members may or may not interact with one an-
other but who share at least one characteristic such as
age, gender, ethnicity, residence, or a shared health
issue such as HIV/AIDS or breast cancer. The common
denominator or shared characteristic may or may not
be a shared geography or other link recognized by the
individuals within that population. For example, per-
sons with type 2 diabetes admitted to a hospital form
a population but do not share a specific culture or place
of residence and may not recognize themselves as part
of this population. In many situations, the terms aggre-
gate and population are used interchangeably. An as-
sessment can be focused on a specific population for
purposes of planning and developing intervention pro-
grams. A population-focused assessment, for example,
might focus on pregnant women or immigrants living

in the community as well as service use patterns, treatment
data, and provider/client ratios.

Finally, the health of a community may be conceptu-
alized as effective community functioning, a concept de-
veloped by Cottrell in the 1970s and expanded by
Goeppinger and Baglioni in the 1980s.8,9 Conditions and
select measures of community competence include com-
mitment to the community, conflict containment, accom-
modation (working together), participant interaction,
decision making, management of the relationships with
society, participation (use of local services), awareness of
self and other, and effective communication. These com-
munities value connections between people in the com-
munity as well as those outside of the community. A
competent community is able to identify its needs,
achieve some goals and priorities, agree on ways to im-
plement those goals, and collaborate effectively.10,11 The
establishment of a Neighborhood Watch program to ad-
dress growing crime in a community is an example of ef-
fective functioning in which the community comes
together, works to come up with a solution to a problem,
and promotes a higher level of functioning by pulling to-
gether to address an issue.

Types of Community Health Assessments
The purpose of assessments is to gather information and
identify areas for improving the health of communities
and populations. Assessment is the first step in the
process of health planning and provides essential data
needed to decide where best to allocate community re-
sources. Assessments also provide baseline data. For ex-
ample, if the community is concerned about the health
of infants and mothers, a community assessment can
provide the data needed to determine what the actual sta-
tus of maternal and infant health (MIH) is for the com-
munity; whether problems exist for the community as a
whole; or whether there is a disparity in MIH based on
socioeconomic status, ethnicity, or geographical location
in the community. Baseline data on premature births, in-
fant mortality, and vaccination rates help health planners
determine whether the intervention had an impact dur-
ing the evaluation phase of health planning (Chapter 5).
The key is to understand what type of assessment is best.
There are several types of community health assessments:

• Comprehensive assessment
• Population-focused assessment
• Setting-specific assessment
• Problem- or health-issue-based assessment
• Health impact assessments
• Rapid needs assessment

C H A P T E R 4 n Introduction to Community Assessment 79

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within a community. One community assessment was
conducted to examine the health needs of Hispanic
immigrants, especially in relation to the issue of
adolescent pregnancy. The findings provided the in-
formation needed for the development of new inter-
ventions that would engage adolescents and other
stakeholders.15

A population-focused assessment can also focus on a
certain age range or a population with a specific health
characteristic that may put the group at risk (e.g., chil-
dren or, specifically, children with disabilities). In health
departments, nurses are often involved with writing
grants to serve the needs of mothers and children (see
Chapter 17). Identifying health indicators of interest is a
beginning step in the process of conducting this type of

assessment. For example, the World Health Organiza-
tion (WHO) identified 11 maternal-child health indica-
tors (Box 4-2).16 These indicators provide insight into the
health of this population and a mechanism for tracking
accomplishment in improving these indicators over time.

Setting-Specific Assessment
Assessments can also be focused on a specific setting.
Assessments of this nature may focus on identifying
strengths and weaknesses of an organization or policies
and programs within an organization. Similar to other
assessments, a setting-specific assessment requires a
clear understanding of the purpose of the assessment to
proceed in an organized manner. An occupational
health assessment conducted within a company will

80 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–1 n Community Assessments Tools

Author, Date
Model Released or Updated Brief Description

Association for Community Health
Improvement, Community
Health Assessment toolkit

(http://www.assesstoolkit.org/)

Catholic Health Association
(http://www.chausa.org/

communitybenefit)

Mobilizing for Action through
Planning and Partnerships (MAPP)

(http://www.naccho.org/programs/
public-health-infrastructure/mapp)

State Health Improvement Planning
(SHIP) Guidance and Resources

(http://www.astho.org/WorkArea/
DownloadAsset.aspx?id=6597)

Community Health Assessment
and Group Evaluation (CHANGE)

(https://www.cdc.gov/healthy
communitiesprogram/tools/
change/pdf/changeactionguide.pdf)

Protocol for Assessing Community
Excellence in Environmental
Health (PACE-EH)

(http://www.naccho.org/topics/
environmental/PACE-EH)

American Hospital
Association,
updated 2011

Catholic Hospital
Association,
updated 2012

National Association
of County and
City Health
Officials and
CDC, 2001

Association of State
and Territorial
Health Officials
and CDC, 2011

CDC, updated 2010

National Association
of County and
City Health
Officials and CDC,
2000

• Toolkit for planning, leading, and using community
health needs assessments

• Provides six-step assessment framework and practical
guidance

• Access to the full toolkit requires paid membership

• For hospital staff who conduct or oversee community
health needs assessments and plan community benefit
programs

• Focus on collaboration, building on existing resources,
and using public health data

• Framework for community health improvement
planning at the local level

• Strong emphasis on community engagement and
collaboration for system-level planning after identifying
assets and needs

• Framework for state health improvement planning
• Emphasis on community engagement and

collaboration for system-level planning after identifying
assets and needs

• Tool for all communities interested in creating social
and built environments that support healthy living

• Focus on gathering and organizing data on community
assets to prioritize needs for policy changes

• Users complete an action plan

• Tasks to investigate the relationships among what they
value, how their local environment impacts their
health, and next steps

• For local health agencies to create a community-based
environmental health assessment

Source: (14)

7711_Ch04_077-106 22/08/19 11:35 AM Page 80

most likely consist of a description of the company, the
working population, the health programs, and stressors
present at the worksite. The same principles apply in as-
sessing a school setting. The PHN must identify indica-
tors relevant to the setting. Health indicators relevant to
an industrial setting might include work-related injury
or days absent. At a school setting the assessment would
most likely begin with a description of the school, the
history, policies, support services, the actual school
building from an environmental perspective, the popu-
lation (teachers, staff, and students), and the existing
programs with an emphasis on health. There are many
additional tools that can be used to assess components
of school health. The School Health Index,17 a tool avail-
able through the CDC, addresses physical activity,
healthy eating, tobacco use prevention, unintentional
injury, violence prevention, and asthma rates within a
school system (see Chapter 18).

This type of health assessment treats the setting as the
community and considers the population located in the
setting. Thus, a setting assessment includes components
of a comprehensive assessment and a population assess-
ment. Taking the example of a health assessment con-
ducted at an industrial worksite by an occupational
health nurse (see Chapter 20), it would be helpful to col-
lect and analyze data relevant to the environment, the re-
sources available to promote health, and health statistics

specific to the population. According to the CDC, a
workplace assessment involves obtaining information re-
lated to the health of employees within the workplace set-
ting, including protective and risk factors to identify
opportunities to improve the health of the workers.18

Problem- or Health-Issue-Based Assessment
Assessments can also focus on a specific problem or
health issue. In many cases, assessments and tool kits for
specific health issues can be found on the Internet. For
example, obesity is a growing problem in the United
States, and communities are identifying the need to pro-
mote an understanding of the policies, practices, and en-
vironmental factors that contribute to the nutrition and
physical activity choices within a community. An assess-
ment can help a community identify physical activity and
nutrition policies, practices, and environmental condi-
tions within the local community at large, such as work-
sites, school systems, and the health-care delivery system.
Assessments can help identify specific issues related to
the health issue and can also be population and/or setting
specific. They can also help reach vulnerable populations
and identify health needs such as an assessment of the
transgender population conducted in Wisconsin. The
community assessment helped identify that health-care
providers play a key role in facilitating access to care for
this population.19 Often assessments related to a specific
health issue include analysis of data to help determine
who is at risk for the disease, such as the use of a case
control study (see Chapter 3).

Health Impact Assessment
There are two other types of assessments: health impact
assessment (HIA) and rapid needs assessment. The
WHO notes that there are several definitions of a HIA.
The main definition it has adopted is based on a 1999
European Centre for Health Policy definition of an HIA.
According to the WHO, an HIA “… is a means of assess-
ing the health impacts of policies, plans, and projects in
diverse economic sectors using quantitative, qualitative,
and participatory techniques.”20 A growing awareness of
the multiple determinants of health, with a focus on the
environment, has resulted in an increased focus and uti-
lization of HIAs throughout the world. HIA methods are
used to evaluate the impact of policies and projects on
health, and a successful HIA is one in which its findings
are considered by decision makers to inform the devel-
opment and implementation of policies, programs, or
projects. HIAs are often associated with assessments of
the environment or assessments focused on the social in-
fluences of large projects. Zoning laws, for example, may

C H A P T E R 4 n Introduction to Community Assessment 81

1. Maternal mortality ratio
2. Under-5 child mortality, with the proportion of

newborn deaths
3. Children under 5 who are stunted
4. Proportion of demand for family planning satisfied

(met need for contraception)
5. Antenatal care coverage (at least four times during

pregnancy)
6. Antiretroviral prophylaxis among HIV-positive

pregnant women to prevent HIV transmission and
antiretroviral therapy for (pregnant) women who
are treatment-eligible

7. Skilled attendant at birth
8. Postnatal care for mothers and babies within 2 days

of birth
9. Exclusive breastfeeding for 6 months (0–5 months)

10. Three doses of combined diphtheria-tetanus-
pertussis immunization coverage (12–23 months)

11. Antibiotic treatment for suspected pneumonia

BOX 4–2 n The WHO 11 Indicators of Maternal,
Newborn, and Child Health

Source: (16)

7711_Ch04_077-106 22/08/19 11:35 AM Page 81

increase the availability of walking paths that in turn may
help to reduce the prevalence of obesity in a community.
Examples of these types of assessments include an HIA
of urban transport systems21 or the value of assessing im-
pact of policies on health inequities.22 An HIA provides
advice to a community on how to optimize the health of
the community, is conducted prior to implementing a
community-level intervention, and includes specific
steps (Box 4-3).20,23

Rapid Needs Assessment
Another type of assessment is a rapid needs assessment,
a tool that helps establish the extent and possible evolu-
tion of an emergency by measuring the present and
potential public health impact of an emergency, deter-
mining existing response capacity, and identifying any
additional immediate needs.24,25 This type of assessment
was first used in international settings during the 1960s
to assess for immunization coverage, morbidity from
diarrheal and respiratory diseases, and service coverage.
In the 1970s, it was used in the smallpox eradication pro-
gram in West Africa and was then adapted by the WHO
for the Expanded Program of Immunization to assess
immunization coverage in the 1980s. At the national
level, the CDC, the Federal Emergency Management
Agency, and the U.S. Public Health Service (USPHS)
have all adopted a rapid needs assessment format when
responding to a disaster. A rapid needs assessment is an
effective use of limited resources and in general involves
a straightforward collection of data. It is undertaken
immediately after a disaster or event usually during the
first week. The goal is to understand immediate needs,
determine possible courses of action, and identify
resource requirements.25

Concepts of Relevance to Community
Assessments
There are important concepts relevant to conducting a
community assessment discussion: needs, assets, and the
use of community-based participatory research. These
reflect the importance of working with a community
while maximizing the strengths of the community rather
than focusing on deficits within the community. In the
past, community assessments were done by outsiders
and, for the most part, highlighted where the health gaps
were without acknowledging assets within the commu-
nity or including the community as a partner.

Needs Assessments Versus Asset Mapping
Initially, community assessments were based on the
premise that the purpose of a community health assess-
ment was to identify needs. In 1995, Witkin and
Altschuld defined a needs assessment as “a systematic
set of procedures undertaken for the purpose of setting
priorities and making decisions about program or or-
ganizational improvement and allocation of resources.
The priorities are based on identified needs.”26 A need
was considered a discrepancy or a gap between what is
and what should be.26

In contrast with this view of community health assess-
ments, Kretzmann and McKnight published a landmark
book that made the argument that an assessment should
focus on the positive assets of a community rather than
on its deficits. Assets are useful qualities, persons, or
things. They combined this concept of assets with the
concept of mapping, that is, exploring, planning, and lo-
cating, and proposed that community assessments
should include asset mapping. Some of their ideas grew
out of the plan to rebuild troubled urban communities
based on capacity building.27 According to Kretzmann
and McKnight, a needs approach characterizes commu-
nities as a list of problems, makes resources available to
service providers instead of residents, contributes to a
cycle of dependence, and focuses on maintenance and
survival strategies instead of development plans. By con-
trast, an asset mapping approach focuses on effectiveness
instead of deficiencies, builds on interdependencies of
people, identifies how people can give of their talents,
and seeks to empower people.27

The assets approach, based on Kretzmann and McK-
night’s work, is based on constructing a map of assets
and capacities. Three aspects of a community can be in-
cluded in an asset map: (1) people, (2) places, and (3) sys-
tems.27 People include individuals and families living
within the community; places include the resources

82 U N I T I n Basis for Public Health Nursing Knowledge and Skills

• Screening (identifying plans, projects, or policies for
which an HIA would be useful)

• Scoping (identifying which health effects to consider)
• Assessing risks and benefits (identifying which people

may be affected and how they may be affected)
• Developing recommendations (suggesting changes

to proposals to promote positive health effects or to
minimize adverse health effects)

• Reporting (presenting the results to decision makers)
• Monitoring and evaluating (determining the effect of

the HIA on the decision)

BOX 4–3 n Major Steps in Conducting a Health
Impact Assessment (HIA)

Source: (20)

7711_Ch04_077-106 22/08/19 11:35 AM Page 82

within the community such as schools, businesses, recre-
ational facilities, and health-care resources. Systems in-
clude both formal systems such as government and
churches as well as informal systems within the commu-
nity such as neighborhood organizations. These systems
are not always discrete and separate but, rather, influence
each other.28 Although these approaches of needs and
assets appear diametrically opposed, the reality is that
comprehensive community assessments consist of the
identification of both weaknesses and strengths. Identi-
fying the strengths as well as the problems is critical in
the analysis of data.

Community-Based Participatory Research
The second concept of particular relevance to assessment
is community engagement in the process of the assess-
ment. There are various terms used to describe this
approach including community engagement, citizen
engagement, public engagement, translational science,
knowledge translation, campus-community partner-
ships, and integrated knowledge translation.34 In this
book, we use the term community-based participatory
research (CBPR). The definitions related to this ap-
proach all include engagement of members of the com-
munity as full partners in the process of assessment. The
idea is to use a collaborative approach that combines the
knowledge and interest of the community members with
the expertise of the professionals. The end goal is to
achieve change that will work toward improving the
health of the community.29-31

CBPR emphasizes the essential principles of capacity
building, shared vision, ownership, trust, active partici-
pation, and mutual benefit.29 A benefit of this approach
is that it is a colearning process wherein the researchers
and community members contribute equally and achieve
a balance of research and action. In addition, it is a way
of providing culturally competent care. For the PHN
working with the community, it is important to be aware
of the principles of CBPR. One of the first steps in the
community assessment is to engage partners in the
process and to develop a common vision.30

The engagement of communities in the community
assessment process using CBPR methods has become an
accepted method for not only engaging the community
in the process but also engaging the end users in the ac-
tion that will be taken to improve health.31 When using
CBPR methods, it is important to evaluate the possible
ethical issues that can arise. These include issues of
power, fairness, appropriate selection of representatives,
obtaining consent, upsetting community equilibrium,
and issues of dissemination of sensitive data.29,32

Assessment Models/Frameworks
Models or frameworks provide the structure and guid-
ance for conducting an assessment. PHNs can choose a
model based on what best fits the type of assessment that
is being conducted. Examples of models that can help
guide a comprehensive community health assessment
are the Community Health Assessment and Group Eval-
uation (CHANGE) tool and the Mobilizing for Actions
Through Planning and Partnerships (MAPP) strategic
model.

Community Health Assessment and Group
Evaluation
The CDC based the CHANGE tool on the socioecolog-
ical model (see Chapter 2) to help communities build
an action plan based on identified assets and areas for
improvement. The stated purpose of the CHANGE
tool is “to enable local stakeholders and community
team members to survey and identify community
strengths and areas for improvement regarding current
policy, systems, and environmental change strate-
gies.”33 The process provides a community with the
foundation for conducting a program evaluation. The
idea is to start with the end in mind and include eval-
uation in the beginning of the assessment process.33

This tool includes a set of Microsoft Office Excel
spreadsheets that communities can use to manage the
data they collect. The tool provides a guide to doing a
community assessment and helps with prioritizing
areas for improvement.

CHANGE uses an eight-step process for conducting
the assessment (Table 4-2) and was updated in 2018.
The first three steps focus on gathering and educating
the team. Steps 4 through 6 involve gathering, in-
putting, and reviewing data from the assessment. The
last two steps are the development of an action plan
starting with an analysis of the consolidated data.
CHANGE is a tool to help a community complete an
assessment that not only provides a diagnosis but also
ends with the presentation of an action plan. The idea
is to create a living document that the community can
use to prioritize the health needs of the community and
provide a means for structuring community activities
around a common goal.33

Mobilizing for Actions Through Planning
and Partnerships
The National Association of County and City Health
Officials in cooperation with the Public Health Practice
Program Office, CDC, developed a planning tool for

C H A P T E R 4 n Introduction to Community Assessment 83

7711_Ch04_077-106 22/08/19 11:35 AM Page 83

improving community health. The tool was developed
with input from a variety of organizations, groups, and
individuals who made up the local public health system
between 1997 and 2000 (Fig. 4-1). The vision for imple-
menting MAPP is for “communities [to achieve] im-
proved health and quality of life (QoL) by mobilizing
partnerships and taking strategic action.”34

The MAPP assessment model was based on earlier
models used by public health departments (PHDs)
such as the Assessment Protocol for Excellence in Pub-
lic Health (APEXPH), which was released in 1991.35

Building on the concepts included in the APEXPH
model, MAPP strengthened the community involve-
ment component of assessment and aligned the
model with the 10 essential public health services (see
Chapter 1).34 The MAPP tool includes the full scope of
health planning including assessing, diagnosing, devel-
oping an intervention, implementing the intervention,
and evaluating the effectiveness of the intervention. By
contrast, CHANGE focuses on assessment and diagno-
sis with evaluation built in as the goal (see Table 4-2).
Communities and PHDs have used MAPP across the
country because it includes an action phase, providing
a comprehensive approach to improving the health of
a community.

The focus of the first five phases of MAPP is the process
involved in working with the community on strategic
planning and conducting four separate assessments. The
MAPP handbook34 contains access to the tools, resources,
and technical assistance needed to conduct the assessment,

including a toolbox to provide an explanation and the
many examples of assessments that have been conducted.
The MAPP process has six phases: (1) organizing for suc-
cess and partnership development, (2) visioning, (3) per-
forming the four assessments, (4) identifying strategic
issues, (5) formulating goals and strategies, and (6) moving
into the action cycle.

Phase 1: Organizing for Success
and Partnership Development
This phase is focused on identifying who should be in-
volved in the process and developing the partners who
will participate in the process. The recommended part-
ners include the core support team and a steering com-
mittee. The core team does the majority of the work
including recruiting participants. The steering commit-
tee provides guidance and oversight to the core support
team and should broadly represent the community. It is
important to obtain broad community involvement
during this phase that includes inviting persons to serve
on the steering committee and informing the commu-
nity of opportunities for involvement that will occur
throughout the planning process.34

Phase 2: Visioning
This phase is done at the beginning of the assessment
process and is focused on mobilizing and engaging the
broader community. An advisory committee guides
the effort by conducting visioning sessions, resulting
in a vision and values statement. The following are

84 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–2 n Best Practice Approach to Public Health Assessment: Comparison of MAPP With CHANGE

Mapp Change

Phase 1: Partnership

Phase 2: Visioning

Phase 3: Assess residents, public
health system, community
health, and forces of change

Phase 4: Identify strategic issues

Phase 5: Formulate goals and
strategies

Phase 6: Action cycle

Action Step 1: Assemble the Community Team.
Action Step 2: Develop team strategy.

Action Step 3: Review all five CHANGE sectors.

Action Step 4: Gather data.
Action Step 5: Review data gathered.
Action Step 6: Enter data.

Action Step 7: Review consolidated data.
Action Step 7a: Create a CHANGE Summary Statement.
Action Step 7b: Complete the Sector Data Grid.
Action Step7c: Fill Out the CHANGE Strategy Worksheets.
Action Step 7d: Complete the Community Health Improvement Planning Template.

Action Step 8: Build an action plan.

Source: (33)

7711_Ch04_077-106 22/08/19 11:35 AM Page 84

some sample questions that can guide brainstorming
during this phase:

• What does a healthy community mean to you?
• What are the important characteristics of a

healthy community for all who live, work, and
play here?

• How do you envision the local public health system
in the next 5 or 10 years?

Phase 3: Performing the Four Assessments
Four assessments form the core of the MAPP process.
The assessment phase results in a comprehensive picture
of a community by using both quantitative and qualita-
tive methods and consists of the following:

Community Themes and Strengths Assessment:
This provides important information about how the res-
idents feel about issues facing the community. It also
provides qualitative information about residents’ percep-
tions of their health and QoL concerns. Some questions
to guide this assessment include:

• What is important to your community?
• How is QoL perceived in your community?
• What assets do you have that can be used to improve

community health?

Local Public Health System Assessment (LPHSA):
This focuses on the organizations and entities that con-
tribute to the public’s health. It is concerned with how
well the public health system collaborates with other
public health services. The LPHSA answers the following
questions:

• What are the components, activities, competencies,
and capacities of your local public health system?

• How are the essential services being provided in your
community?

Community Health Status Assessment: The com-
munity health status assessment is largely focused on
quantitative data about many health indicators. These in-
clude the traditional morbidity and mortality indicators,
QoL indicators, and behavioral risk factors resulting in
a broad view of health.

Forces of Change Assessment: This is an analysis of
the external forces, positive and negative, that have an im-
pact on the promotion and protection of the public’s
health. It is concerned with legislation, technology, and
other impending changes that can influence how the pub-
lic health system can work. It answers questions such as:

• What is occurring or might occur that affects the health
of our community or the local public health system?

C H A P T E R 4 n Introduction to Community Assessment 85

Figure 4-1 Mobilizing for
Action Through Planning and
Partnerships (MAPP). (Source:
National Association of County
and Community Health Officials.
[2013]. Retrieved from http://
www.naccho.org/topics/
infrastructure/MAPP/index.cfm.)

7711_Ch04_077-106 22/08/19 11:35 AM Page 85

• What specific threats or opportunities are generated
by these occurrences?

Phase 4: Identifying Strategic Issues
During this phase, the assessment data are used to deter-
mine the strategic issues the community must address to
reach its vision. Some questions to help the community
in determining the important strategic issues include the
following:

• How large a public health issue is the item?
• Can we do it?
• Is it reasonable, feasible, and financially cost

effective?
• What happens if we do nothing about it?

Phase 5: Formulating Goals and Strategies
Goals and strategies are formulated for each of the strate-
gic issues. A community health improvement plan is
often created during this phase. Both the steering com-
mittee and the core team work together to “… identify
broad strategies for addressing issues and achieving goals
related to the community’s vision.”34

Phase 6: Moving Into the Action Cycle
This is the phase in which the actual planning, imple-
menting, and evaluating of the strategic plan takes place.
Phases 5 and 6 are described in more detail in Chapter 5,
which is focused on health planning.34

A Comprehensive Community Health
Assessment
MAPP and CHANGE are examples of frameworks that
provide blueprints for conducting a community health
assessment. Regardless of the framework, the first step is
engagement of partners in the process. As described in
the CHANGE tool, this first action step involves assem-
bling a diverse and representative community team. The
team then establishes the purpose of the assessment. This
begins with a clarification of how the community is being
defined. Is the community being defined in relation to a
clear geopolitical community such as a city or a county,
or is the community a neighborhood that may not have
clear geopolitical boundaries? For example, a group of
researchers was conducting a focused assessment of ma-
ternal and infant care in subsidized housing in Winton
Hills, Ohio, a neighborhood located within the Cincin-
nati, Ohio, metropolitan area. It had no political stand-
ing (it was designated as a town or city but did not
have governmental systems in place). Instead, it was a

neighborhood that roughly matched a designated ZIP
code, so for the purposes of the assessment the commu-
nity was defined based on a specific ZIP code.36

Once the community has been defined, it is important
to identify indicators and the sources of data for those
indicators. This step often involves a discussion of the
history of the community and the proposed project.
Through these efforts, the team can identify sources of
data that are already in existence. In some cases, previous
surveys have been conducted that can provide good base-
line data to help understand trends and changes in the
community. Other data can be obtained from national-
level surveys; the U.S. Census Bureau; and sources of
local data, such as reports on crime, motor vehicle acci-
dent, and fire.

Next, the team can develop a timeline to help guide
the assessment. A timeline helps the team decide at
what point each step in the assessment will take place,
the estimated time for completing each of the steps,
and who will be responsible for each step. If the team
is using the CHANGE model, the members will try
to understand the total picture and will include as-
sessment of five sectors of the community: (1) the
community-at-large sector, (2) the community insti-
tution/organization sector, (3) the health-care sector,
(4) the school sector, and (5) the worksite sector. Once
this is complete, the team will then begin to gather
data for each sector and evaluate the quality of the
data. Different methods can be used to collect data, in-
cluding obtaining secondary data available from other
sources and collecting primary data. Primary data
includes any data collected directly by the assessment
team, in contrast to secondary data, which is the
examination of data already collected for another
purpose such as census data. Under step 4 in the
CHANGE model, the different primary data collection
methods listed that can be used include doing a wind-
shield survey, PhotoVoice, doing a walkability audit,
conducting focus groups, and administering a survey
to individuals.

Windshield Survey
A windshield survey is an example of primary data
collection that can help the team get an initial under-
standing of the community and is sometimes viewed
as part of a preassessment phase. The windshield sur-
vey is what it sounds like—a drive-through or walk-
through the community to observe the community.
The idea is to observe the community to help in
understanding it prior to conducting a more formal
assessment.

86 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch04_077-106 22/08/19 11:35 AM Page 86

A windshield survey is the first step in taking the pulse
of the community. The questions a windshield survey can
begin to answer include:

• Are there obvious health-related problems?
• What is the perspective of the media in relation to

the community?
• What does the community look like?

Just by driving around, key issues related to the envi-
ronmental health of the community can be observed,
such as the number of for-sale signs, the amount of green
space, the number of bars, the number of churches, the
number of open (or closed) businesses, and the general
upkeep of the community. Clean streets, well-kept parks,
busy grocery stores, and religious places of worship with
multiple services offered are signs of a healthy commu-
nity. By contrast, trash in the streets, vacant lots, multiple
bars, vacant places of worship, boarded-up businesses,
and a lack of grocery stores are all visual indicators of a
community that may have some serious health challenges.

A windshield survey can also provide information on
the demographics of a community. Observations made

while driving through (or walking around) can provide
a beginning understanding of the age groups in the com-
munity simply by observing how many children, older
adults, or young people are on the street. This can be
time-dependent. For example, in the early morning,
young parents and children may be observed as the chil-
dren walk to the school. Later in the morning, older
adults may be observed.

The use of a windshield survey template provides guid-
ance when conducting a windshield survey. A template in-
cludes a list of specific aspects of the community to be
aware of during the drive/walk through and provides a
place to make observations (Table 4-3). It is important to
record the observations while conducting the survey
rather than filling them in later. Be sure to add observa-
tions that stand out even if they are not included in the
template. The template should serve as a guide but may
not cover all of the information that emerges. For example,
in one windshield survey the team was struck by the use
of black metal fencing around a neighborhood composed
solely of subsidized housing. Later, when conducting
interviews with key informants they discovered that the

C H A P T E R 4 n Introduction to Community Assessment 87

TABLE 4–3 n A Sample Template for Conducting a Windshield Survey

Area Suggested Prompts for Observation Findings Follow Up Needed

Prior to
conducting
the survey

Green space

Community
Organizations

Health Care

Transportation

Food, beverages
and tobacco

• Establish geopolitical boundaries that define the community
• Access census data for overall information based on census

track or ZIP code
• Obtain other secondary data as determined by the survey team

• Parks
• Playgrounds
• Trees and other plantings

• Churches
• Senior citizen centers
• Others?

• Pharmacies
• Clinics/physician’s offices
• Hospitals
• Dentists

• Bus and trolley lines
• Trains
• Cars

• Big chain grocery stores
• Corner markets
• Farmers’ markets
• Liquor stores
• Bars
• Vaping and hookah lounges

Continued

7711_Ch04_077-106 22/08/19 11:35 AM Page 87

residents felt the fencing further confirmed their percep-
tion of being separated from the larger urban community.

One approach to observing the formal institutions
within a community is to examine the interrelationship be-
tween different aspects of a community, often referred to
as KEEPRA (Kinship/Economics/Education/Political/
Religious/Associations) . It provides a list of categories to
consider while collecting observational related data:

• Kinship—What observations can you make about
family and family life?

• Economics—Does the community appear to have
a stable economy or are there signs of economic
decline or economic growth?

• Education—What observations can you make related
to schools and other educational institutions such as
libraries and museums?

• Political—Is there evidence of political activity in
the community such as signs supporting someone’s
candidacy for elected office?

• Religious—Are there any mosques, churches, or
synagogues in the community?

• Associations—What evidence do you see of neighbor-
hood associations? Business associations? What other
resources are present such as recreation centers?

Using the CHANGE list of sectors is another possible
approach to conducting an observational review of the
formal institutions in a community:

• Community-at-Large Sector includes community-
wide efforts that have an impact on the social and
built environments such as improving food access,
walkability or bikeability, tobacco use and exposure,
or personal safety.

• Community Institution/Organization Sector
includes entities within the community that
provide a broad range of human services
and access to facilities such as childcare
settings, faith-based organizations, senior
centers, boys and girls clubs, YMCAs, and
colleges or universities.

• Health-Care Sector includes places where
people go to receive preventive care or treatment,
or emergency health-care services such as
hospitals, private doctors’ offices, and community
clinics.

• School Sector includes all primary and secondary
learning institutions (e.g., elementary, middle,
and high schools, whether private, public, or
parochial).

88 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–3 n A Sample Template for Conducting a Windshield Survey—cont’d

Area Suggested Prompts for Observation Findings Follow Up Needed

Entertainment

Housing

Business

Education

People

Environment

Other
observations

• Theaters (movie and live)
• Concert halls

• Types of housing (single family, apartments, subsidized housing
• Appearance of houses and lawns
• Abandoned houses/apartment buildings

• Store fronts
• Types of businesses (dollar stores, pawn shops, check cashing

vs. upper end stores)
• Empty store fronts

• Schools (public/private)
• Colleges/universities
• School bus routes

• Gender, ethnicity, and age distribution by time of day
• Appearance
• Interactions

• Air quality
• Cleanliness of community

• Add other observations that do not fit into the previous
categories

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C H A P T E R 4 n Introduction to Community Assessment 89

• Worksite Sector includes places of employment such
as private offices, restaurants, retail establishments,
and government offices.33

Secondary Community Health Data Collection
Once the windshield survey is complete it is often helpful
to review secondary data prior to collecting more pri-
mary data. Examples of secondary data sources include
census data, crime report data, national health survey
data, and health statistics from the state or local depart-
ment of health. What is usually available is aggregate
data, data that do not include individual level data, such
as infant mortality rate. Many of the sources of aggregate
level community data are accessible via the Internet. Ob-
taining other sources of secondary data, especially data
at the individual level, usually requires seeking permis-
sion and is usually provided as deidentified data, that is,
data that does not include individual identifiers.

An essential component of a community health as-
sessment is the review of sociodemographic data. From
a geographical perspective, the team can access census
data relevant to their community from the U.S. Census
Bureau. These data provide the team with information
on the number of people in their community; the num-
ber of households; and information related to age, gen-
der, marital status, occupation, income, education, and
race/ethnicity. The U.S. Census Bureau collects census
data in the United States every 10 years. The data are re-
ported at the aggregate level based on geopolitical per-
spective. Aggregate data are obtainable at the national,
state, county, metropolitan area, city, town, census track,
or census block. According to the U.S. Census Bureau, a
census tract is a relatively permanent statistical subdivi-
sion of a county that averages between 2,500 and 8,000
inhabitants that is designed to be homogeneous with re-
spect to population characteristics and economic status.
A census block is an area bounded on all sides by visible
features. Examples of boundaries provided by the U.S.
Census Bureau include visible boundaries such as roads,
streams, and railroad tracks, and by invisible boundaries
such as the geographical limits of a city or county. Typi-
cally, it is a smaller geographical area, but in some rural
areas a census block may be large.37 The data provide a
snapshot of the population every 10 years. In between
those years, changes may occur, and local data may be
needed to supplement census data especially toward the
end of a decade.

Another source of secondary health data at the aggre-
gate level about a community is the PHD. Examples of
public health information related to morbidity and mor-
tality, and potentially available at the PHD include the

crude mortality rate, the infant mortality rate, motor ve-
hicle crash rate, and the incidence and prevalence rates
of communicable and noncommunicable diseases. To
get a better understanding of the rates, it helps to obtain
age-specific mortality rates for leading causes of death
and age-adjusted, race-, or sex-specific mortality rates.
An example of Web-based sources of health-related ag-
gregate data at the county level is the Web site main-
tained by the University of Wisconsin Population Health
Institute and sponsored by the Robert Wood Johnson
Foundation. It provides information on health indicators
at the county level with comparative statistics at the state
and national levels.38 Another source of data is vital sta-
tistics. These statistics provide information about births,
deaths, adoptions, divorces, and marriages. These data
are available through state public health departments.

Information on the health of a community can also be
obtained from surveys that are conducted routinely at
the national level and often at the regional level. The Na-
tional Center for Health Statistics (NCHS), a division of
the CDC, provides data about the prevalence of health
conditions in the United States. The NCHS manages sur-
veillance systems including the National Health Inter-
view Survey (NHIS) and the National Health and
Nutrition Examination Survey (NHANES). The NHIS
surveys approximately 35,000 households annually. The
survey focuses on a core component of health questions
including health status and limitations, injuries, health-
care access and use, health insurance, and income and
assets. In addition, a supplement is used each year to re-
spond to new public health data needs as they arise.39 The
NHANES is an annual survey that began in the 1960s
and combines an interview with medical, dental, and lab
tests, and physiological measures.40 The Behavioral Risk
Factor Surveillance System (BRFSS), administered by the
CDC, is a telephone survey of 350,000 adults in 50 states,
the District of Columbia, Puerto Rico, the U.S. Virgin Is-
lands, and Guam. It has been conducted on an annual
basis since 1984 and collects information on health risk
behaviors, preventive health practices, and health-care
access primarily related to chronic disease and injury.42

The CDC also publishes the Morbidity and Mortality
Weekly Report, which reports communicable diseases and
health concerns by state with each publication providing
current state- and city-level incidence data on reportable
diseases. Other examples of aggregate health data include
the annual report to Congress and other reports to Con-
gress on health-related issues such as alcohol and drug
use (see Chapter 11). Other sources of health data in-
clude cancer registries and the National Institute of Oc-
cupational Safety and Health (NIOSH). The National

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Cancer Center of the National Institutes of Health main-
tains 11 population-based cancer registries. They provide
data on the number of individuals diagnosed with cancer
during the year. NIOSH monitors exposures to environ-
mental factors in work settings.

Secondary data are also available that are not specific
to individuals, that is, data related to the environment.
The Environmental Protection Agency (EPA) collects
data on environmental pollutants and the Department
of Transportation collects data on the number of vehi-
cles using the roads. Another example is information
obtained and maintained by the U.S. Department of
Agriculture (USDA), which includes information on
farmers markets, the Food Access Research Atlas, and
the Food Desert Locator, an online map highlighting
thousands of areas where, the USDA says, low-income
families have little or no access to healthy fresh food.42

Secondary sources of local data also exist but may not
be readily available in aggregate form on the Internet.
These include information on the organizations within
the community such as hospitals, schools, and police
department information. Gathering the data from var-
ious local organizations (minutes, reports) may be help-
ful in relation to the different sectors included in the
CHANGE model such as information about the
schools. Although these records may be helpful to some
extent, there are limitations. Records of any nature
often have limitations because they may not be com-
plete, may not be in a usable format, or the keepers of
the data may not be willing to provide the information
to the community assessment team. The list of available
secondary data is long and interesting, and should be
reviewed as the first step to avoid the more expensive
process of having the team collect the data.

Primary Community Health Data Collection
When the review of the available secondary data is com-
plete, the next step is to determine gaps in the data and
decide what further data needs to be collected by the
team. The CHANGE model provides a list of possible
methods and suggests that multiple methods should be
used (two or more).33 These data are then combined with
the secondary data to determine needs and assets.

Inventory of Resources
The agencies and organizations present in a community
often have a significant effect on health. The CHANGE
handbook has sample organizational questionnaires that
can be used for each of the five sectors to help collect data
on different organizations such as health-care organiza-
tions and schools.33 The use of these questionnaires can

help the team gather essential information about the re-
sources within the community.

Quantitative Data: Surveys
When gaps in data are identified, one method for obtain-
ing the missing data is to conduct a survey to collect
community level quantitative data. Quantitative data are
data that can be assigned numerical values such as the
number of new cases of tuberculosis or the assigning of
a number to a categorical variable such as ethnic group.

A first step in conducting a community health survey
is to outline the purpose of the survey. The team decides
on the information needed then decides on the target
population and the method for obtaining a representa-
tive sample of the population and the survey delivery
method. For example, a hypothetical community assess-
ment team in county X found that the members did not
have enough information on the health-related quality
of life (HRQoL) of older adults living in their commu-
nity. The county had just completed a telephone health
survey, and this population was underrepresented. After
careful consideration they decided that their target pop-
ulation was in fact those older than age 65 who were not
currently residing in a health-care facility. The use of an
e-mailed survey seemed to pose even more problems re-
lated to response rate than did a telephone survey. So
they decided that a face-to-face approach was best to de-
liver the survey. The team members decided they needed
to reach those living in different areas of the county as
well, so they put together a sampling process that would
help them include older adults living in different areas of
the county. This example demonstrates that conducting
a survey can be complex and may include issues related
to time, which requires careful planning. The advantages
of surveys include their cost-effectiveness and ability to
make inferences about a population based on the repre-
sentativeness of the sample. A survey allows for the col-
lection of a large amount of information from a large
number of individuals.

Defining the Sample: There are several approaches
to defining the sample. Defining the community or target
population is once again the critical step. If the focus of
the assessment is on adolescents within a specific school,
the sampling will be based on the adolescents in that
school; however, if the purpose of the assessment is to
say something about adolescents in the city, a different
sampling approach is needed.

Sampling Approaches: Once the target population is
defined, there are several types of sampling approaches.
A simple random sample involves a list of the eligible in-
dividuals and then selection is made based on a random

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selection, possibly based on using a list of random num-
bers. Convenience sampling is a common approach that
takes into consideration the availability of participants.
Some different types of convenience sampling include
quota sampling, which involves a fixed number of sub-
jects; interval sampling, which is the selection of subjects
in a sequence (i.e., every eighth person); or snowball sam-
pling, which starts with a small group of participants and
then uses those participants to identify other participants.
One other type of sampling used with large numbers is
systematic sampling, in which a list of the possible par-
ticipants is presented, and the number needed for the
sample is divided into the total population. For example,
from that point, n, every nth person is chosen.

Methods for Conducting a Survey: There are also
several methods for conducting a survey. A survey can
be mailed, done by telephone, given in certain settings as
a written document or by computer, or conducted
through a face-to-face interview. The format for the sur-
vey is determined based on consideration of cost, re-
sources, and preference. In some cases, the choice of the
format may be determined by the study participants, as
noted in the previous example of the survey conducted
with the older adults in the county.

Deciding Items to Be Included in a Survey: Choos-
ing and developing the items to be included in a survey
is another decision to be made in planning the actual as-
sessment. Most health surveys use a quantitative ap-
proach; that is, the questions are closed-ended and can
be entered into a database using statistical software to
help with analysis. Some surveys also include open-
ended questions that allow respondents to provide infor-
mation not asked in the survey questions.

Evidence-Based Tools for Community Assess-
ment: There are several health status evidenced-based
instruments available for conducting a community
health assessment. One example is the CDC HRQoL
questionnaire, either the 14-item or 4-item set of
Healthy Days core questions (CDC HRQoL– 4).43 The
questionnaire is based on the broad concept of QoL as
it relates to health. Assessment of QoL includes subjec-
tive evaluations of both positive and negative aspects
of life. Health is only one aspect of QoL. Other aspects
include employment, education, culture, values, and
spirituality. The advantage of using the CDC HRQoL
questionnaire is that it allows for comparison of the
community sample with national benchmarks. The
HRQoL has been in the State-based Behavioral Risk Fac-
tor Surveillance System (BRFSS) since 1993.

Other reliable and valid tools are available to include
in an assessment. The challenge is to find a tool that

matches the information needs based on gaps in knowl-
edge related to the health of the community you are
assessing and the utilization of the right format for
obtaining the data. Most community health assessment
surveys include multiple instruments to assess the health
of the community. Along with the 4-item HRQoL ques-
tionnaire, the team may decide to include a number of
other tools within the survey such as a tool that measures
satisfaction with available of health care. The key is to use
valid and reliable tools whenever possible.

Qualitative Data
Although quantitative data can provide a wealth of in-
formation, other approaches to data collection provide
an opportunity to gather more in-depth information
about the health of a community. One approach to
achieving this is to gather qualitative data, that is, data
that cannot be assigned a value and that represent the
viewpoint of the person providing the information.
These data are not generalizable to a large population but
can provide insight into the how, why, what, and where
of the phenomenon being studied, in this case, the health
status of a community.

Focus Groups: The most commonly used method for
collecting data when conducting a community assess-
ment is the focus group(s). A focus group is an interview
with a group of people with similar experiences or back-
grounds who meet to discuss a topic of interest. It is usu-
ally a one-time event that is semistructured and informal,
and there is a facilitator and possibly a cofacilitator who
guide the discussion.44 A focus group typically includes
six to eight participants. The facilitator(s) use an inter-
view guide that has unstructured open-ended questions
for purposes of discovering opinions, problems, and
solutions to issues. The interview generally lasts for 1 to
2 hours. Once the focus group has been conducted, an
analysis of either the transcribed tape recording or notes
from the group session consists of examining the data for
patterns that emerge, common themes, new questions
that arise, and conclusions that can be reached.44

Key Informants: Another approach to gathering more
in-depth data is to conduct individual interviews with key
informants. A key informant is often represented as a gate-
keeper, one who comes closest to representing the com-
munity. Although interviews can be time consuming,
interviews with one or more key informants can provide a
wealth of information about the opinions, assumptions,
and perceptions of others about the health of a community.
The interview can be conducted face-to-face or over the
telephone, and the tool to conduct the interview can be
structured, semistructured, or unstructured. A structured

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interview is more formal, with specific identical questions
being asked of each person interviewed. A semistructured
interview is less structured, with a list of questions that
guide the interview but with time for a more relaxed con-
versation. An unstructured interview is conducted by ask-
ing questions that seem appropriate for the person being
interviewed.

The next consideration is who to interview. This really
depends on the purpose of the assessment and the inter-
view. If a PHN wants to learn more about the resources
for adolescents in a community, the nurse will want to
interview personnel in health clinics and recreation cen-
ters, school nurses, parents, and adolescents about their
perceptions of resources and needs in the community. If
there is a need to learn about the needs of the older adults
living in the community, the sites for identifying key in-
formants may now shift to health clinics, senior citizen
centers, nursing homes, long-term care sites, seniors
themselves, and organizations representing them. If it is
a comprehensive assessment, it is important to make sure
that everyone is represented. It is important to include
business representatives, government employees, and
members of voluntary organizations. Another issue to
examine is the makeup of the community based on eth-
nicity to make sure that each group’s members have had
a chance to voice their opinions. For example, during a
community assessment conducted in Lancaster County,
Pennsylvania, the team realized they would have a zero-
response rate on the telephone health survey for residents
in the county who belonged to the Amish community
because they do not use telephones. To address this issue,
the team conducted focus groups with both the women
and the men in the Amish community.45

Determining the type of interview to conduct with a
key informant, face-to-face or by telephone, requires
some thought about the advantages and disadvantages
of both formats. Some of the advantages of face-to-face
interviews are flexibility, ability to probe for specific an-
swers, ability to observe nonverbal behavior, control of
the physical environment, and use of more complex
questions. The telephone interview needs to be shorter
but allows for the ability to interview people who do not
have the time to meet face-to-face. It is important to
summarize the interview immediately, especially if it is
not being recorded. An analysis of the interview data is
similar to the analysis of focus group data. The commu-
nity health assessment team reads the notes or tran-
scripts from the interviews and identifies common
themes between key informants as well as specific issues
for the group they represent. To help verify the infor-
mation provided by a key informant, it is helpful to use

triangulation, a technique that allows the interviewer to
verify the information with another source.

PhotoVoice: PhotoVoice is another qualitative
methodology used to enhance community assessments. It
is based on the theoretical literature on education for crit-
ical consciousness, feminist theory, and community-based
approaches to document photography.46,47 PhotoVoice in-
volves having community members photograph their
everyday lives within the context of their community, par-
ticipate in group discussions about their photographs, and
have an active voice in mobilizing action within the com-
munity. When using this technique in a community assess-
ment, residents can be provided with disposable cameras
and asked to take pictures that reflect family, maternal, and
child health assets and concerns in the community. From
these photographs, the participants’ concerns will be high-
lighted, and concerns such as developing safe places for
recreation and making improvements in the community
environment can emerge.

Additional Tools and Strategies
Community Mapping: Community mapping is an-

other step during the assessment phase that can be used
in the initial windshield survey, during the inventory
data collection, during interviews, and in more advanced
analyses of both assets and problems in a community.
The advantages of mapping assets are that the strengths
of the community are outlined and can be used then in
developing an action plan. Mapping allows the commu-
nity assessment team to visualize the community and to
study concentrations of disease, to identify at-risk pop-
ulations, to better understand program implementation,
to examine risk factors, or to study interactions that affect
health. It is a process of collecting data through direct
observation and using secondary data sources to describe
the physical characteristics of a neighborhood or com-
munity, the location of institutions and resources, and
the social and demographic characteristics of a commu-
nity. It has the potential to provide data that can help
identify place-based social determinants of health that
could then lead to interventions at the individual and the
community level to initiate precise risk reduction and
mitigation.48 In the study by Aronson and colleagues,
primary data were collected by walking through the com-
munity with residents noting categories of interest.
Secondary data collected included housing inspection
data, liquor license data, crime reports, and birth certifi-
cates. The purpose of this assessment was to study the
community context and how it might contribute to
infant mortality, with an evaluation of Baltimore
City Healthy Start, a federally funded infant mortality

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prevention project. The Healthy Start Program was an
initiative whose purpose was to reduce infant mortality
by providing comprehensive services to women and their
children and partners, and at the same time to contribute
toward a neighborhood transformation. The researchers
mapped vacant houses, liquor stores, and crime data. The
data showed that participation in the prevention pro-
gram was higher in lower risk census blocks. Changes
were made to obtain better penetration of the program
based on these findings.49

Geographic Information System (GIS): A geo-
graphic information system (GIS) is a tool that is increas-
ingly used in public health. GIS is a computer-based
program that can be used to collect, store, retrieve, and
manipulate geographical or location-based information.50

GIS databases consist of both spatial and nonspatial data.
Nonspatial data include demographic or socioeconomic
data that can be identified by geographical boundaries,
whereas spatial data are assigned by exact geographical lo-
cation by geocoding or address matching. It is used glob-
ally to help identify populations at risk such as maternal
and infant populations in Iran and in the U.S.51,52 In the
study conducted in Iran related to maternal health, they
were able to identify priority geographical areas.51 In New
Jersey, researchers used GIS to link neighborhood charac-
teristics with maternal infant outcomes.52 The GIS maps
generated demonstrated the associations between adverse
birth outcomes, poverty, and crime.52

Analysis of the Data
Once the data have been collected, it is important to an-
alyze them. The CHANGE model includes three action
steps related to this phase of the assessment: (1) review
the data, (2) enter the data, and then (3) review the con-
solidated data. Reviewing the data refers to having the
team brainstorm, debate, and reach consensus on the
meaning of the data. Entering the data is the process of
transcribing the data into a software program such as
Excel to help with the analysis and interpretation of the
data. Data are then rated by all researchers. Reviewing
the data includes four steps: (1) create a CHANGE sum-
mary statement, (2) complete a sector data grid, (3) fill
out the CHANGE strategy worksheets, and (4) complete
the Community Health Improvement Planning tem-
plate. Doing so provides the foundation for the final step
in CHANGE, building the community action plan.33

Making sense of the collected data is done via a variety
of ways. One of the most important points to consider is
what changes over time or noticeable trends. Sociodemo-
graphic comparisons include changes from one census
data collection period to another. The time-period for

comparing disease trends varies by the prevalence of dis-
ease. A communicable disease outbreak may be monitored
on a weekly or monthly basis, whereas trends in heart dis-
ease might require a trend analysis during a 5-year period.
Trends can help identify improvements or declines in
health indicators in the community over time, such as the
infant mortality rate, or they can be used to determine
whether there have been changes in the demographics of
the population over time. For example, is the population
aging or have there been changes in home ownership?

The health indicators and the demographics of the
community can be compared with other populations such
as similar local jurisdictions, the state, and ultimately na-
tional data. The data can also be compared within the
community. Do disparities exist on key health indicators
such as prevalence of disease or access to needed re-
sources? These analyses allow the team to interpret the
statistics to identify the important health issues for the
community. It is a complex process that involves combin-
ing the information obtained from all sources and coming
to conclusions. The CHANGE handbook provides an ex-
cellent guide for a team to use to complete the analysis. It
often requires having a member of the team who not only
is familiar with software but who also has a background
in statistical analysis so that the team can compute rates
and complete a meaningful presentation of the data.

Postassessment Phase: Creating,
Disseminating, and Developing an Action Plan
In the final action step outlined in the CHANGE model,
the community assessment team builds a community ac-
tion plan.33 This requires the development of a project
period with annual objectives and should reflect the data
that were collected. The result of a community health as-
sessment should include a brief narrative describing the
adequacy of services currently provided in relation to the
overall needs of the community. It should highlight the
areas of need in the community that are not met and list
any additional resources that could be developed to meet
any unmet needs in the community.

Evaluating the Assessment Process
Evaluating assessments is as important as conducting as-
sessments to better understand their impact. It involves
including stakeholders in reviewing the findings and
having an opportunity for feedback. To use the data to
help identify priorities, teams may seek validation from
stakeholders or they may engage in a more collaborative
process to help come to a final decision on priorities.53

This is done at the end of the assessment phase and be-
fore the beginning of the planning phase (Chapter 5).

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94 U N I T I n Basis for Public Health Nursing Knowledge and Skills

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Sick Little Town
Public Health Science Topics Covered:

• Assessment
• Epidemiology and biostatistics

The director of nurses (DON) at a regional Visiting
Nurse Association (VNA) that covered a large regional
area including four rural towns noticed that there was
an increase in patients being referred for home visiting
services from Small Town, a small rural community
within their service area. They provided follow-up care
for persons following a hospitalization and well-baby vis-
its for mothers and infants deemed to be at risk such as
premature infants and teenage mothers. The VNA was
part of a large medical center that had just launched its
“We are community!” campaign. The DON approached
the vice-president responsible for community outreach
services, pointed out the increase to him, and suggested
that a community assessment might help to identify
what was behind the increased admissions. The vice-
president stated that this matched the medical center’s
“We are community!” campaign and asked the DON
whether her team would be willing to form a task force
to conduct an assessment of the community to uncover
the reason for the increase in admissions, better under-
stand the health issues and strengths within the commu-
nity, and at the same time build a better bridge to the
community. He authorized a certain part of the DON’s
workload to include leading the assessment project and
authorized her to designate two of her visiting nurses as
members of her initial outreach team.

The next day the DON met with the two of her
home health nurses, Sonja and Viki, who covered Small
Town. She also invited Donna, the PHN who worked
for the county health department, to meet with them
and join their assessment team. As they began, Sonja
remembered from her public health nursing course
that it was important to start with a model to guide the
assessment. She also remembered doing a windshield
survey for her community health project in school.
“I drive around Small Town frequently to see my
patients, and I never thought about really looking at
the town from a community assessment point of view.”
Viki agreed and suggested that not only should they
do a windshield survey, but they should also invite
members of the community to join them.

Donna told them the county PHD was in the planning
stages of a county assessment, so the concerns of the
visiting nurses were in line with efforts just beginning at

the PHD where they were using the CHANGE model33

to guide the process. She conveyed the health concerns
of the visiting nurses to the head of the county PHD
who then agreed to support the VNA’s work assessing
Small Town as a part of their overall comprehensive as-
sessment for the county thus setting up a collaborative
effort between the VNA, the regional Medical Center
and the county PHD.

For their next step, Sonja, Viki and Donna made a
list of those who should be a part of the CHANGE
committee and planned how to get broad community
involvement. They used the CHANGE guidelines to
help develop their process. Sonja and Viki, who had
been working in the community and knew some key
stakeholders in the community, and the PHN asked the
county PHD epidemiologist to assist with the data
collection and analysis.

The core team then began building a CHANGE
committee that could help broaden community
involvement. When completed, the preliminary
CHANGE committee consisted of four residents of the
community; the school nurse; the director of the
community recreation center; a member of the police
force; the CEO of the regional medical center; Donna,
the PHN from the county PHD; the two visiting
nurses, Sonja and Vicki, and their DON; the PHD epi-
demiologist; and the publisher of the town newspaper.

The CHANGE committee and the core team next
began to work on developing the team strategy process
included in the CHANGE model. One of the visiting
nurses was worried that the project was no longer
under the control of the medical center. Donna ex-
plained that having the assessment come from the com-
munity rather than the medical center would truly
support the medical center’s “We are community!”
campaign. Further, she explained that the CHANGE
model would conclude with a community action plan.
She explained that having a clear picture of the health of
Small Town USA required buy-in from multiple con-
stituents within the community.

The core team expanded to reflect the diversity of
the community. The team talked with the town historian
to find former community initiatives and built communi-
cation strategies for keeping the community informed by
writing an article for the weekly newspaper, seeking
input and suggestions. After running the article, the edi-
tor reported getting many e-mails about the campaign
with suggestions for information that the team should
include. The committee worked to bring this input
together and came up with a final vision statement:
“Small Town, the place to be for healthy living.”

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C H A P T E R 4 n Introduction to Community Assessment 95

The next logical step was to map out the borders of
Small Town, located in the state of Massachusetts along
a small river, using local maps. The town included a total
of 75 square miles and was a 35-minute drive from the
medical center. Four towns bordered Small Town, three
of which had a smaller population than Small Town. The
town with the slightly higher population was to the east
of the town and could be reached by a main road that
went through Small Town. It took 20 to 25 minutes to
drive from the center of Small Town to the center of
each of the other four towns. Most of the population
lived in the center of town. The outskirts of town were
wooded and included a small state park.

Collect Secondary Data: Sociodemographic Data

Descendants from the Mayflower and their contempo-
raries initially settled the town. That gave the team a
starting point for the original culture—English and Puri-
tan. These early settlers had moved west to farm. Man-
ufacturing grew over time with the river providing a
source of power for mills. The founding families built
mills and brought more settlers to the area to work in
the mills. Merchants then came to sell goods to the
workers. The town developed an informal class system
of workers, owners, and merchants. Although the first
wave of workers was Irish, eventually most of the
workforce came from French Canada. The team found
that many of the residents of the town had last names
that were French. By World War I, the Irish section of
town was small and was considered the lowest rung of
the social classes. The church with the largest congrega-
tion was the Catholic Church, because this was a town
of few owners and many workers, almost all of whom
were Catholic. Thus, Small Town had a firm class struc-
ture as well as three major ethnic groups—English,
French Canadian, and Irish—for most of its history.

In the 1970s, when the town was the recipient of
state funds to build subsidized housing for families on
welfare, there was an influx of families into the town who
were at or below the poverty level, all of whom were
white and most of whom were single mothers. They be-
came the new lowest rung on the class ladder. By 2015, a
few Hispanic families from Puerto Rico were moving into
the town. Despite this modest influx, the majority (89%)
of the population still identified themselves as white.

Knowing the history, the team’s next step was to
complete a demographic assessment of the town
beginning with specific demographic indicators that
were available from the U.S. Census Bureau includ-
ing gender, age, race, home ownership, and income.
They constructed a population pyramid related

to the age of the population from estimates using
the 2016 American Community Survey data and the
2010 census data located on the U.S. Census Bureau
Web site American Fact Finder for 2010, and com-
pared it with the population of the United States
(Fig. 4-2).54

Male Female

-6
Percent

-4 -2 0

Ye
ar

s

100+
95–99
90–94
85–89
80–84
75–79
70–74
65–69
60–64
55–59
50–54
45–49
40–44
35–39
30–34
25–29
20–24
15–19
10–14

5–9
0–4

2 4 6

Male Female

-6
Percent

-4 -2 0

Ye
ar

s

100+
95–99
90–94
85–89
80–84
75–79
70–74
65–69
60–64
55–59
50–54
45–49
40–44
35–39
30–34
25–29
20–24
15–19
10–14

5–9
0–4

2 4 6

Figure 4-2 Population pyramids: Small Town (top) and
the United States (bottom). (Source: A, Data from Centers for
Disease Control and Prevention [2010]. Community Health
Assessment and Group Evaluation [CHANGE] action guide:
Building a foundation of knowledge to prioritize community
needs. Atlanta, GA: U.S. Department of Health and Human
Services; B, Data from U.S. Census Bureau, Population Division.)

A

B

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96 U N I T I n Basis for Public Health Nursing Knowledge and Skills

10

20

30

40

50

60

70

80

90

100
105

0
0

United States Virgin Islands: 2050

5 5

10

20

30

40

50

60

70

80

90

100
105

0
0

United States Virgin Islands: 2100

5 5
(Thousands)

10

20

30

40

50

60

70

80

90

100
105

0
0

United States Virgin Islands: 1950

5

FemalesMales

10

20

30

40

50

60

70

80

90

100
105

0
0

United States Virgin Islands: 2010

5 5

A population pyramid can tell you a lot about a
population. If the pyramid has a broad base and a small
top, it is an example of an expansive pyramid in which
there is most likely a rapid rate of population growth.
A population pyramid with indentations that even out
from top to bottom indicates slow growth. A stationary
pyramid has a narrow base, with equal numbers over
the rest of the age groups and tapering off in the oldest
age groups. A declining pyramid is one that has a high
proportion of people in the higher age groups. In 2010,
the population pyramid for North America met the
definition of a slow growth pyramid. The projected
2050 pyramid for North America is a classic example of
a stationary pyramid. By contrast, the population pyra-
mid for Somalia in 2010 demonstrated a clear example
of an expansive pyramid, indicative of rapid population

growth. However, it also indicated that the longevity of
the population was lower than in North America. By
2050 the population pyramid for Somalia is projected to
match the 2010 pyramid for North America, indicating
that population growth is projected to slow (Fig. 4-3).55

The team examined their population pyramid
and compared it to the U.S. Data (Fig. 4-2), and made
some conclusions about the population in Small Town.
What would they be? How does Small Town compare
with the United States? Note the larger base and the
wide top. This indicates that the population seems to
be made up of young families and older adults with a
smaller number of in the 45-year to 59-year range.
These data provided the team with a starting point for
understanding the possible reason for the increase in
requests for home health services.

Figure 4-3 United States
populations pyramids
compared with population
pyramids of Somalia. A,
United States; B, Somalia.
(Data from Worldlifeexpectancy
available at http://www.
worldlifeexpectancy.com/
world-population-pyramid.)A

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C H A P T E R 4 n Introduction to Community Assessment 97

10

20

30

40

50

60

70

80

90

100
105

0
0

Somalia: 2050

4 2 2 4

10

20

30

40

50

60

70

80

90

100
105

0
0

Somalia: 2100

4 2 2 4
(Millions)

10

20

30

40

50

60

70

80

90

100
105

0
0

Somalia: 1950

4 2

Males Females

2 4

10

20

30

40

50

60

70

80

90

100
105

0
0

Somalia: 2010

4 2 2 4

Figure 4-3—cont’d B

The epidemiologist from the county PHD recom-
mended that they track the population based on age
and race, and determine the percent change from
2010 to 2016 using census track data. Percent change
(see Chapter 3) represents the change in a variable
from one point in time to another. They were sur-
prised at the simplicity of the math required to
calculate the percent change. The epidemiologist
explained that they should subtract the old value
from the new value. They then would divide this by
the old value. Then when they multiplied the result
by 100, they had the percent change. He showed
them how to set it up in an Excel file so that they
could enter all the population numbers they were
interested in, set up the formula, and then have
a table ready for distribution to the committee
(Box 4-4, Table 4-4). Percent change can tell a lot

New value minus the old value divided by the old value
times 100 equals the percent change.
Example:
If the town’s population in 2000 was 2,000, and in 2010
it grew to 2,520, the percent change is 26%:

2,520 – 2,000 = 520

520/2,000 = 0.26 × 100 = 26%

BOX 4–4 n Percent Change

about a population. In the case of Small Town, the
percent change in the Hispanic population showed a
shift in the town. In 2010, almost 97% of the popula-
tion was white. In 2016, 89% of the population
was white. This information can also help estimate

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98 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–4 n Percent Change for Demographic
Characteristics in Small Town USA,
2010–2016

2010 2016 % Change

Total

Male

Female

White

Black

American Indian

Asian

Other

Two or More
Races

Hispanic

Vacant Housing
Units

Population 25 Years
or Older

High School
Graduates

Bachelor’s Degree
or Higher

Mean Travel Time
to Work

Median Household
Income

Families Below
Poverty Level

9,611

4,766

4,845

9,223

77

29

60

98

124

195

213

6,056

4,974

848

29.5

$43,750.00

171

10,164

5,039

5,125

9,018

122

33

45

101

152

693

189

6,591

6%

6%

6%

–2%

58%

14%

–25%

3%

23%

255%

–11%

9%

changes in the population in the future. If the current
trend continues with a 2% decline in the white popu-
lation and a 255% increase in the Hispanic population
during the next 6 years, what would the population
look like in 2021?

Using Census Bureau data, the team looked at
gender, age, race, home ownership, poverty level,
crime, and fire safety. As discussed earlier in the
section Secondary Community Health Data Collec-
tion, secondary data are collected for a different
purpose from the current study or assessment. In
this case, the federal government collected census

data. These data are collected every 10 years, the
decennial census, to compile information about the
people living in the United States. In addition, the
census bureau conducts the American Community
survey to provide 5-year estimates. These data
provide the federal government with the information
needed for the apportionment of seats in the U.S.
House of Representatives. The U.S. Census Bureau
also conducts many other surveys and is a rich
source of secondary population data. The Census
Bureau provides these data in aggregate format
and by law cannot release data in a way that could
identify individuals.56

To access the census data, the team went to
the American FactFinder section of the U.S. Census
Bureau’s Web site and were able to print out a
sheet that included the estimates for 201654 including
general, social, economic, and housing characteristics.
Under economic characteristics, they found that,
in Small Town, 67% of the population older than
age 16 were in the workforce, and the median
household income was $42,625. The fact sheet
also listed comparative percentages for the United
States so that they could compare Small Town
with the nation. Small Town statistics were compara-
ble to the national statistics on all the economic
indicators except poverty. In Small Town, 18.5% of
the families lived below the poverty level compared
with 15% of the U.S. population. They were also
able to print out fact sheets for the county, the
state, and the surrounding towns, thus comparing
Small Town with its neighbors. The economic
indicators between the closest neighboring town
and Small Town differed in relation to income, with
Small Town having a lower median household income
($38,564 compared with $46,589), although the
poverty level statistics were approximately the same.
Again, compared with the state, the town had a
lower median income ($38,564 compared with
$75,297).

The team then reviewed the other demographic
categories. A few facts were noted as possibly being
important. First, the median value of the houses in
Small Town USA was lower than in the rest of the
state ($173,600 versus $358,000) and the percentage
of the population older than age 25 with a bachelor’s
degree or higher was lower than in the rest of the
state (14% versus 41%). Based on the review of the
demographics, a picture was beginning to emerge
of the town. What would your impressions be?

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C H A P T E R 4 n Introduction to Community Assessment 99

What further data would you need if you were
on this team?

Health Status Assessment Using
Secondary Data

At this point, Sonja wondered about the actual health
of the town. She reminded the team that this project
was started because of the increased requests for
visiting nursing services and suggested that the team
look at the Massachusetts Department of Health
Community Health Profile that included a health status
indicator report for Small Town. This report provided
information on health indicators and reduced the need
for the team to find these data themselves. This report
used secondary sources of data collected by PHDs,
referred to as vital records including information
on death certificates, reportable diseases, hospital
discharges, and infant mortality.

The health status indicators chosen by the
Massachusetts Department of Health included
perinatal and child health indicators, communicable
diseases, injury, chronic disease, substance use
and hospital discharge data. The core group brought
the published information to the larger community
group for discussion. One of the members of the
community group noted that at the top of the report
was a section on small numbers and wanted to know
what that meant. The epidemiologist explained that
the numbers of cases for each indicator are placed in
a cell in a table. Sometimes the numbers in these
cells for smaller towns contain small numbers. The
general rule of thumb, he explained, is that if there
are fewer than five observations (or cases) then
the rates are usually not reported. If they are
reported, then rates based on small numbers should
be interpreted very cautiously, because there are
not enough cases to create a base from which to
draw conclusions.

The perinatal and child health indicators included
births, infant deaths, and other perinatal and postnatal
data from 2016. They found a small numbers problem
right away with only one infant death in 2016. How-
ever, Small Town had a higher low-birth-weight rate
than the state (9.4 per 100 live births versus 7.4 per
100 live births). They also found that the rate of births
to teenage mothers was higher than the rate for the
state (12.5% versus 9.4%). There were no differences
in prenatal care in the first trimester or the percentage
of mothers receiving publicly funded prenatal care
compared with the rate for the state.

On most of the other indicators, Small Town had
lower or similar rates to the state. The rates that
were higher than the state rates were those for
cardiovascular deaths (397 per 100,000 deaths versus
214 per 100,000 deaths) and for hospital discharges
related to bacterial pneumonia (495.3 per 100,000 deaths
versus 329.6 per 100,000 deaths). The team also noted
that some of the rates were age-adjusted, and they
wanted to know more about the process. The county
epidemiologist explained that crude rates may not be
as good an indicator because populations may differ
on a characteristic, in this case age, which accounts
for some of the difference between the rates in two
populations. For example, if death rates for cardiovas-
cular disease in a city in Florida with a high proportion
of retirees in the community were compared with
the rates in a town that has a younger population,
the crude death rate would most likely be higher in
the Florida community. Adjusting the rate based on age
allows for comparing rates in such a way that controls
for the age variance between the two populations. The
age-adjusted rate is the total expected number of
deaths divided by the total standard population times
100,000, which is why the rate is expressed as per
100,000 deaths.
Comparing Rates
The team concluded that there was a difference
between Small Town and the state in relation to low
birth weight, teen births, bacterial pneumonia, and
cardiovascular disease–related deaths. A member of
the team living in the community wanted to know
whether these differences should cause concern.
The epidemiologist agreed to compare the town’s rates
with the rates of the state and the four towns adjacent
to Small Town to help determine whether the differences
were significant, that is, not attributable to chance. He
also explained that he would use a different approach
to compare the rates between Small Town and
Massachusetts than he would when comparing the
town with the rates of the other four towns. When
comparing the rates between the town and the state,
the rates are dependent, that is, the cases in the town
are included in the total number of cases for the state.
But when comparing the different towns with one
another they are independent rates, because the cases
in one town are not included in the number of cases
in the other town. When he was done, he reported
that all the rates were significantly higher than the
state rates. However, only three rates—bacterial pneu-
monia, teen births, and cardiovascular disease–related

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100 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 4–5 n BRFSS Adult Data for Small Town

Prevalence in Prevalence in
Health Behavior Small Town USA Massachusetts

Current smoking
(2010-2016)

Binge drinking
(2010-2016)

Overweight

Leisure-time
activity

19%

18%

67%

68%

18%

17%

54%

74%

deaths—were significantly higher than the rates in the
adjoining towns.

The team was also interested in gathering secondary
data regarding behavioral risk factors. One of the mem-
bers reminded the group that the Behavioral Risk Fac-
tor Surveillance System (BRFSS) was available for the
community. Since 1984, the BRFSS has been tracking
health conditions and risk behaviors.41 The assessment
committee was interested in lifestyle factors affecting
premature mortality. The lifestyle risk factors that they
were particularly interested in were tobacco use, alco-
hol use, exercise, and nutritional patterns. Some of
these findings can be seen in Table 4-5. Based on these
data, they concluded that nutrition and obesity were
important risk factors that might help explain the
higher cardiovascular mortality rate.

Health Status Assessment Using Primary Data

At this point, one of the members of the community
who regularly attended the meetings stated that this
information was good, but it was all just numbers and
rates, and did not really capture how the individuals in
the town viewed their own health. Others agreed, and
they asked whether there was a way to collect data from
people living in the town about how healthy they thought
they were. They concluded that they could conduct a
survey. In addition, the committee members realized they
needed to complete an inventory of resources first
to have a better idea of the resources within the commu-
nity. They divided the community up and identified
common resources in which they were interested. They
wanted more information about schools, recreation
centers and activities, neighborhood associations,
churches, health-related clinics, hospitals, and agencies.
They used the CHANGE handbook to help guide their
data collection related to these organizations.33

Health Status Surveys

When this was complete, it was time to begin the
survey. Donna explained that a survey could be
constructed to collect health-related information from
individuals by using a paper-and-pencil method. Unlike
the secondary data they had been reviewing, a survey
relies on self-report in which individuals respond to
the survey designed for a specific purpose in the
assessment. She further explained that a health survey
is quite useful when doing a comprehensive community
health assessment, because the researchers can decide
ahead of time what information they need and provide
information missing from the secondary data sets.
Donna also told them that they did not have to
reinvent the wheel; in other words, different surveys
were available for them to review and adapt to their
own community. She showed them a survey that
included questions related to specific health indictors
including HRQoL, protective health practices (see
Chapter 3), and behavioral health issues. It also had
space at the end for open-ended questions.

The members of the team who were residents of
the community began making suggestions on how to
improve the survey. The member who worked in the
fire department thought that questions should be
added about safety, and one of the other community
members wanted to know whether people were using
the recreation center or the new playground. As the
discussion continued, the team built a survey that
included key health issues that the team decided were
important—safety, recreation, nutrition, and number
of hospitalizations in the past year. They also addressed
issues related to the cultural relevance of the survey
and the language used. The final survey was four pages
long and was approved by the members of the commit-
tee who lived in the community as being culturally
appropriate.

Modifying the survey took some time, but Donna
explained that it was better to take the time now
rather than rush, then find out they had missed a key
piece of information. The team considered how to
distribute the survey. They seriously considered the
telephone survey approach, but someone pointed out
that many households in the town no longer had a
landline, especially younger families. The editor of the
town newspaper offered to distribute the survey in
an issue of the paper (an example of a convenience
sample); however, the problem with getting people to
return the survey was raised. Another approach for
conducting the survey was discussed: taking the survey

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C H A P T E R 4 n Introduction to Community Assessment 101

door to door and having members of the community
administer it. This approach seemed the most feasible.
Donna explained that they could do a stratified random
selection of households. Stratification would allow
them to include different types of households based
on home ownership. According to the Census Bureau
data, Small Town USA had 3,660 housing units, of
which 68% were owner occupied, 26% were renter
occupied, and 5.8% were vacant. The team members
decided they wanted to attempt to get a minimum of
10% of the households to respond to the survey in the
two strata. Then someone else spoke up and said that
the community was split, with the growing Hispanic
population living in one part of town in less expensive
housing. They turned to the epidemiologist, who

helped them come up with a strategy to include an
adequate sample based on both ethnic group and home
ownership. Once they identified the strata and their
actual representation in the population, random sam-
pling was then used to select the households. The
final number of households that needed to be surveyed
was approximately 400. The community members
of the committee formed a subcommittee to recruit
volunteers in the community to administer the survey.
Donna agreed to train the volunteers in the adminis-
tration of the survey.

With the help of the epidemiologist, they analyzed
the data and prepared a report on the survey for the
community (Box 4-5). The editor of the paper included
the report as an insert in the weekly paper. The core

Health Survey Report
Small Town USA, Massachusetts
Vision: “Small Town USA, the place to be for healthy living”

To help provide information about the health of Small
Town USA and to obtain recommendations from the
community, a health survey was conducted. This report
includes the findings from this survey.
Methods
A random sample of households was selected to complete
a door-to-door survey. The survey included items designed
to measure HRQoL and access to care.
Findings
Of the 400 surveys that were completed, a total of 396
were included in this analysis. Four were not included
because they contained incomplete data. The majority
(80%) of the respondents were female, 95% identified
themselves as white. The mean age was 52 with a range
from 27 years of age to 95. Twenty-two percent of the
respondents were older than 64. Only 8% of the respon-
dents lived alone, with 56% reporting that there were three
or more in their households. Forty-three percent reported
that a child younger than 18 years of age lived in their
household. Ninety-five percent reported that they had
health insurance, and 60% reported having dental insurance.
Health-Related Quality of Life: The majority of respondents
reported that their general health was good, very good, or
excellent (see the following figure on general health). In
relation to the two questions related to physical function,
15% of respondents stated that they were limited physi-
cally “a lot” on the first question and 13% on the second.
In relation to the two questions related to physical role,
9% responded all or most of the time they accomplished
less and/or were limited in the work they could do.

The responses on the next two sections of the SF-12,
vitality and pain, had interesting results. Only a little more
than half of the respondents (52%) reported having energy
(vitality) all or most of the time, and 23% reported that
pain at least moderately interfered with their activities.
Thirty-two percent reported that their physical and/or
emotional health interfered with their social activities.

The last section of the SF-12 relates to emotional
health. More than a quarter of the respondents reported
that they felt downhearted or depressed at least some of
the time (see the following figure on mood) and 8% felt
calm only a little or none of the time. In relation to the
two questions related to emotional health and their role,
11% responded all or most of the time that they accom-
plished less than they would like and 6% were limited in
the work they could do.
Access to Care and Health Practices: The majority of
respondents (84%) reported that they had had a checkup
in the past year. However, 30% reported that they did not
get care when they needed it, with the majority of these
respondents reporting that the reason was lack of money
or insurance. The majority of respondents received
screening in the past year, with 95% reporting they had
had their blood pressure checked, 75% had their choles-
terol checked, and 67% had their blood sugar checked.
Less than half (48%) had received a flu shot.

Half of the respondents (51%) stated they had a
medical condition, and the majority of these (40%) re-
ported a cardiovascular-related diagnosis. Only 7.5% of
respondents reported that they were current smokers,
and almost half (48%) reported that they did not drink
alcohol at all. Of those that reported alcohol use,
25% were daily drinkers.

BOX 4–5 n Sample Report on Findings from a Health Survey

Continued

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102 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Obesity: Of the 94 respondents, height and weight infor-
mation was available for 89 respondents. Using the stan-
dard calculation, a body mass index (BMI) was computed
for each respondent. Using the national guidelines, 55% of
the respondents were overweight or obese. One quarter
of respondents met the criteria for obesity.
Conclusions
There is a match between one of the findings of the health
survey and the suggestions given by the respondents.
With the majority of the respondents having a BMI greater
than 25, the suggestions to develop nutrition and exercise
programs would address this issue. However, although
respondents rated their general health at the high end, a
large percentage reported issues having to do with depres-
sion, pain, and the negative impact of both their emotional
and physical health on their daily role and ability to func-
tion. Suggestions were made to address some of these

issues, but only two respondents mentioned mental health
in the open-ended questions. Also, although most respon-
dents indicated that they had health insurance, insurance
and access to care were listed in the open-ended ques-
tions section. Finally, there were numerous suggestions
to include support programs for various health issues.
Suggestions ranged from new moms, to seniors, to reach-
ing out to those who were homebound and/or ill.
Recommendations
1. Develop a healthy eating and physical exercise program.
2. Review models for support programs for seniors, new

moms, and families experiencing illness and adapt for
this community. Include links to existing programs such
as Meals on Wheels.

3. Put together an informational packet on existing health
services in the community with a focus on helping those
with limited or no health insurance.

BOX 4–5 n Sample Report on Findings from a Health Survey—cont’d

members of the team met to discuss where they
were with the MAPP model that they were using. They
decided that they had been mainly focused on the
Community Health Status Assessment and they now
had data on the traditional morbidity and mortality
indicators, QoL indicators, and behavioral risk factors.

The team members then decided to review how to
create their CHANGE summary statement as outlined
by the CHANGE model. One of the community mem-
bers suggested that they use the town hall format
to have an open town forum on the health of the
community. He said that the current town governance
structure lent itself to obtaining this more qualitative
data from the community and could also reengage
the community in the work they had been doing. They
enlisted the help of the town moderator and the town
selectpersons to help run the meeting. The members
of their committee who represented different sections
of the community, such as the Hispanic member and
the member living in the senior housing complex,
agreed to encourage their neighbors and friends to
attend.

On the day of the forum more than 900 members
of the community attended, more than triple the num-
ber that usually attended town hall meetings. The town
moderator opened the meeting with one question:
“How healthy a community is Small Town?” During the
next 2 hours the community engaged in a lively debate
over how healthy the community was and what health

problems they thought the town had (Fig. 4-4). The
talk began with the lack of health care. The plant in the
neighboring town had closed 6 months earlier, and
many local people were now signing up for health care
through the state health exchange. Some people were
now threatened with foreclosure on their homes. The

Figure 4-4 Town Hall participation. Raising her hand to
pose a question, this African-American woman was one
of a number of attendees to a town hall meeting held on
behalf of the Agency for Toxic Substances and Disease
Registry (ATSDR). The purpose of these meetings is to
collect community concerns and share health messages
about local environmental issues. (Source: Centers for Disease
Control and Prevention/Dawn Arlotta.)

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C H A P T E R 4 n Introduction to Community Assessment 103

cost of gasoline had gone up, making it more problem-
atic to get to the doctor.

One community member brought up the rise in
teen births and wanted to know why there was not a
family planning clinic in town. This brought opposition
from several people. The town moderator demon-
strated his skills in working with the community. He
carefully brought the discussion back to the vision of
healthy living and away from the more polarizing issue
of family planning. People then shared opinions about
the difficulty of obtaining prenatal care and well-child
services because none were available in the town. Even
the federally subsidized program for Women, Infants,
and Children that provides supplemental foods to
women and children at nutritional risk no longer had
an office in town. Finally, one person stood up and said
that the air seemed to be thicker. Someone else volun-
teered that there were too many wood stoves burning
because of the high cost of heating oil, and that was
why the air was hard to breathe. Others chimed in
and stated they had to keep their thermostats down
because they could not afford the oil, and that their
children had more colds in winter.

After the forum ended, committee members com-
pared their notes and concluded that access to care
was a major concern for members of the community.
They discussed the heated debate that occurred when
teen pregnancy was raised. The members of the com-
mittee who lived in the community reminded everyone
that Small Town has a large population of French
Canadians as well as the growing community of
Hispanics who had opposed family planning clinics in
the past. The committee acknowledged that, for this
community to be successful, the issue of teen preg-
nancy would need to be addressed within the culture
of the community. They were also interested in looking
into the issue of heating and possible reduction in air
quality. They concluded that the town forum had added
additional information to their assessment. An interest-
ing finding was the value of the town moderator, and it
was suggested that he be added to the committee.

The use of the sector approach to the assessment
included in the CHANGE model helped to guide the
team in including an examination of the components,
activities, capacities, and competencies of the local
public health system. By this time, the momentum
for the assessment had raised a certain amount of
enthusiasm in the community. New members were
eager to join the activities. The subcommittee consisted
of Donna, the local fire department representative, a

local physician in the community, and the vice-president
of the hospital who met to discuss how the Ten Essential
Public Health Services were being provided in the com-
munity. Organizations within the community providing
the services were then identified and gaps were noted.
The assessment revealed that many organizations in
the community were providing more than one of the
essential services. The essential services that received
the most attention by several agencies were service #1,
monitoring health status to identify community health
problems; service #3, informing, educating, and em-
powering people about health issues; and service #7,
linking people who needed personal health services
and assuring the provision of health care.

Weaknesses of the public health system included a
need to develop better use of technology such as GIS
(see previous discussion) to better understand vulnera-
bilities. Another weakness was limited activities and
resources for teens, especially those teens who were
pregnant. With a recent economic downturn, there
was some concern about the adequacy of the workforce.
The recent budgetary cuts in public health prevented
the public health system from exploring new and
innovative solutions to health problems.

The team now came together to reach consensus
in relation to the data collected. The broad categories
that the committee considered important to consider
were: (1) trends or patterns over time; (2) factors that
are discrete elements such as a change in a large ethnic
population; and (3) events of a one-time occurrence.
The core steering committee helped to lead the brain-
storming sessions with the final identification of three
major trends in the community:

1. Changing demographics
2. Emerging public health issues—teen pregnancy in

particular
3. Shifting funding streams within the health department,

particularly a loss of a grant that focused on maternal
child issues

The core team members next began the final analysis
of the data as a means for determining priorities and
building the community action plan. They examined
trends over time, compared statistics in different juris-
dictions, and identified high-risk populations. The primary
data corroborated the secondary data in several areas,
including cardiovascular health, teen pregnancies, and
bacterial pneumonia. Analysis of both the secondary
and primary data indicated that access to care was a key
issue. The BRFSS data and the survey data supported

7711_Ch04_077-106 22/08/19 11:35 AM Page 103

• In interpreting the level of health of a community, it is
important to join secondary data with the primary data.
One needs to consider trends or changes over time,
comparison of local data with data from other jurisdic-
tions, and an identification of populations at risk.

• Prioritization of health issues is based on several crite-
ria: magnitude of the problem, seriousness of the con-
sequences, feasibility of correcting, and other criteria
as determined by the community assessment team.

104 U N I T I n Basis for Public Health Nursing Knowledge and Skills

the need to address some lifestyle behavior issues. The
additional assessments supported the need to examine
the resources both within the community and the local
health department, including the lack of support for
young teens in the community and the local health
department.

The team used the forms suggested by CHANGE
to outline the strengths and problems identified both
through secondary data and primary data. The data
were presented at another town meeting. This was
followed by the core committee and steering commit-
tee prioritizing the problems based on the criteria of
magnitude of the problem, seriousness of the problem,
and feasibility of correcting the problem. In the case of
Small Town, the assessment process informed the
county of the need for a program to address teen
pregnancy. This seemed to be a primary concern of
most people in the community. This was followed by
the need for additional resources to address the needs
of older adults, especially as they related to increased
cardiovascular health needs, bacterial pneumonia, and
growing problems with being overweight. The down-
turn in the economy and the changing workforce
were important issues. The report highlighted the
importance of providing resource information to
those experiencing difficulties. Their next steps
included completing the final report and the beginning
development of an action plan.

n Summary Points
• The purpose of an assessment is to provide an

accurate portrayal of the health of a community to
develop priorities, obtain resources, and plan actions
to improve health.

• There are seven different approaches to assessment,
varying from comprehensive assessments to more spe-
cific narrow assessments focused on a health problem,
a specific health issue, or population. Other types of as-
sessments include HIAs and rapid needs assessments.

• Frameworks or models can be used to guide the
community assessment process. Two models include
MAPP and CHANGE.

• Assessment data consist of both secondary and
primary data.

• Qualitative methods of data collection include focus
groups and key informant interviews. Quantitative
methods often include surveys.

• Newer techniques of collecting data include the use
of GIS and PhotoVoice.

t CASE STUDY
Exploring Your Town

Many of us think we know a lot about our town, but
we do not know the particulars. How many residents
own their home and how many are renters? How many
vacant homes are in our town? Has the population got-
ten older, poorer, or richer? The U.S. Census Bureau
has already aggregated much of the data that answer
these questions and more. It is possible to drill down
right to your own neighborhood if you know your cen-
sus tract. To obtain census tract data, you must first
identify the census tract number. This can be identified
by a street address or by consulting a census tract map.
If you have a street address, use the street address
search.
1. Go to American Factfinder at http://factfinder.

census.gov.
2. Enter the name of a town in which you are interested.

What information can you find about the percentage
of families living in poverty? What is the mean income?

3. Identify census tract information.
4. If you have a street address, use the Select

Geographies drop-down box to determine in
which census tract a family lives in. What does
this information tell you about the neighborhood?

5. If you do not have an address, use the reference
map feature by selecting Maps from the left menu
and then Reference Maps.

6. Select a state from the map and zoom so that you
can see census tract boundaries. Determine the
correct tract number.

7. Switch to search (on the top menu) and select the
Geography tab.

8. Show more selection methods and more geographi-
cal types.

9. Change the search boxes with the name of the
state, county, and tract number.

10. Search for the map of the census track to determine
the population.

7711_Ch04_077-106 22/08/19 11:35 AM Page 104

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107

KEY TERMS

Community capacity
Community diagnosis
Community organizing
Formative evaluation
Goal

Health program planning
Impact
Objective
Outcome
Output

Process evaluation
Program evaluation
Program implementation
Resources
SMART objectives

Social justice
Summative evaluation

n Introduction
We all want to live in healthy communities. A healthy com-
munity is a place where children are safe to play and learn;
a place where there are educational and employment
opportunities; a place with safe, affordable housing; and a
neighborhood with good communication and support. In
a healthy community, if teenagers use alcohol, older adults
have difficulty accessing health care, or the percentage of
obese adults increases, the community works together with
other collaborative partners to solve the problem. Program
planning can lead to increased community capacity to solve
these problems and create healthier communities.

Community program planning is the process that
helps communities understand how to move from where
they are to where they would like to be.1 Health program
planning is “a multistep process that generally begins
with the definition of the problem and development of
an evaluation plan. Although specific steps may vary, they
usually include a feedback loop, with findings from pro-
gram evaluation being used for program improvement.”2

Planning occurs at the local level with both public and pri-
vate agencies, at the state and federal levels, and also as part
of strategic planning for the public’s health at the global
level. Today, public health program planning is one of the

10 essential public health services that should be under-
taken in all communities.3 Program planning is most
successful when the community is a collaborative partner,
bringing together resources to achieve agreed-upon goals
and increasing community capacity. Community capacity
refers to the ability of community members to work to-
gether to organize their assets and resources to improve the
health of the community. It is the ability of a community
to recognize, evaluate, and address key problems. Building
community capacity can increase the quality of the lives of
individual community residents; it can promote long-term
community health and increase community resilience. The
community as a whole can become self-reliant in identify-
ing root causes of health problems and achieving identified
outcomes. It can be quite self-sustaining when community
members are empowered to make their own decisions
about interventions and outcomes. Community capacity
building is about working in partnerships and supporting
community members in their decision making.4

Health program planning is a four-step process that
includes assessment, developing of interventions, imple-
menting interventions, and evaluating the effectiveness
of interventions. It is the same basic steps of the nursing
process applied to populations rather than individuals.
It begins with the assessment phase covered in Chapter 4.

Chapter 5

Health Program Planning
Gordon Gillespie, Christine Savage, and Sara Groves

LEARNING OUTCOMES

After reading the chapter, the student will be able to:
1. Discuss the use of Healthy People 2020 in health

program planning.
2. Identify components of different health planning

models.
3. Describe the steps in writing community diagnoses.

4. Explain the importance of evidence-based practice in
program planning.

5. Describe the process of writing goals, objectives, and
activities for a health program.

6. Discuss the different types and value of program evaluation.

7711_Ch05_107-127 21/08/19 11:04 AM Page 107

Based on the assessment, the collaborative community
partners arrive at a community diagnosis. They then
decide what action would be most productive to improve
the health of the community and begin to plan a program
or programs to address the priority health issues identi-
fied. Once the plan is in place, they act (implement the
plan). The final stages are to evaluate how well the plan
addressed the priority issue and, if it works, how best to
sustain the program.4 The program could involve such
things as policy change, health education, or the creation
of new public health services. Frequently, it means put-
ting in place a program to address the community health
diagnosis with the goal of improving health outcomes
for the population, reducing the risk of disease, and/or
minimizing the impact of disease. Program planning
follows the same process for the population level that
the nursing process uses with individuals and is similar
to the development of a care plan in the nursing process
and the evaluation of the effectiveness of the intervention.

National Perspective
Program planning has been an integral part of public health
practice since its conception and has received a lot of at-
tention in the past 30 years. In 1988, the Institute of Med-
icine (IOM) (now the Health and Medicine Division of the
National Academies, Engineering, and Medicine) published
a landmark report focusing on the future of public health
(see Chapter 1). In this document, public health practice
was recognized as population focused, not individual
focused, health planning was recognized as important at
the local level, and the core public health functions of as-
sessment, policy development, and service assurances were
identified.5 The IOM report of 2002 further defined public
health practice and the shift from individuals to popula-
tions with the essential engagement of the community and
diverse partners in the practice of public health.6 The 2012
IOM report strongly advocated for increased funding of
public health and population-level interventions.7 Public
health nurses (PHNs) today embrace this population focus
with their community-based assessments, health planning,
population-based program designs and interventions,
program evaluation, and policy development.8 Both PHNs
and nurses working in other settings need skills related to
engaging community partners in these program efforts and
how to make successful programs sustainable. Keller and
colleagues have been instrumental in identifying the areas
of community organizing, coalition building, collaborating,
social marketing, and policy development9,10 within the
Intervention Wheel Practice Model (see Chapter 2). All
of these perspectives are useful in health planning and
program design, implementation, and evaluation.

108 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Healthy People
A key federal effort that provides a tool for community
public health planning in the United States is Healthy
People (HP), a national compilation of disease prevention
and health promotion goals and objectives for better
health (see Chapter 1). During the past 4 decades, HP has
become a part of health planning at the local, state, and
federal levels. HP provides a guide to communities wish-
ing to implement HP guidelines.11 The guide uses MAPIT
(Mobilize, Assess, Plan, Intervene, and Track progress)
to help communities set targets and identify indicators of
success (Box 5-1).

In addition, one of the topics included in HP 2020 is
educational and community-based programs.12 Thus,
HP acknowledges the need for health planning at the
community level and provides clear objectives and strate-
gies for population-based health programs.

n HEALTHY PEOPLE 2020
Health Planning and Evaluation

Targeted Topics: Educational and Community-Based
Programs
Goal: Increase the quality, availability, and effectiveness
of educational and community-based programs designed
to prevent disease and injury, improve health, and
enhance quality of life.
Overview: Educational and community-based programs
play a key role in:

• Preventing disease and injury
• Improving health
• Enhancing quality of life

Health status and related health behaviors are
determined by influences at multiple levels: personal,
organizational/institutional, environmental, and policy
based. Because significant and dynamic interrelation-
ships exist among these different levels of health
determinants, educational and community-based pro-
grams are most likely to succeed in improving health
and wellness when they address influences at all levels
and in a variety of environments/settings.
Midcourse Review: Of the original 107 objectives,
10 were archived for HP 2020, 7 were developmental, and
90 were measurable. At the midcourse review, 12 objec-
tives had met or exceeded the 2020 targets, 11 were im-
proving, and 16 had demonstrated little or no detectable
change. In addition, 17 objectives were getting worse,
31 had baseline data only, and 3 were informational only.

Source: (12)

7711_Ch05_107-127 21/08/19 11:04 AM Page 108

Healthy People goals and objectives were first pre-
sented in 1979, and they have continued to influence
the nation, not just to assess health status but also to
project improved status with outcome measurement
(see Chapter 1). The Healthy People document in 1979
established national health objectives for the first time
and provided the structure for the development of state
and community health plans. The first 10-year plan had
five goals, each established for distinct age groups,
and 226 objectives.13 The success of the first plan was
limited. The reasons may have included too many goals,
not enough significant interest generated in the public
health and community arenas, and a lack of political
support.14

The next 10-year plan, Healthy People 2000 (1990–
2000), replaced the first five goals with three new goals,
22 priority areas, and 319 objectives that included
specific subobjectives to measure outcomes with special
populations experiencing health disparities. The goals
were: (1) increase the span of healthy life for Americans,
(2) reduce health disparities among Americans, and
(3) provide access to preventive health services for all
Americans. These goals and objectives were influenced
by the first 10-year plan, but they also were influenced
by a concern for high-risk populations and the need to
increase community organizing to better plan health.
In the evaluation of the objectives at the end of the sec-
ond decade of HP, there were some excellent out-
comes, but there were situations in which health
worsened.

The support for Healthy People as a planning tool
grew and has now become part of the local, state, and
national public health practice.11 The Healthy People 2010
(2000–2010) plan continued to build on previous Healthy
People plans and refined the goals to two: (1) increase
quality and years of life and (2) eliminate health dispar-
ity. It had more detailed objectives and 28 specific focus
areas to help measure outcomes. HP 2020 built on these
previous efforts and included 42 topics (Box 5-2).15

All health-related agencies are encouraged to use this
document and its indicators, such as a school for its
breakfast program and industry in its worksite wellness
programs. The proposed HP 2030 plan is continuing to
foster change in health behavior, but it also looks at long-
range planning and priority programs for target popula-
tions. The intention of HP is to continue to guide efforts
to plan, implement, and evaluate health promotion and
disease prevention interventions for the nation. This is
an important document to review and implement when
planning health programs. It gives guidance in writing
program objectives and identifying appropriate health
indicators.

Overview of Health Program Planning
To provide population-focused care, it is necessary to
have skill in health program planning and evaluation.
Issel states the purpose of health program planning is “to
ensure that a program has the best possible likelihood of
being successful, defined in terms of being effective with
the least possible resources.”16 To design appropriate
programs, nurses who are part of a team must contribute
to the completion of a reliable community assessment,
participate in analyzing the community data, construct
the community diagnoses, prioritize needs, and deter-
mine resource availability. Using this information, the
nurses, other public health staff, community partners,
and community members can begin the program plan-
ning process.

Health Program Planning Models
A number of models are available to assist with health
program planning and evaluation. Program planning
begins with a clear statement of the health problem. The
assessment helps the team developing health programs
to identify the priority health problems for the popula-
tion and/or community. Following the establishment of
the health priority, the team then works to understand
the underlying factors contributing to the problem. As
explained by Issel, this is the first step in deciding what
intervention(s) are the best choice for addressing the

C H A P T E R 5 n Health Program Planning 109

Implementing HP using MAPIT
Healthy People is based on a simple but powerful model
that helps to:

• Establish national health objectives
• Provide data and tools to enable states, cities, commu-

nities, and individuals across the country to combine
their efforts to achieve them

Use the MAPIT framework to help:

• Mobilize partners
• Assess the needs of a community
• Create and implement a plan to reach HP objectives
• Track a community’s progress

BOX 5–1 n Healthy People

Source: U.S. Department of Health and Human Services. (2018). Program planning.
Retrieved from https://www.healthypeople.gov/2020/tools-and-resources/
Program-Planning.

7711_Ch05_107-127 21/08/19 11:04 AM Page 109

These models all incorporate basic steps, and there are
multiple resources that can be used to assist with each
step (Table 5-1).

PRECEDE-PROCEED Model
Planning is essential to guarantee appropriate use of
resources. One of the oldest models for program planning
comes from Lawrence Green’s well-researched PRECEDE-
PROCEED model. Two other community health planning
models in current use that can assist in program planning
include Community Health Assessment and Group
Evaluation (CHANGE) Action Guide and Mobilizing
for Action Through Planning and Partnerships (MAPP)
(see Chapter 4). The CHANGE model (see Chapter 4) has
eight phases and only the last phase, develop the commu-
nity action plan, deals with program planning. MAPP’s ac-
tion cycle is the program planning phase.

A model not discussed in Chapter 4 is the PRECEDE-
PROCEED model, which gives insight into how to de-
velop an educational program that will positively change
health behavior. This model, designed in 1968, has gen-
erated evidence-based practice (EBP) in many diverse
areas of health education. Green started out with two
ideas: (1) health problems and health risks are caused by
multiple factors, and (2) efforts to produce change must
be multidimensional, multisectoral, and participatory.17

The PRECEDE component letters stand for Predis-
posing, Reinforcing and Enabling factors, and Causes
in Educational Diagnosis and Evaluation. When a
community uses the PRECEDE process, it begins with
a comprehensive community assessment process as
described in Chapter 4. When the assessment phase is
complete, the model provides guidance on how to exam-
ine the administrative and organizational issues that
need to be dealt with before implementing a program
aimed at improving the community’s health. The final
steps of PRECEDE relate to the design, implementation,
and evaluation of a program. Evaluation includes exam-
ining data related to process, outcome, and impact objec-
tives and indicators established during the development
phase of the program planning.

Green believed that the more active and participatory
the program interventions were for the recipients of the
program, the more likely the recipients were to change
behavior. Green also noted that, for behavior change
to take place, recipients must be willing to work with
the program; the ultimate decision to change behavior
remains up to the recipients. The second half of the
model is the PROCEED component that was devel-
oped from the work with the PRECEDE component.
PROCEED goes beyond the recipients of the interventions

110 U N I T I n Basis for Public Health Nursing Knowledge and Skills

1. Access to Health Services
2. Adolescent Health
3. Arthritis, Osteoporosis, and Chronic Back Conditions
4. Blood Disorders and Blood Safety
5. Cancer
6. Chronic Kidney Disease
7. Dementias, including Alzheimer’s Disease
8. Diabetes
9. Disability and Health

10. Early and Middle Childhood
11. Educational and Community-Based Programs
12. Environmental Health
13. Family Planning
14. Food Safety
15. Genomics
16. Global Health
17. Health Communication and Health Information

Technology
18. 30 Health-Care-Associated Infections
19. Health-Related Quality of Life and Well-Being
20. Hearing and Other Sensory or Communication

Disorders
21. Heart Disease and Stroke
22. HIV
23. Immunization and Infectious Diseases
24. Injury and Violence Prevention
25. Lesbian, Gay, Bisexual, and Transgender Health
26. Maternal, Infant, and Child Health
27. Medical Product Safety
28. Mental Health and Mental Disorders
29. Nutrition and Weight Status
30. Occupational Safety and Health
31. Older Adults
32. Oral Health
33. Physical Activity
34. Preparedness
35. Public Health Infrastructure
36. Respiratory Diseases
37. Sexually Transmitted Infections
38. Sleep Health
39. Social Determinants of Health
40. Substance Abuse
41. Tobacco Use
42. Vision

BOX 5–2 n HP 2020’s 42 Topics

Source: https://www.healthypeople.gov/2020/topics-objectives.

problem and ultimately improving the health of the pop-
ulation and/or community.16

Most program planning models use a systems ap-
proach and provide guidance on how to identify the
problem and then systematically apply the best solution.

7711_Ch05_107-127 21/08/19 11:04 AM Page 110

C H A P T E R 5 n Health Program Planning 111

TABLE 5–1 n Steps in Health Program Planning

The types of steps generally used in program planning are listed here, along with selected resources that may be useful at
each step.

Using Evidence-Based Resources for Program Design, Implementation, and Evaluation

Step Description Suggested Resources

1

2

3

4

5

1–5

Identify primary health issues in your
community.

Develop measurable process and
outcome objectives to assess
progress in addressing these health
issues.

Select effective interventions to help
achieve these objectives.

Implement selected interventions.

Evaluate selected interventions
based on objectives; use this
information to improve the
program.

All of the above.

• Community Health Assessment and Group Evaluation (CHANGE)
• County health rankings
• National Public Health Performance Standards
• MAPP (Mobilizing for Action Through Planning and Partnerships)

• HP Leading Health Indicators
• HEDIS (Healthcare Effectiveness Data and Information Set)

performance measures

• The Guide to Clinical Preventive Services
• Health Evidence
• National Guideline Clearinghouse

• Partnership for Prevention
• CDCynergy

• Framework for Program Evaluation in Public Health
• CDCynergy

• The Community Health Promotion Handbook: Action Guides to
Improve Community Health

• Cancer Control P.L.A.N.E.T. (Plan, Link, Act, Network With
Evidence-Based Tools)

• Community Tool Box
• Diffusion of Effective Behavioral Interventions (DEBI)

and reflects an effort to modify social environment and
promote healthy lifestyle, which evolved as a clear need.
PROCEED involves Policy, Regulatory, Organizational
Constructs in Education, and Environmental Design.17

This model has served as the basis for other health pro-
gram planning and assessment models, such as MAPP
and CHANGE (see Chapter 4).

Logic Model
Another model used by many program planners is the
logic model. A logic model provides the underlying
theory that drives the program design. This model guides
a team in the careful planning of a well-thought-out
program. A logic model approach to program planning
can result in a plan that is clear to implement and evalu-
ate; is based on theoretical knowledge; and includes
a clear understanding of resources, time, and expected
outcomes. Logic models are such useful tools for program

evaluation that many grant agencies now require a logic
model in their grant application.18

The concept of a logic model is it logically moves like
a chain of reasoning from the planned work to the
intended results in five steps, starting with input and
resources to program activities to outputs to outcomes
to impact (Fig. 5-1). The model is read from left to right.
The first two components make up the planned work of
the health program:19

1. Resources (inputs) are those items needed and
available for the program. This includes human
resources, financial resources, equipment, institu-
tional resources, and community resources.

2. Next come the activities that produce the program
intervention. It can involve processes such as
health education, as well as tools, technology, or
other types of activities classified as the intended
intervention.

7711_Ch05_107-127 21/08/19 11:04 AM Page 111

The next three components of a logic model make up
the intended results:

3. Outputs are the direct product of the activities of
the program, for example, a class completed on fam-
ily planning, immunization for tetanus, or a service
from the dentist. This is the process component of
program evaluation. Successful output occurs when
the program’s intended outcome is achieved.

4. Outcomes are the intended results or benefits of the
planned intervention and are those items that the
team plans to measure. This can include a change in
knowledge, skills, behavior, or attitude. The outcomes
should be reasonable, realistic, and significant. The
short-term and medium-term outcomes are the
objectives, which reflect the previously discussed
characteristics. In program planning, it is always
important to think about potential unexpected or
unintended outcomes if a program is implemented.

5. Impact is the program goal, producing long-term
change in the community. This may often occur only
after the program has been in effect for 5 to 8 years
and even after the program funding has ended.19,20

Although linear reasoning occurs in all logic models,
the model can come in all sizes and shapes. Some organ-
izations have added other components and complexities
to the model to help with particular clarification of the

program design. Two areas can be added and can help in
understanding the theory of the logic model. First, the
assumptions the program planners have made, such as
principles behind the program development; how and
why a change in strategies will work; and any research
knowledge and clinical experience. Second is a listing
of external factors (culture, economics, demographics,
policies, priorities) that will affect both resources and the
program activities (see Fig. 5-1). A logic model is built
on the community assessment, a clear identification of
the problem, and best solutions within the context of the
community in which the program will take place.

A logic model is a good tool for everyone involved in
the program to use to help them organize their thoughts
and ideas to work cooperatively for the same outcomes.
It helps the program implementers understand why the
activities are structured the way they are, helping to
maintain the integrity of the program. The model is not
static and can be adjusted and improved as the need
arises with good, ongoing review and evaluation. If you
are entering the program as an implementer after the
design has been established, the logic model, read from
left to right, offers you an excellent road map of what
resources are available for implementation, what program
is to be produced, with what results.

If you are entering the program as one of the stake-
holders to help with the design, it is often best to start

112 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Problem

Priorities

Input Activities
Output Outcome Impact

To provide this
program, we will
need the
following
resources:

Activities: In order to
address the problem,
we will conduct the
following activities:

Outputs: We expect
that once completed
or underway, these
activities will
produce the
following evidence of
service delivery:

We expect that if
completed or
ongoing, these
activities will lead
to the following
changes in 1–3
then 4–6 years.

We expect that if
completed, these
activities will lead
to the following
changes in 7–10
years.

Assumptions External

Figure 5-1 The basic logic model.

7711_Ch05_107-127 21/08/19 11:04 AM Page 112

from what you hope the program will have as an impact
(goal), move to the left identifying objectives (outcomes),
and then determine which activities and output would
help the community reach the intended objectives. Then
you establish what resources are necessary to implement
the intended activities.

In the program planning stage, you read a logic model
from right to left. However, as previously noted, there is
nothing static in the program planning process. As
you complete the different sections you may find that you
need to rewrite objectives based on the best practices
you have found in the literature about a particular activ-
ity you would like to implement. You may find you have
fewer resources than what you need to implement a

particular activity, which will change your intended
outcomes. You can try various scenarios to determine
which one is the best fit for the community and the
organization, identifying strengths and weaknesses of
the plan.

By the end of the process, the stakeholders will be able
to see visually how the program goal(s) relate directly to
the objectives that, in turn, relate directly to the program
activities and the resources available. An example of a
logic model is presented for the Elwood Community
incorporating the assessment data, goal, objectives,
activities, and output (Table 5-2).

The logic model is not the only tool available for pro-
gram planning and, like all tools, has its drawbacks. In

C H A P T E R 5 n Health Program Planning 113

TABLE 5–2 n Logic Model: Program to Create Social Integration Among Elmwood Residents

Resources Activities Outputs Outcome Impact

• Space in residential
building including
heat and electricity

• Support (human
and material) from
the Primary Public
School

• Support from the
community center
(staff) at the
residential site

• PHN time, 8 hours
per week for the
program and other
time for nursing care
of the population

• Residents of the
facility

• Support of time
and resources from
the two local
churches

• Additional community
support

1. A senior outreach
program to the
public schools for
2 hours twice
a week

2. A reading program
for young children
attending the
Primary Public
School

3. Creation and
maintenance
of a resident
organization
with one of its
objectives being
the improvement
of communication
among residents

4. Presentation/
discussion groups
twice a month
with initial church
leadership;
suggested first
topics include:
a. safety in the

community
b. celebrating

differences in
culture and
ethnicity

• 15 seniors are
working with
30 children at the
Primary Public School

• There is a reading
session once a month
with 10 seniors and
20 first grade children
for 1 hour at the
housing site

• There is an Elmwood
Community
Association that has
elected leaders and
representatives from
both buildings that
meets regularly

• There is a larger
community
organization that is
meeting regularly to
unite against crime in
the community

• The churches are
working together
to provide twice-
monthly interactive
programs at
Elmwood

1. Establishment of a
volunteer school
program run by
Elmwood
residents to work
with 50 children
at the school and
25 children on
site within
6 months

2. Development of
consistent monthly
programs in each
building with a
minimum of
40 resident
attendees that
foster social
interaction by
October 2023

3. Formation of
a resident
community
organization

• Meaningful
communication
occurs among
the elderly
population in
the two senior
high-rise
Elmwood
residential
buildings

• Seniors are
integrated into
the community,
feeling valued

Assumptions: (1) If residents of the Elmwood Buildings work together on programs and reach out to the community, the
communication among themselves will increase. (2) If the residents believe their work is meaningful and interesting, they will convey
this to other residents, the program will expand, and there will be increased communication. (3) If the residents are offered interesting
and appropriate programs in the building, they will attend, have more interaction, and communication will continue to increase.

7711_Ch05_107-127 21/08/19 11:04 AM Page 113

evaluating the use of the logic model, researchers have
found that the emphasis on activities and outcomes has
decreased the importance of understanding the rationale
for the program choice.20 Other tools such as concept
mapping (a pictorial relation of concepts and relation-
ships), a geographic information system (GIS; a computer-
based program that can be used with geographical
or location-based information; see Chapter 4), and
community mapping (a visual map representation of
resources and information corridors) are useful but also
are limited. The University of Maryland, like many uni-
versities and organizations, created a program plan that
can be modeled by others when developing a new pro-
gram.21 The tools are comprehensive and interactive,
such as the Decision Support System (DSS), which is a
step-by-step program planning series that gives on-screen
feedback; Empower, which is based on the PRECEDE/
PROCEED model; and the Outcome Toolkit, which
facilitates planning and data analysis to make commu-
nity improvement efforts measurable and accountable.

The logic model can serve several functions in addi-
tion to the actual program plan. For example, one group
of researchers used the logic model to provide “. . . stake-
holders with a common framework for the innovation
or further development of pharmaceutical care”.22 It also
helped the staff to discuss and specify assumptions they
all held in common. For example, one assumption within
the community was that all families have strengths,
and appropriate job training and related activities will
prevent homelessness. This then helped them to better
define their goal: to prevent homelessness and move
families to self-sufficiency. Mulroy and Lauber also were
able to limit their activities and more precisely determine
immediate and intermediate outcomes. These authors
agreed that logic modeling helped provide an analytical
structure for better outcome development and better
program management and evaluation.

One group developed the ¡Cuídate! Program using
the logic model as a means to “… plan, implement, and
evaluate a sustainable model of sexual health group pro-
graming in a U.S. high school with a large Latinx student
population”.23 The nurses believed the logic model was
most helpful in providing a visual diagram that could be
easily communicated to others. It became the heart of the
program development and identified the future direction
for the program.

Key Components of Health Program Planning
The important components of health program planning are:

• Active involvement of the community as a partner
• Skill and time to do a competent assessment

• Shared conclusions with the partners of the needed
interventions

• Actual program planning, interventions, and
evaluation1

Nurses at all levels of practice are involved in these
processes, and it is critical nurses understand program
planning to make significant contributions to the process.

As part of health program planning, nurses need to be
involved in community organizing because this plays
a pivotal role in successful planning as was recognized
in the focus of HP 2020 and in the Centers for Disease
Control and Prevention (CDC) assessment and program
model CHANGE (see Chapter 4).24 Community organ-
izing is bringing people together to get things done. It is
helping people to act jointly in the best interest of their
community. Most frequently, community organizing
occurs with poorer communities that are disenfran-
chised, uniting people to gain power and fight for social
justice. The process is inclusive of everyone in the com-
munity and is a powerful tool for health planning and
program design. The role of the nurse in community
organizing is not one of leadership but one of listener,
facilitator, and developer of community leadership skills.
It is to provide opportunities for the development of new
relationships within the community.1

Inclusion of the community begins during the assess-
ment phase (see Chapter 4) and continues through the
action and evaluation phases. The key is to assemble
a representative team from the community to help develop,
implement, and evaluate a community health program.
The CHANGE manual provides a guide on how to begin
to assemble a team (Box 5-3). The public health system
described by the CDC (Figure 5-2) also stresses the
importance of including the community and provides
extensive guidance and examples on how to accomplish
this. This includes bringing together a diverse group,
actively recruiting members, and developing a plan for
engaging the larger community in the process.1

Social Justice
Another key construct central to health program planning
is social justice (see Chapter 7). Improving the health
of everyone in the community often requires addressing
social injustices. It is also a basic underlying construct of
public health. Social justice dictates that society is based
on the constructs of human rights and equity. The idea
is that those who have plenty will be willing to share with
those who do not have enough to provide for equity.
In a just health-care system, everyone should have the
basic opportunities for a healthy life. Poverty, illness,
and premature mortality are a tragic waste of human

114 U N I T I n Basis for Public Health Nursing Knowledge and Skills

7711_Ch05_107-127 21/08/19 11:04 AM Page 114

resources that defy the dignity and inherent worth of
the individual. Social justice dictates everyone should
have access to basic health services, economic security,
adequate housing and food, satisfactory education, and
a lack of discrimination based on race or religion. It
is more often the distal social determinants (income,
education, housing, racism) that are more impactful to
changing the health status of individuals and populations
than putting into place programs that change individual
behavior in communities with limited resources. Pro-
viding adequate education leading to employment with
a satisfactory income for housing and food can make a
greater impact on health than teaching low-income
individuals how to use their minimal income for healthy
foods or better housing. Communities with scant resources
frequently organize around issues of disparity. As they
build their skills in organizing and create change within
the community, they build community capacity and
work toward social justice. As the community capacity
increases, the health of the community improves.
Community members learn how to be independent in
identifying their problems, the root causes, and the
skills to solve these problems.

C H A P T E R 5 n Health Program Planning 115

Action Step 1: Assemble the Community Team
Assembling a community team starts the commitment

phase of the community change process. Representation
from diverse sectors is a key component of successful
teamwork; enables easy and accurate data collection;
and enables data assessment, the next phase of the
community change process. All members of the commu-
nity team should play an active role in the assessment
process, from recommending sites within the sectors to
identifying the appropriate data collection method. This
process also ensures the community team has equitable
access to and informed knowledge of the process,
thereby solidifying their support. Consider the makeup
of the community team (10 to 12 individuals maximum
is desirable to ensure the size is manageable and to
account for attrition of members). Include key decision
makers—the CEO of a worksite or the superintendent
of the school board—to diversify the team and use the
skill sets of all involved.

BOX 5–3 n Assembling the Community Team

Source: Centers for Disease Control and Prevention. (2018). Community
health assessment and group evaluation (CHANGE) tool. Retrieved from
https://www.cdc.gov/nccdphp/dnpao/state-local-programs/change-tool/
index.html

Monitor
Health

ResearchResearchResearch

Diagnose
& Investigate

Inform,
Educate,

Empower

Mobilize
Community
PartnershipsEnforce

Laws
Develop
Policies

Link
to/Provide
Care

Assure
Competent
Workforce

Evaluate

Sy
st

em
Management

A
S

S
U

R
A

N
C

E

P
O

LICY DEVELOPMENT

ASSESSMENT

Figure 5-2 The 10 essential public health services.
(From Centers for Disease Control and Prevention. [2018]. The
public health system. Retrieved from https://www.cdc.gov/
stltpublichealth/publichealthservices/essentialhealth
services.html)

n CELLULAR TO GLOBAL
The social determinants of health (see Chapter 7)
play an important role in the development of humans
and their ability to achieve optimal health. Pregnant
women require adequate health and health care to
deliver a healthy infant. When access to foods that
support healthy eating patterns and access to primary
care are limited, fetuses are less likely to develop
healthily in utero. The fetuses then have a greater risk
for being born premature and/or with long-term physi-
cal or cognitive limitations. These limitations can later
manifest with decreased educational attainment and
increased poverty. Challenges to the social determi-
nants of health are unique to each individual country
but occur in all developing and developed nations
across the globe. Increased health program planning
that directly addresses these determinants will assure
the highest likelihood for health for all.

The nurse must always consider social justice in pro-
gram planning. In making the decision about public
health action, there is the consideration of equitable dis-
tribution of benefits and burdens based on needs and
contribution of the community. The community must
decide the minimum goods and services required, how
they can be acquired, and what programs will best serve

7711_Ch05_107-127 21/08/19 11:04 AM Page 115

the population with the available resources. In 2008,
Buchanan warned against public health paternalism
where individual rights are limited for the greater public
good. He argued that if communities are given freedom
to make choices, including the level of availability of
those choices, they will achieve good health.25 Striking a
balance between public health mandates and community
freedom of choice continues to present a dilemma for
public health today as evidenced by vaccine requirements
for attendance at schools.

Working to ensure universal health care has a great
impact on health planning in the United States and is a
social justice action particularly important to the PHN.
It was a major platform promise during President
Obama’s first campaign and resulted in the establish-
ment of the Patient Protection and Affordable Care Act
(ACA). The American Nurses Association has long been
a supporter of health-care reform and supported the
passing of the ACA.26 Although the future of the ACA
is uncertain, the positive impact of the ACA to date has
been documented,27-29 and it can have a major impact
on the health of the entire population. Nurses can also
advocate, support, and work for the distal social deter-
minants of a better educational systems, better child
welfare, better housing laws, and better occupational
and environmental protection. These actions will help
the nation achieve the objectives set out in HP 2030, with
people living longer and leading more active lives with
less health disparity.

Community Diagnoses
Community diagnoses have been used in public health
by multidisciplinary groups for many years, evolving
separately from nursing and medical diagnoses, which
tend to focus on individual need. Community diag-
noses represent the last phase of the community assess-
ment process and the first phase of the health program
planning process. A clear statement of the health prob-
lem and the causal reasons or theories for it provide the
basis for designing a health program that will actually
improve the health issue. A community diagnosis is a
summary statement resulting from the community
assessment and the analysis of the data collected. The
diagnosis guides the community team’s thinking in
how to design the program and what components are
necessary. A community-specific diagnosis is needed
because each community is unique in how the problems
are manifested and solved. There are many types of
community diagnoses and most share many parts in
common, but the more detailed and complete the diag-
noses, the easier it is to tailor them to an appropriate
program.

Nursing community diagnoses generally contain four
parts:30 (1) the problem, (2) the population, (3) what the
problem is related to (characteristics of the population),
and (4) how the problem is demonstrated (indicators of
the problem).16,30

116 U N I T I n Basis for Public Health Nursing Knowledge and Skills

w SOLVING THE MYSTERY
The Case of the Lonely Older Adults
Public Health Science Topics Covered:
• Assessment
• Community diagnosis

The PHN, Meghan, is working with a geriatric popu-
lation in the Elmwood senior high-rise, composed of
publicly funded housing units. Her employer, the city
health department, has allocated her one day a week
for health programming in these two closely spaced
buildings located in the inner city of a moderately large
urban area. To determine what kind of programs
would be most useful, Meghan enlisted community
partners in the Elmwood community and the city
housing authority to do an assessment to help identify
community strengths and health needs.

During the assessment, residents of the buildings
were interviewed, as were both formal and informal
leaders. The assessment group toured the Elmwood
buildings looking at the apartments and other resources
that were part of the units. They spoke with key
community informants including the employees in the
neighborhood schools and local churches. The group
evaluated community safety and resources within walk-
ing distance of the Elmwood buildings, which included
supermarkets, pharmacies, banks, health-care facilities,
social service resources, and local stores. They reviewed
demographic data, vital statistics, and other community
indicators for the neighborhood, and compared the
data with the city and with other areas in the United
States. The community partnership, with the help of
the PHN as a member of the team, summarized their
assessment findings. One of the identified problems,
which was at the top of the list for many residents, was
the lack of meaningful activities for the residents within
their apartment buildings. The residents were justifiably
concerned about safety outside their buildings and had
many mobility issues, which resulted in boredom and
isolation, without an avenue for social communication.

Meghan had initially imagined she would implement
an educational program, for example, teaching the resi-
dents about the health benefits of eating vegetables, the
correct way to take their medications, or the impor-
tance of a low-fat diet. This was based on the type of

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C H A P T E R 5 n Health Program Planning 117

interventions she had already been doing in the build-
ings one-on-one with individual clients. However, she
was more than willing to explore a community-specific
program that would facilitate social interaction. To do
this, with the help of her community partners she elab-
orated this problem in a community diagnosis (Box 5-4).

Meghan also decided to include mediating and mod-
erating factors as part of her community diagnosis.30

This allowed her not only to examine the health prob-
lem, the population, indicators, and causal factors but
also how the problem was mediated by specific moder-
ating factors and the presence of antecedent factors
(those behaviors that existed prior to the health prob-
lem).30 It is frequently important to know that some
behaviors may directly cause the problem and others
may be more indirect. Moderating factors can make
the problem better or worse. Mediating factors occur
between the causal factors and the outcomes, and are
significant when designing the program because they
alter outcome. Increased details of the specific health
problem can contribute significantly in determining the
best program design.

In reviewing the analysis of the assessment,
Meghan noted that in the Elmwood senior buildings
the housing authorities mixed two ethnic neighbor-
hood groups that had been hostile to each other for
the past 20 years. Also, 15 years ago two of the large
churches in this community held different positions
on several neighborhood political and religious issues,
and each congregation had united against the other with
several harsh words spoken in public. The churches had
subsequently left the decaying neighborhood, but many
of the congregants were still living in the community.

This antecedent information contributed to a better
understanding of the current problem of limited com-
munication among Elmwood residents that led to social
isolation.

The assessment committee had also spoken with the
community center staff 10 blocks from Elmwood. The
workers were frustrated at not attracting more senior
clients for their multiple programs and expressed con-
cern they might need to discontinue these programs
due to lack of participation. They admitted they had
done little marketing to the seniors at Elmwood, had
no means to transport residents of the apartments
to their center, and had little knowledge of the com-
munity dynamics, especially in relation to the senior
population. They did provide escort services for
schoolchildren coming to the community center
because of a recent outbreak of gang violence in the
area. They had not considered that this might also have
an impact on the seniors’ decision not to come to the
center.

The local churches confirmed that there had been
community discord, and many of their current older
members were still angry. This had caused some
friction in the current churches, but the pastors were
working on mediating these factors to create more
united congregations and better sharing among the
memberships. All of the local churches provided trans-
portation to services on Sunday and Wednesday
evenings. They currently had no other outreach to
the senior residential buildings.

When visiting the primary school one block from
the senior housing, the teachers and principal talked
about a lack of resources in the school. They repeat-
edly mentioned the need for many of the children to
have more one-on-one interactions to increase their
basic skills of reading and writing. With this additional
information, Meghan added to the community diagno-
sis, and she now had a clearer understanding of some
of the origins of the problems and the mediating and
moderating factors that could help design a program
that not only would provide opportunity for more
social interaction among the senior residents but also
could enhance the health of the entire community
(Fig. 5-3).

Having completed the community diagnosis, Meghan
explained to the team it was time to begin the program
development phase. She explained they would work
together with the stakeholders from all aspects of
the identified community to determine how they
could solve the problem of the lonely older adults.
Meghan said they first must decide who will receive

Problem: Lack of meaningful social interaction resulting in
social isolation.

Population: Older adult population in the two Elmwood
senior residential buildings.

The isolation of the older adults was related to no
formal programs in the building, limited social contact
among residents, inadequate community safety, and resi-
dents’ restricted mobility as indicated by residents being
able to name only one other person in the building, the
fact that no one spoke to others while waiting for the
elevator, the neighborhood had the second highest crime
rate in the city, 62% of residents complained of loneli-
ness, and 59% of the residents had mobility problems.

BOX 5–4 n Community Diagnosis

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118 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Antecedent
Hostile ethnic
groups, discordant
churches, decaying
community, age of
resident

Causal Factors
No community
organization, no
program in building,
high crime, client
immobility, no
resident social
interaction

Moderating
Neighborhood
gangs, no
transportation, no
community center
outreach

Mediating
Primary school,
community center,
local churches,
public health nurse

Health Problem
Elderly social
isolation,
loneliness

Impact
Social integration
among Elmwood
residents

Figure 5-3 Diagram of community diagnosis for Elmwood Senior Housing.

the intervention. They needed to decide whether it
would be individuals, families, communities, or a whole
system. She cautioned that this was the time to care-
fully consider what interventions would be most
appropriate and effective, and if there was evidence
to confirm their decision. The team would together
decide what immediate effects they would like this
program to have and what long-term effects they
might expect. All of this should be reflected from their
community diagnosis and would guide the community
discussion.

Meghan stressed this approach because she knew
the clearer and more rational the explanation for
solving the problem, the stronger the program would
be. This was the time to discuss what kind of program
activities the group would like to implement and what
evidence-based practices existed to help guide the devel-
opment of a program. The team began with a review
of the literature, looking not only for established
approaches but for new and innovative ones as well.
Their discussion was tempered by resources, nature of
the community, culture of the community, and other
distal variables that influence receptivity to different
types of programs. Much of the information gathered
during their assessment helped them to think about
what might work in their community.

The discussions were somewhat time intensive
because of the multiple agendas of the people at the
table, different approaches to problem-solving, varied
understanding of the process of program planning,
different cultural and communication styles, and differ-
ent expectations. Yet Meghan persevered and helped

guide the discussion, allowing members to voice their
opinions, and then bringing them back to the task at
hand. Because she had worked in the community for a
long time, she was able to help interpret cultural and
value differences, facilitate communication, and encour-
age the planning team to use the community diagnosis
statement to guide the design.

Megan carefully considered who should participate
in the discussion. Based on the community diagnosis,
Meghan specifically invited leadership from the school,
churches, and community center. After she reviewed
the community diagnosis with the group, the school
representative immediately repeated the need for help
with more one-on-one activity with the students at the
school and mentioned several ways the seniors could
participate. The school representative said they could
provide on-site orientation at Elmwood for the seniors
who would be willing to come to the school. He first
suggested a 3-week training program, after which they
would provide escorts to the school one block away
on Tuesdays and Thursdays for the seniors to work
2 hours each of these days with the children. The
Elmwood residents at the meeting asked whether the
school also could bring some of the children to the
Elmwood buildings once a month for story time with
those seniors whose mobility was more limited. Several
community members suggested this could be accom-
plished by creating the Elmwood Community Action
Committee, which could meet jointly with school
representatives to design the reading program. The
community center offered to provide staff to help
support these meetings. The community center saw

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C H A P T E R 5 n Health Program Planning 119

this as an opportunity to get involved with a program
the seniors would attend and were happy to do it at
the Elmwood site. Other ideas included on-site,
church-sponsored discussion groups about ways to
decrease crime in the community and participatory
cultural presentations (food, music, beliefs) from
different ethnic groups in the community. At the
end of the brainstorming meeting there were more
than eight suggestions, and several people agreed to
research programs similar to these for more in-depth
applications, successful outcomes, and identification
of potential problems when applied to other
communities.

Once the planning group reached consensus about
the broad aspects of the program design, Meghan ex-
plained to them the next step was to write the goals
and objectives for the program. She pointed out there
were two important points to remember at this stage
of program development. The creation of a program is
a process, and as a process the planning is fluid. She
explained to the group they might decide on an inter-
vention, only to change it later as they start to write
goals and objectives and identify indicators, and that
this was a normal part of the process. Likewise, the
goals and objectives might change as the group more
carefully defined the program activities. However, she
stressed it was important in the final program design
that the activities and outcomes correspond to the
goals and objectives agreed on by the team, and this
was again reflected in the process and outcome evalua-
tion. She stated members of the group would need to
be responsible for monitoring the process and making
sure the goals, objectives, activities, and evaluation all
worked together. She volunteered to be part of this
subgroup.

She then explained to the team the second consid-
eration was how best to write the goals and objectives
and determine health indicators. She cautioned that a
very large group discussion could be time consuming
and result in poorly worded objectives. The team
decided to appoint a smaller task force to write these
up and present them back to the full group. They asked
Meghan to be the facilitator for this task force.

When the task force had its first meeting, Meghan
began with an overview of how to write goals and
objectives for the program plan and how they formed
the framework of the plan. She explained that goals and
objectives are different and each has a specific purpose.
A goal is a broad statement of the impact expected
by implementing a program, that is, a short general

statement of the overall purpose of a program with a
focus on the intention of the program. In most situa-
tions, it is a statement of outcome, rather than activity,
and frequently projects to a future situation, such as
5 years from program initiation. There are usually only
a few goals for a program. There may be only one goal
for a simple program and two or three for a more
complex program. Because it is a general statement,
there are usually no actual outcome measurements in
it, but the goal should be realistic and reachable.

Meghan provided the team with examples. One
example of a goal she provided was from a colleague
of hers who was a high school nurse who developed a
program to prevent teen pregnancies. The goal of that
program was to prevent all teenage pregnancies at
Reed High School. Another example she provided was
from a community in Alabama concerned about the
increase in obesity in all age groups. They designed a
community-based fitness program with the goal of
providing opportunities for all community residents
to increase or maintain the necessary physical activities
for them to be physically fit. After much discussion the
task force decided that the goal for the program was
the following:

To increase meaningful communication among the older
adult population in the two senior high-rise Elmwood residen-
tial buildings.

The next step for the task force was to come
up with specific objectives for the program. Megan
explained that objectives clarify the goal, are an out-
come measurement, and keep the program focused on
the intended intervention. She knew writing objectives
was not easy, but she also understood well-written
and well-thought-out objectives were components for
the success of the program and key in the process of
program planning. Objectives include who will achieve
what by how much by when. They are measurable, time-
limited, and action-oriented. She suggested they use
an accepted approach to writing objectives first intro-
duced in 1981 called SMART objectives. SMART
stands for Specific, Measurable, Assignable, Realistic,
and Time-related.31 She explained SMART objectives
are action-oriented and specify the goals and the
desired results in a concrete, well-defined, and detail-
focused statement. A specific objective answers the
six “w” questions: who, what, where, when, which,
and why. An objective that is measurable tells you the
measurement criteria to determine when you have
succeeded in meeting the objective, the most essential

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120 U N I T I n Basis for Public Health Nursing Knowledge and Skills

component of an objective. An objective that is
achievable is one that can attain the desired outcome
in the prescribed time frame. An objective that is
realistic is one in which the resources (economic,
human, skills) are available to implement the action.
An objective that has defined time parameters indi-
cates when this objective will be achieved and pro-
vides a deadline. All of these components working
together in one objective can give you the clearest
outcome measure.

The task force began to write up their objectives.
They made sure there was an objective for every
major program activity with a description and desired
outcome that was clear to everyone. They hoped this
would decrease confusion among stakeholders and
the larger team when they presented it to them. They
also realized it needed to be clear to those who would
implement the program.

As they reviewed each objective, they examined
how each would help guide the intended implementa-
tion of the program. They asked whether the objec-
tives would work well taken all together and would
reflect the goal for the program. Meghan explained
this program was somewhat complex. To help provide
clarity, the group first added some level objectives that
gave more detail. They also added process objectives
to measure what the staff would do, how much they
would do, and during what time period.

Meghan knew she needed to become very familiar
with the objectives and the indicators identified for
this program as well as other programs she worked
with for the health department. She was particularly
concerned with ensuring the integrity of these programs
when implemented and ensuring the right data were
collected for the program evaluation phase. As the
objectives were developed, Meghan identified indica-
tors with which to measure the objectives chosen by
the group and helped demonstrate how the program
performed. She knew that good indicators are relevant
to any health program; are scientifically defensible,
when possible; are based on national benchmarks; are
feasible to collect; are easy to interpret and analyze;
and changes can be tracked over time.32 The team
developed clear and specific objectives and then were
able to identify appropriate indicators to measure what
was expected to change. The indicators they chose
were practical and specific steps were in place to
collect the necessary data.

The Elmwood task force presented their final draft of
the goals and objectives to the larger community team.

The team accepted the draft and began to move into
the implementation of the program.
Goal:
To increase social communication among the older
adult population in the two senior high-rise Elmwood
residential buildings.
Objectives:
1. To establish a volunteer school program run by Elmwood

residents to work with 50 children at the school and
25 children on-site within 6 months.

2. To develop consistent monthly programs in each building
with a minimum of 40 resident attendees that foster
social interaction by October 2023.

n CULTURAL CONTEXT
When assessing communities, analyzing data, and
designing programs, the partnership must always con-
sider the culture, ethnicity, and language of the commu-
nity. It is important for staff and community members
to feel secure asking questions and gaining information,
so they feel comfortable with the culture of the com-
munity the program serves. It also is important that
organizations have clearly stated values that endorse
cultural competency and sensitivity.

Although cultural competency is always an essential
component in program planning, in some programs it
takes on a central role. Aitato and colleagues in Hawaii
noted in their assessment that cancer is the leading
cause of death for Samoans in the United States.33

They concluded the design of a program aimed at
decreasing morbidity and mortality related to cancer for
this population required a culturally relevant approach.
When designing the program, they linked the Samoan
beliefs about health and illness with the need for early
cancer detection. They reviewed the sociological and
cultural literature to better understand appropriate
interventions. Through their examination of the culture
they found that most Samoans were fatalistic and pas-
sive in response to cancer. This also was observed
in clinical settings. Aitato et al. also reported church
affiliation was exceptionally important for this immigrant
group, especially because it provided them a commu-
nity where they could practice their traditional lifestyle.
Based on this evidence, the program designers used a
community-based participatory research method to
gather information within the Samoan churches.
Through focus groups, the Samoans as a community
determined the most appropriate programs, including
the need to use the Samoan language, the serving of

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Evidence-Based Practice in Program
Planning
It is important to use EBP in the steps of program plan-
ning. The development of a health program begins
with a review of the literature for similar problems, the
population-based approaches to solving the problem(s),
and the evidence that the approach worked. Look at the-
ory and rationales for these other programs and see how
they relate to your program. Look for similar programs
in similar communities and see whether your strategies
are also similar. Note whether the strategies in these
other communities produced their expected outcomes.
If you want to try something unique, see whether there
is anything in the literature that allows you to build your
own rationale for the effectiveness of your selected
approach. Arguments for using a specific intervention are
strongest when there is demonstrated previous success
with the method, especially with a similar population.

C H A P T E R 5 n Health Program Planning 121

appropriate Samoan food, and the need to recognize a
traditional leader.

Integrating cultural components into program plan-
ning is essential. Take, for example, the Discovery
Dating program in a western U.S. tribal middle
school.34 The two facilitators of the program were a
Native American PHN from the western tribal commu-
nity and a Native American community health educator
from a different tribal community. The use of two facili-
tators from two different tribal communities showed
an understanding that a great deal of diversity exists
between tribes in relation to language, spiritual prac-
tices, gender roles, and customs among tribal groups.34

n EVIDENCE-BASED PRACTICE
Engagement of the Older Adult

Practice Statement: Social isolation poses a significant
health risk for older adults.
Targeted Outcome: Engagement with the community
Supporting Evidence: Intergenerational programs at
schools that include older adults and young children are
shown to have a beneficial impact on both (Fig. 5-4).
The children receive additional attention, and the
older adults feel needed and appreciated. Specifically,
researchers found that older adults had increased self-
esteem and better health. Children at risk for failure
did much better in these programs, and all the children
had a more positive attitude toward older adults.

Figure 5-4 Adopt a Grandparent. (From the Centers for
Disease Control and Prevention, Richard Duncan, MRP, Sr. Proj.
Mngr, North Carolina State University, the Center for Universal
Design, 2000.)

Another finding was the older adults had a calming
effect on the classroom. In one study, the researchers
compared two programs, one with a formal design
with older adults receiving pretraining and one
accepting volunteers and integrating them into the
classroom without any training. The final outcome of
effectiveness was the same.
Recommend Approaches: Promote an intergenera-
tional program between older adults and school-aged
children.

Sources
1. Kaplan, M.S. (2001). School-based intergenerational

programs. Retrieved from http://unesdoc.unesco.org/
images/0020/002004/200481e.pdf.

2. David, J., Yeung, M., Vu, J., Got, T., MacKinnon, C.
(2018). Connecting the young and young at heart: An
intergenerational music program: Program profile.
Journal of Interpersonal Relationships, 16(3), 330-338.

3. Gualano, M.R., Voglino, G., Bert, F., Thomas, R.,
Camussi, E., & Siliquini, R. (2018). The impact of
intergenerational programs on children and older
adults: A review. International Psychogeriatrics, 30(4),
451-468.

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Resources for Evidence-Based Programs
The Community Tool Box, created by the University of
Kansas, offers additional suggested resources for infor-
mation on promising evidence-based programs or
programs with interesting new interventions.1 A central
suggestion in the Community Tool Box is networking
with local and state agencies, and checking public and
private professional organizations or advocacy groups
to see whether they have published information on
evidence-based programs.

The importance of integrating evidenced-based pro-
grams into public health departments was underlined
by the National Association of County & City Health
Officials’ (NACCHO) nationwide support system to dis-
seminate Chronic Disease Self-Management Programs
through local health departments (LHD) into commu-
nities. With the support of the CDC, NACCHO has
provided grants to LHDs with emerging evidence that
they are successfully implementing these programs in
the communities they serve.35 They acknowledged that,
according to the literature, merely gaining knowledge
about nutrition and fitness frequently did not translate
into behavior change. Based on their review of the liter-
ature, setting goals, strengthening self-efficacy, and using
theory of change had more success in actually changing
behavior than just providing information. They also
found that multifaceted community efforts have increased
physical activities. With this evidence, they designed
their program.

Determining whether a program has good evidence
to support it can be accomplished using a few different
approaches. First, examining both the quantitative and
qualitative data from studies, as well as from the current
program, provides essential information. Even simple
statistical analysis can help determine whether a program
is thriving, whether participants are reaching their out-
comes, and whether positive things are happening in the
community. Good indicators that the community likes
the program are the continued use of the program by
participants and ongoing program growth. However, it
is important to know whether there are outside factors
contributing to program success that might make it diffi-
cult to duplicate the program in other communities
or with other groups. Another issue may be that the out-
comes are really a measurement of behavior change
and not real outcomes. When reviewing program data,
it is important to note whether there is a researched the-
oretical framework to support the intervention, whether
the statistical analysis is clear, whether there are enough
participants to make conclusions, whether the target
outcomes are appropriate, and whether the program

reached these targets. In reviewing the program, it helps
to evaluate whether the indicators seemed appropriate
and whether the tools were well designed. It also helps
to think about the usefulness of the indicators of the
program. Did the intervention reach the intended pop-
ulation, and is this population similar to or different from
the intended population? It also is important to be aware
of what resources were used and to compare the amount
of resources available for your program. In the 1990s,
Lisbeth Schorr, a well-known social analyst, identified
seven characteristics of highly effective programs still
relevant today.36 Although they are focused on programs
aimed at improving the health of children, they can also
be applied to other populations. Effective programs:

• Are comprehensive, flexible, responsive, and
persevering

• See children in the context of their families
• Incorporate families as parts of neighborhoods
• Have a long-term, preventive orientation, a clear

mission, and continue to evolve over time
• Are well managed by competent and committed

individuals with clearly identifiable skills
• Have staff who are trained and supported to provide

high-quality, responsive services
• Operate in settings that encourage practitioners to

build strong relationships of mutual trust and respect

Many of these attributes are part of effective program
planning, implementation, and evaluation, and include
looking at communities and not just individuals, being
flexible and persevering, having clear goals, forming
partnerships and working collaboratively, and having
passion on the part of staff for the work and for social
justice. In successful programs, the staff is nurtured and
supported, and the program is well managed.

Program Implementation
After the program has been designed and the logic model
solidified, it is time to implement the program. Program
implementation encompasses the resources needed to
provide a program as well as the mechanism for putting
the program in place. Prior to putting a program in place,
it is important to map out exactly how this will be done.
For example, when implementing a screening program,
it is important to know how many participants are
anticipated, how many screening tools/how much equip-
ment will be needed, how many personnel are needed,
and what the flow for participants from arrival through
the screening and referral process will be. Nurses are
frequently part of the implementation team and assist in

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adding the necessary detail to the actual program activ-
ities. Ervin identified five stages related to program
implementation:30

1. Community accepting the program
2. Specifying tasks and estimating needed resources
3. Developing specific plans for program activity
4. Establishing a mechanism for program management
5. Putting the plan into action

Partnering with the community from the beginning
of the planning process facilitates community interest
and ownership of the program, which should be cultur-
ally and politically specific and acceptable. Although
adequate resources to implement the program were iden-
tified in the planning, it is important to confirm that
the resources are available and adequate, and how these
resources are to be used in the program activities and
evaluation.

The implementation team needs to make certain the
indicators for the outcomes are identified and a mecha-
nism is in place to collect the data. Everyone needs to
know the steps of the program. It may be necessary to
write protocols and procedures for the intervention. If
additional staff members are needed, they need to be
hired and undergo orientation. There also may be a need
for additional staff training. Several program evaluations
have stressed the importance of pilot testing the program
or components of the program and the planned evalua-
tion before implementation of the complete program, as
was done in one study in China that helped to identify
challenges related to the implementation of a community-
based stable coronary artery disease management pro-
gram.37 The first was the importance of establishing
a personal working relationship with the community.
They also suggested the program leader strive to build
partnerships by listening, observing, and integrating the
experiences between the program and the community.
They found it was best to be flexible and emphasized
simplicity when implementing community activities.

Program Evaluation
Project management and program evaluation are inex-
tricably linked whether in public health programs, a
health program, or in an acute care setting.16,38 Program
evaluation is the systematic collection of information
about the activities, outputs, and outcomes to enhance a
program and its effectiveness. Evaluation is defined as
the systematic acquirement and analysis of information
to provide useful feedback. Evaluation is essential to
good management and program design, and evaluation

strategies should be developed prior to the project man-
agement and programs being implemented. Evaluation
is used to evaluate the effectiveness of the program and
provide information to guide any needed improvement
of the program. Through evaluation you strengthen the
project. Programs need to be evaluated for multiple
reasons. You need to know whether objectives and goals
are being met. From the evaluation you can determine
whether the:

• Activities are implemented as they were designed
• Program is cost effective
• Intervention and program theories are correct
• Time line is appropriate
• Program should be expanded or duplicated in

another location

Evaluation helps with program planning, program
development, and program accountability. Frequently
the PHN works with comprehensive collaborative com-
munity interventions that are complex to evaluate, as
there may be no clear cause and effect with multiple
interventions. Often the program operates within the
unique local political issues, and circumstances of the
community demand a customized evaluation to really
understand what is happening. PHNs and other local
providers can help interpret this information for the
interior or exterior evaluators or as part of an evalua-
tion team.

Percy provided a good example that underscores the
necessity for program evaluation.39 She described a
school health program in one school district that was
so busy providing good health care to the schoolchild-
ren that the district failed to design and implement an
evaluation plan. Without an evaluation of the program,
the district was unable to determine whether the pro-
gram was effective. Because the program required a
registered nurse (RN) in each school, the lack of eval-
uation data resulted in an inability to demonstrate the
need for the added cost of the school health nurses.
The city council members had budget constraints and
needed to cut programs. Without the evaluation data,
the nurses could not show the council members the
importance of this nursing intervention. To have a
more cost-effective budget, the city council replaced
the nurses with nursing assistants. When the city tried
to extend this cost savings to another school district,
the nurses in the second school district had already
been evaluating their program routinely, and they had
excellent outcome data to demonstrate the effective-
ness of having an RN in each school. Their program
did not get cut.

C H A P T E R 5 n Health Program Planning 123

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Evaluation of family and individual care, community
services, and programs has grown over the past several
decades as a response to the stakeholders, especially
the funders, who need to know whether the nurse and
colleagues from other disciplines are successful in im-
proving health and are doing so in a cost-effective manner.
Most grant agencies funding these types of interventions
now require evaluation.

Evaluation Models
Formative Evaluation
There are several models for program evaluation. One
model is to divide the evaluation into either formative or
summative or both. Formative evaluation occurs during
the development of a program, while the activities are
forming and being implemented for the first time. It is
an ongoing feedback on the performance of the program,
identifying aspects needing improvement and providing
opportunities to offer corrective suggestions. Formative
evaluation is concerned with the delivery of the program
and the organizational context, including structure and
procedures. This is an opportunity to examine what
happens in the reality of the implementation, and it
provides the opportunity to see whether the program
outputs can really create the change necessary to meet
the objectives and goals. Usually a formative evaluation
is internal and ongoing, with the staff constantly assess-
ing the strengths, weaknesses, barriers, and unexpected
opportunities of these new program activities. The activ-
ities and outputs are the dynamic part of the program
and lend themselves to formative evaluation. The pro-
gram can positively respond to the evaluation and can
change interventions, change the way outcome measure-
ments are collected, or change other parts of the program
design to better meet the program goals and objectives.
It is appropriate to change things if the program is not
working as well as possible.

Process Evaluation
Process evaluation is a type of formative evaluation used
to investigate the process of delivering the program or
technology, including alternative delivery procedures.
The main concern with process evaluation is to docu-
ment to what extent the program has been delivered and
whether the delivery was what was defined in the pro-
gram design. There should be detailed information on
how the program actually worked (the program opera-
tions), any changes made to the program, and how those
changes have had an impact on the program. It is also
important for an evaluator to be aware of any outside
environmental events or intervening events that may

have influenced the program activities. This type of data
can be collected by noting actual numbers related to the
interventions, such as the number of people attending
a class, the number of pamphlets handed out, or the
number of screening tests performed. Qualitative data
collection methods can include, among others, direct
observations, in-depth interviews, focus groups, and
review of documents.

The importance of formative evaluation should
not be underestimated. It is a strong tool in helping to
improve the activities and output of a program and for
determining whether the theoretical understanding of
how the program will influence change is accurate and
appropriate.

Summative Evaluation
Summative evaluation occurs at the end of the program
and is the evaluation of the objectives and the goal. It is
judging the worth of the program at the end of the activ-
ities and discovering whether the program achieved the
intended change. It is an assessment of the outcome
and impact of the benefits the selected population has
received by participating in the program. It evaluates
the causal relationship and the theoretical understanding
of the planned intervention. It also can examine program
cost, looking at cost-effectiveness and cost benefit.40

When conducted on well-established programs, it
allows funders and policy makers to make major deci-
sions on the continuation of programs and determine
how the outcomes could influence policy at the local to
the national levels.

As more hospitals strive for magnet status, baccalau-
reate nurses are being called to initiate health programs
in acute care settings and to evaluate their effectiveness.
In public health settings, the PHN is often responsible
for managing community-based programs in which
evaluation is essential to the sustainability of the pro-
grams. Several nonprofit funding agencies and the CDC
offer suggestions on how to do internal evaluations and
when to seek external evaluator assistance.

Nine Steps of Program Evaluation
The W.W. Kellogg Foundation identified essential steps
for developing a program evaluation that is useful for
both smaller programs and for the complex multiactivity
community program interventions that many organiza-
tions implement (Box 5-5).40 The first four steps occur
in the program planning stage, the next three in the im-
plementation of the program, and the last two after the
program evaluation is complete. Program evaluation is
an integral part of the program design, and the program

124 U N I T I n Basis for Public Health Nursing Knowledge and Skills

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evaluation plan should be in place before the program is
initiated.

Step 1: Step 1 is completed before the program begins.
It identifies from among the stakeholders who
should be included on the evaluation team, staff
representation, and what community representation
and participants are needed in the program.

Step 2: In step 2, evaluation questions are created. All
participants need to help phrase questions that will be
useful in reflecting the program theory, improving the
program, and determining effectiveness. These ques-
tions can include the following: What data do you
need to collect? What kind of information is needed?
What do we want to accomplish? What do we need to
know about the program? How will we know when we
have accomplished our goal? Where do we find the
data, and what indicators do we need? The questions
also will involve how this information is communi-
cated to others: Who is the audience for the results?
What kind of information should we tell them?

Step 3: Step 3 is the creation of a budget. The amount
of the budget varies depending on several compo-
nents such as the size of the program, the number of
staff needed to carry out the evaluation, the need for
other resources such as software for data entry and
analysis, and the length of time needed to complete
the evaluation.

Step 4: In step 4, a decision must be made about
whether the evaluation will be internal or have an
external evaluator. If you decide on an external eval-
uator, it is good to identify that person, so the evalu-
ator can be a part of the program planning process
from the beginning. These are all components of the
planning and occur as the program is designed.

Step 5: Steps 5 through 7 occur during the program
implementation phase. In step 5, data collection
methods are determined.

Step 6: In step 6, data are collected.
Step 7: In step 7, the results are analyzed and interpreted.
Step 8: After the completion of the evaluation, in step 8

the findings and new perceptions of the program are
communicated to the stakeholders. It is important
that the appropriate information is communicated
to the identified audiences.

Step 9: In step 9, evaluation information is used to show
evidence for or to improve the program. The better
informed we are, the better we are at making good
program decisions. This may be sharing with funding
agencies to receive more funding for the successful
program; it may be to change some of the program
activities and outputs to improve outcomes; or it may
be to refine the population served, to help change
policy, or to discontinue the program (see Box 5-5).
When developing the process for health program

evaluation, it is important to be as objective as possible.
Some of the ethical dilemmas that can emerge during
program evaluation include:
• Pressure to slant the findings in the direction wanted

by key stakeholders
• Compromised confidentiality of data sources
• Response on the part of the evaluator to one interest

group more than to others
• Misinterpretation or misuse of the findings by the

program stakeholders
• Evaluator using a familiar tool to collect data rather

than a more appropriate one
The team can use these points to examine the methods

chosen to evaluate a program as a means of eliminating
as much bias as possible.

Through successful programs, communities can im-
prove their health. These programs can be synergistic
in creating positive change and lead to new policies with
an even wider influence on health. The purpose of health
programs is to strive for a community in which everyone
is safe, environments support health, actions are taken
to prevent and control acute and chronic disease, and
individuals and families can thrive.

C H A P T E R 5 n Health Program Planning 125

Program
1. Select the evaluation team.

Planning Stage
2. Develop the evaluation questions.
3. Have a budget in place for the evaluation.
4. Decide whether to use an internal or external evaluator.

Program Implemented
5. Determine data collection methods.
6. Collect the data.
7. Analyze and interpret the results.

Evaluation Complete
8. Communicate findings.
9. Improve the program.

BOX 5–5 n Nine Steps in Developing a Program
Evaluation

Source: W.K. Kellogg Foundation. (1998). W.K. Kellogg Foundation evaluation
handbook. Battle Creek, MI: Author. Retrieved from https://www.wkkf.org/
resource-directory/resource/2010/w-k-kellogg-foundation-evaluation-
handbook.

7711_Ch05_107-127 21/08/19 11:04 AM Page 125

n Summary Points
• Health planning occurs across health-care settings

including public health settings, primary care, acute
care, and schools, with the focus on improving the
health of the populations served.

• Healthy People provides a framework of goals and
indicators that can help in creating health programs
for our communities.

• All models of program planning include the commu-
nity as a partner, and it is important that the com-
munity is involved in every step of the process.

• Health planning includes community assessment,
community diagnoses, program design, program
implementation, and program evaluation.

• Using logic modeling can help create a well-structured
program with clear indication of how to do both
process and outcome evaluation of the program.

• Every program should be evaluated, and evaluation
begins when you start designing the program.

• Formative, process, and summative evaluations each
provide important information about the program
and how to make it more effective.

REFERENCES

1. Center for Community Health and Development at the
University of Kansas. (2018). Community tool box: A model
for getting started. Retrieved from https://ctb.ku.edu/en/
get-started#plan.

2. U.S. Department of Health and Human Services. (n.d.).
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thecommunityguide.org/about/about-community-guide.

3. Centers for Disease Control and Prevention. (2017).
National public health performance standards. Retrieved from
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4. Fawcett, S.B. (2018). Section 3. Our model of practice: Build-
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5. Institute of Medicine. (1988). The future of public health.
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8. American Public Health Association: Public Health Nursing
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apha.org/apha-communities/member-sections/public-health-
nursing.

9. Keller, L.O., Schaffer, M., Lia-Hoagberg, B., & Strohschein, S.
(2002). Assessment, program planning, and evaluation in
population-based public health practice. Journal of Public
Health Management and Practice, 8, 30-43.

10. Keller, L.O., Strohschein, S., Lia-Hoagberg, B., Schaffer, M.
(2004). Population-based public health interventions: Practice-
based and evidence-supported. Part I. Public Health Nursing,
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11. U.S. Department of Health and Human Services. (2018).
Program planning. Retrieved from https://www.healthypeople.
gov/2020/tools-and-resources/Program-Planning.

12. U.S. Department of Health and Human Services. (2016).
Educational and community-based programs (ECBP).

126 U N I T I n Basis for Public Health Nursing Knowledge and Skills

l APPLYING PUBLIC HEALTH PRACTICE
The Case of Program Evaluation
at Elmwood
Public Health Science Topics Covered:

• Assessment
• Community diagnosis

The Elmwood Senior Housing program was designed
to increase social integration and has been in place
for 9 months. The activities include residents work-
ing in the public schools in an intergenerational
program, the first and second graders each coming
to Elmwood once a month for a 2-hour reading
program, the solidification of an Elmwood community
organization, and weekly discussion and activity
programs at the center with assistance from the
community center and the local churches. The PHN
and other members of the team have been doing
ongoing process evaluation and are now meeting
to discuss the implementation of their outcome
evaluation plan.

To answer the following questions, use the estab-
lished goal, outcomes, and output in the logic model
(Fig. 5-1) developed by the community group. You
also can reference the Community Tool Box from
Center for Community Health and Development at

the University of Kansas (https://ctb.ku.edu/en/table-
of-contents), Evaluating Community Programs and
Initiative, Chapters 36–39.

1. What data would you collect as part of the process
evaluation? How would these data help you in the
formative process of your program? Would you
change activities based on these data?

2. What would have been the steps in setting up the
evaluation plan? What might be your evaluation
questions? What would be your indicators? What
kind of data should you collect? How would you
specifically know whether your program has been
successful?

7711_Ch05_107-127 21/08/19 11:04 AM Page 126

Retrieved from https://www.cdc.gov/nchs/data/hpdata2020/
CH11_ECBP.pdf.

13. Public Health Service. (1979). “Healthy People”: The Surgeon
General’s report on health promotion and disease prevention.
Washington, DC: U.S. Government Printing Office, DHEW.

14. Chrvala, C., & Bugar, R. (Eds.). (1999). IOM report. Leading
health indicators for “Healthy People 2010”: Final report.
Washington, DC: National Academies Press.

15. U.S. Department of Health and Human Services. (2018).
2020 topics and objectives – objectives A-Z. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives.

16. Issel, L.M. (2018). Health program planning and evaluation:
A practical, systematic approach for community health
(4th ed.). Sudbury, MA: Jones & Bartlett.

17. Green, L.W., & Kreuter, M.W. (2005). Health program plan-
ning: An educational and ecological approach (4th ed.).
New York, NY: McGraw-Hill Higher Education.

18. W.K. Kellogg Foundation. (2004). Logic model development
guide. Battle Creek, MI: Author. Retrieved from https://
www.wkkf.org/resource-directory/resource/2006/02/wk-
kellogg-foundation-logic-model-development-guide.

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

20. Ball, L., Ball, D., Leveritt, M., Ray, S., Collins, C., Patterson, E.,
Chaboyer, W., et al. (2017). Using logic models to enhance
the methodological quality of primary health-care interven-
tions: guidance from an intervention to promote nutrition
care by general practitioners and practice nurses. Australian
Journal of Primary Health, 23(1), 53–60. https://doi-org.ezp.
welch.jhmi.edu/10.1071/PY16038.

21. University of Maryland Extension. (2017). Guide to
2018 University of Maryland extension program planning.
Retrieved from https://wiki.moo.umd.edu/display/umean-
swers/Program+Planning+and+Implementation?preview=
%2F84902254%2F121897117%2FUME+Program+Planning+
Guide+2018.pdf.

22. Moltó-Puigmarí, C., Vonk, R., van Ommeren, G., & Hegger,
I. (2018). A logic model for pharmaceutical care. Journal of
Health Services Research & Policy, 23(3), 148–157. https://
doi-org.ezp.welch.jhmi.edu/10.1177/1355819618768343.

23. Serowoky, M.L., George, N., & Yarandi, H. (2015). Using the
program logic model to evaluate ¡Cuídate!: A Sexual health
program for latino adolescents in a school-based health center.
Worldviews on Evidence-Based Nursing, 12(5), 297–305.
https://doi-org.ezp.welch.jhmi.edu/10.1111/wvn.12110.

24. Centers for Disease Control and Prevention. (2018). Com-
munity health assessment and group evaluation (CHANGE)
tool. Retrieved from https://www.cdc.gov/nccdphp/dnpao/
state-local-programs/change-tool/index.html.

25. Buchanan, D. (2008). Autonomy, paternalism, and justice:
Ethical priorities in public health. American Journal of Public
Health, 98, 15-21.

26. American Nurses Association. (2015). Health care reform.
Retrieved from https://www.nursingworld.org/practice-
policy/health-policy/health-system-reform/.

27. Blewett, L. A., Planalp, C., & Alarcon, G. (2018). Affordable
Care Act impact in Kentucky: Increasing access, reducing
disparities. American Journal of Public Health, 108(7),
924-929.

28. Frean, M., Gruber, J., & Sommers, B. D. (2017). Premium
subsidies, the mandate, and Medicaid expansion: Coverage
effects of the Affordable Care Act. Journal of Health Economics,
53, 72-86.

29. Rice, T., Unruh, L. Y., van Ginneken, E., Rosenau, P., &
Barners, A. J. (2018). Universal coverage reforms in the USA:
From Obamacare through Trump. Health Policy, 122(7),
698-702.

30. Ervin, N., & Kulbok, P.A. (Eds.). (2018). Advanced public and
community health nursing practice: Population assessment,
program planning, and evaluation. New York City, NY:
Springer Publishing.

31. Doran, G.T. (1981). There’s a S.M.A.R.T. way to write man-
agement’s goals and objectives. Management Review, 70(11),
35-36.

32. United Nations Fund for Population Activities. (2004). Pro-
gramme manager’s planning monitoring & evaluation toolkit.
Retrieved from https://www.betterevaluation.org/sites/
default/files/stakeholder.pdf.

33. Aitato, N., Braun, K., Dang, K., & So’a, T. (2007). Cultural
considerations in developing church-based programs to
reduce cancer health disparities among Samoans. Ethnicity
and Health, 12(4), 381-400.

34. Schanen, J.G., Skenandore, A., Scow, B., & Hagen, J.
(2017). Assessing the impact of a healthy relationships
curriculum on Native American adolescents. Social Work,
62(3), 251–258. https://doi-org.ezp.welch.jhmi.edu/10.
1093/sw/swx021.

35. National Association of County & City Health Officials
(2018). Chronic disease resources. Retrieved from https://
www.naccho.org/programs/community-health/chronic-
disease/resources.

36. Schorr, L. (1997). Common purpose: Strengthening families
and neighborhoods to rebuild America. New York, NY:
Anchor Books.

37. Shen, Z., Jiang, C., & Chen, L. (2018). Evaluation of a train-the-
trainer program for stable coronary artery disease manage-
ment in community settings: A pilot study. Patient Education
& Counseling, 101(2), 256–265. https://doi-org.ezp.welch.
jhmi.edu/10.1016/j.pec.2017.07.025.

38. Ramos Freire, E.M., Rocha Batista, R.C., & Martinez, M.R.
(2016). Project management for hospital accreditation: a case
study. Online Brazilian Journal of Nursing, 15(1), 96–108.
Retrieved from http://search.ebscohost.com.ezp.welch.jhmi.
edu/login.aspx?direct=true&db=rzh&AN=115736473&site=
ehost-live&scope=site.

39. Percy, M. (2007). School health. Quality of care: or why you
HAVE to evaluate your program. Journal for Specialists in
Pediatric Nursing, 12(1), 66-68.

40. W.K. Kellogg Foundation. (2017) The step-by-step guide to
evaluation: How to become savvy evaluation consumers.
Battle Creek, MI: Author. Retrieved from http://ww2.wkkf.
org/digital/evaluationguide/view.html#p=10.

C H A P T E R 5 n Health Program Planning 127

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Chapter 6

Environmental Health
Christine Savage

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Describe the role of nursing in environmental health.
2. Describe the impact of the built environment on health.
3. Use the principles of home visiting and an environmental

health assessment to identify health risk factors at the
family and community level.

4. Examine the concept of exposure to hazardous
substances from a cellular to global level.

5. Explain the concept of environmental justice.
6. List social, behavioral, cultural, and physical characteristics

that increase susceptibility to health effects associated
with environmental exposures.

7. Discuss gene-environment interaction.
8. Describe issues related to air and water quality.

Air Quality Index (AQI)
Ambient air
Ambient air standard
Area sources
Blood Lead Level (BLL)
Bioaccumulation
Built environment
Community environmental

health assessment

Criteria air pollutants
Environmental exposure
Environmental health
Environmental justice
Environmental

sustainability
Exposure
Gene-environment

interaction

Half-life
Integrated pest

management
International building

codes
Latency period
Mobile sources
Point sources
Risk assessment

Routes of entry
Safe Drinking Water Act
Toxicity
Warm handoff

n Introduction
Whether tainted water in Flint, Michigan; air pollution
on the rise in low income countries;1 airborne mercury
pollution in Victoria, Australia;2 or natural disasters
and climate change,3 our environment has a direct rela-
tionship with our health. The environment affects the air
we breathe, the food we eat, the water we drink, and the
availability of resources to sustain our economies. The
environment also influences our exposure to toxins and
infectious agents, and access to resources that support
healthy living.

Hardly a day goes by without a report in the media
that links environmental conditions to human health.
High rates of childhood asthma, industrial explosions,
hurricanes and other natural disasters, as well as reports
of polluted water and air remind us of the many ways
we are affected by the world around us and how the
health of individuals and communities strongly depends

on environmental determinants. The adverse environ-
mental impact of human-made and natural disasters
such as the lack of potable water and lead exposure in
Flint, Michigan, and numerous hurricanes as well as
the day-to-day aspects of the environment in which we
live, work, and play can cause immediate or long-term
benefits or harm.

The World Health Organization (WHO) defines
environmental health as follows:

Environmental health addresses all the physical, chemical,
and biological factors external to a person, and all the re-
lated factors impacting behaviors. It encompasses the as-
sessment and control of those environmental factors that
can potentially affect health. It is targeted toward prevent-
ing disease and creating health-supportive environments.
This definition excludes behavior not related to environ-
ment, as well as behavior related to the social and cultural
environment, and genetics.4

128

7711_Ch06_128-156 21/08/19 11:03 AM Page 128

This perspective of environmental health extends
beyond food, air, water, soil, dust, and even consumer
products and waste. It includes all aspects of our living
conditions, the use and misuse of resources, and the
overall design of communities. The ecological models
of health promotion (see Chapter 1) encompass the en-
vironment in which we live.5 Using an ecological ap-
proach requires an understanding that individuals and
populations interact with their environment. In an ed-
itorial, one author stressed the need for interventions
aimed at protecting the natural environment as an up-
stream approach to improving our health.6

The broad scope of environmental determinants of
health is obvious with the inclusion of 68 main and sub-
objectives under the Healthy People 2020 (HP 2020) topic
of environmental health.7 Based on the midcourse review,
six of these were archived and four were developmental,
which left 58 that were measurable.

The WHO’s 10 facts on environmental health pub-
lished in 2016 illustrated the association between the en-
vironment and health.10 Almost a quarter of all deaths
globally were attributable to the environment. Five key
factors emerged through an analysis of data related to the
global burden of disease attributable to the environment
(Table 6-1). Twenty-two percent of the disability-adjusted
life years (DALY) (see Chapter 9) were attributable to
the environment, and low-income countries (LIC) bore
more of the burden of disease associated with the envi-
ronment. Age and gender play a role in risk for environ-
mental attributable disease with children, older adults, and
males at higher risk. Although communicable diseases
are the main cause of environmentally attributed deaths
in Sub-Sahara Africa, there has been a shift globally to
noncommunicable diseases as the main cause of deaths
are attributable to the environment. The list of diseases
associated with the environment include cardiovascular
diseases, diarrheal diseases, and lower respiratory infec-
tions. The environmental factors associated with these
diseases include ambient and household air pollution,
water, sanitation, and hygiene.10

C H A P T E R 6 n Environmental Health 129

n HEALTHY PEOPLE 2020
Environmental Health

Targeted Topic: Environmental Health
Goal: Promote health for all through a healthy
environment.
Overview: Humans constantly interact with the
environment. These interactions affect quality of
life, years of healthy life lived, and health disparities.
The WHO defines environment, as it relates to health,
as “all the physical, chemical, and biological factors
external to a person, and all the related behaviors.”1

Environmental health consists of preventing or
controlling disease, injury, and disability related
to the interactions between people and their
environment.

The HP 2020 Environmental Health objectives
focused on six themes, each of which highlighted an
element of environmental health:

1. Outdoor air quality
2. Surface and groundwater quality
3. Toxic substances and hazardous wastes
4. Homes and communities
5. Infrastructure and surveillance
6. Global environmental health7

Midcourse Review: Of the 58 measurable objectives
in the Environmental Health Topic Area, 10 of them met
or exceeded their 2020 targets, 11 were improving,
10 showed little or no detectable change, and 11 objec-
tives were getting worse. Sixteen objectives had base-
line data only (Fig. 6-1).8

28%
Base line
Getting worse
Little or no change
Improving
Met or exceeded

19%

17%

19%

17%

Healthy People 2020 Midcourse Review:
Environmental Health

Figure 6-1 Healthy People Midcourse Review for 2020.

Healthy People 2030 Proposed Framework
and Environmental Health
There are seven proposed foundational principles
for the HP 2030 proposed framework. One pertains
specifically to environmental health and reflects the
ecological model:

“What guides our actions … Healthy physical, social,
and economic environments strengthen the potential to
achieve health and well-being.”9

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The Role of Nursing in Environmental
Health
Nurses, particularly those in the field of public health,
play a significant role in preventing harm from occurring
and in restoring well-being to all who face hazardous
conditions in their environment. Nurses are among the
environmental health professionals with the responsibil-
ity to detect and assess the presence of environmental
hazards as well as the health risks they pose, and to act
to protect the health of populations.11

In 2007, the American Nurses Association (ANA)
published a report titled ANA’s Principles of Environmen-
tal Health for Nursing Practice With Implementation
Strategies.11 According to the report, registered nurses
play a critical role in both assessing environmental health
issues and addressing them. The report included 10 prin-
ciples (Box 6-1) for healthy safe environments that are
applicable across settings.

Armed with an appreciation for the complexities of the
interaction of environment and health, nurses are leaders
in defining and encouraging solutions. As experts in
educating individuals and communities, and appreciat-
ing the value of leading by example, nurses are catalysts
in improving the health of the environment, thus

improving health. The environmental health issues in
the ANA report specific to nursing practice include:
(1) knowledge of the role environment plays in the health
of individuals, families, and populations; (2) ability to
assess for environmental health hazards and make appro-
priate referrals; (3) advocacy; (4) utilization of appropri-
ate risk communication strategies; and (5) understanding
of policies and legislation related to environmental
health. The ANA principles were designed to help sup-
port the nurse in the role of environmental health
activist.11

Approaches to Environmental Health
A useful framework to use in examining human-
environment interactions and their potential impact
on health of individuals, families, and communities is
the well-established epidemiological triangle, which
describes the relationship between an agent (exposure),
host (human), and environment (the complex setting
in which agent and host come together) (see Chapters 3
and 8). In actuality, the epidemiological triangle is a
simplistic model and must be placed in the context of
the real world to better appreciate the importance of the
triangle point—environment—that brings agent and
host together in the places we live, that is, housing,

130 U N I T I n Basis for Public Health Nursing Knowledge and Skills

TABLE 6–1 n Global Burden of Disease Attributable to the Environment

Percent of Deaths Attributable Percent of the DISEASE BURDEN in
Five Key Factors to the Environment DALYs Attributable to the Environment

Environmental risks and the global
burden of disease

Environmental impacts on health
are uneven across life course
and gender

Low- and middle-income countries
bear the greatest share of
environmental disease

Total environmental deaths are
unchanged since 2002, but show
a strong shift to noncommunicable
diseases

The evidence on quantitative links
between health and environment
has increased

23%

The highest number of deaths
per capita attributable to
the environment occurs in
sub-Saharan Africa

22%

Men: 22.8% versus women: 20.6%

The diseases with the largest environmental
risk include cardiovascular diseases, diarrheal
diseases, and lower respiratory infections.
Ambient and household air pollution, and
water, sanitation, and hygiene are the main
environmental drivers of those diseases.

A greater share of the estimates of the
burden of disease attributable to the
environment can now be determined using
more robust methods than previously used.

7711_Ch06_128-156 21/08/19 11:03 AM Page 130

schools, workplaces, recreational spaces, communities,
and, ultimately, the world (Fig. 6-2).

The approach in the United States for handling envi-
ronmental health in the past was usually at the state and
local health department level rather than at the federal
level. Local health departments focused on sanitation and
waste management to provide potable (safe, drinkable)
water. However, maintaining healthy air and reducing
pollutants in water, air, and soil became an issue that
crossed state borders. In 1970, the U.S. Environmental
Protection Agency (EPA) was formed with the mission
to protect human health and to safeguard the natural
environment—air, water, and land—by writing and
enforcing regulation based on laws passed by Congress.12

The EPA is a regulatory body that performs environmen-
tal assessments, does research, educates, and sets and
enforces national environmental standards. Since the
early 1970s there have been multiple federal laws passed
by Congress. This legislation includes the Clean Air Act;

the Occupational Health and Safety Act; the National
Institute of Occupational Safety and Health; the Clean
Water Act; and the Comprehensive Environmental Re-
sponse, Compensation, and Liability Act, also known as
the Superfund; among others. The growing concerns
among the American people about the environment have
created pressure to increasingly monitor and regulate the
environment. These concerns have clashed with con-
cerns by industry of overregulation resulting in a relaxing
of some of these regulations in 2017 and 2018. Thus, the
health benefits of regulating industry and pollution of the
environment often conflicts with the economic benefits
of relaxed regulations.

In the United States, there is a network of environmental
health specialists housed in the Centers for Disease Control
and Prevention (CDC) National Center for Environmental
Health that, using the epidemiological triangle (Fig. 6-2),
works collaboratively with the Environmental Health Serv-
ices Network to identify and prevent environmental factors
that can produce disease. Their stated purpose is to help
identify underlying environmental factors, assist with
improving prevention efforts, train environmental health
specialists, and help strengthen the collaboration among
different disciplines and services involved in improving
environmental health.13 Key issues include the built
environment, toxic materials, air and water quality, and
environmental stability.

C H A P T E R 6 n Environmental Health 131

1. Knowledge of environmental health concepts is
essential to nursing practice.

2. The Precautionary Principle guides nurses in their
practice to use products and practices that do not
harm human health or the environment and to take
preventive action in the face of uncertainty.

3. Nurses have a right to work in an environment that
is safe and healthy.

4. Healthy environments are sustained through multi-
disciplinary collaboration.

5. Choices of materials, products, technology, and
practices in the environment that impact nursing
practice are based on the best evidence available.

6. Approaches to promoting a healthy environment
respect the diverse values, beliefs, cultures, and
circumstances of patients and their families.

7. Nurses participate in assessing the quality of the
environment in which they practice and live.

8. Nurses, other health care workers, patients, and
communities have the right to know relevant and
timely information about the potentially harmful
products, chemicals, pollutants, and hazards to which
they are exposed.

9. Nurses participate in research of best practices that
promote a safe and healthy environment.

10. Nurses must be supported in advocating for and
implementing environmental health principles in
nursing practice.

BOX 6–1 n ANA’s Principles of Environmental
Health for Nursing Practice

Environmental assess-
ment determines: “Why
was the agent present
in the environment
in such a way that
the host could
be exposed?”

Interaction between
host and environment

Interaction between
agent and environment

Epidemiology deter-
mines: “Who was

exposed?” “When?”
“Where?” “How?”

Interaction between host and agent

Epidemiology determines: “What disease?”
Lab identifies and/or confirms agent.

Environment
(EHS-Net)

Agent Host

Figure 6-2 Environmental health specialists and the
epidemiologic triangle.

Source: (11)

7711_Ch06_128-156 21/08/19 11:03 AM Page 131

The Built Environment
The built environment, the human-made surroundings
created for the daily activities of humans, reflects the
range of physical and social elements that make up a
community.14 Scientists are examining how the structure
and infrastructure of a community facilitate or impede
health. Poor communities often have a built environ-
ment with limited resources, higher pollution, poorer
maintenance of buildings, fewer options for outside ac-
tivities, a smaller selection of goods (including groceries),
and limited transportation, all leading to poorer health
(e.g., lead poisoning, asthma, cancer). There is consider-
able interest in examining how communities can modify
their built environment to promote the health of the
community residents.14,15

An example of the relationship between the built
environment and health is obesity. There is strong
evidence that aspects of the built environment, such as
food availability and access to recreational opportuni-
ties, are associated with obesity.10 Many programs have
been instituted to help reduce the epidemic of obesity
in the United States with growing evidence of the com-
plexity of the built environment including the role not
only of walkability but air pollution.16

Hazardous Substances
The probability that individuals will be adversely affected
by a hazardous substance depends on three major fac-
tors: (1) its inherent toxicity, that is, ability to cause harm
to humans; (2) whether it enters the body and reaches
susceptible organs; and (3) the amount that is present.
Toxicologists are fond of summarizing the teaching of
Renaissance alchemist Paracelsus with the phrase “the
dose makes the poison.” In other words, it is very impor-
tant to recognize that the mere presence of an agent, even
if it is known to have toxic properties, does not necessar-
ily mean there is a risk to health. For example, we know
that lead can harm several organ systems (as presented
in an example later in this chapter). However, it must
first be ingested or inhaled, or it will not reach the organs
that are sensitive to its effects. When an x-ray technician
uses a lead apron for protection from radiation, lead is
serving a helpful function and will not cause toxicity to
the gastrointestinal, nervous, or hematological system
because it is not in a form that allows it to be absorbed.
However, if lead is heated and the fumes are inhaled, or

132 U N I T I n Basis for Public Health Nursing Knowledge and Skills

n EVIDENCE-BASED PRACTICE
Obesity and the Built Environment

Practice Statement: An increasing number of studies
have documented that obesity, which has reached
epidemic proportions in the United States, is related
to several aspects of the built environment.17-19

Targeted Outcome: Reduction in prevalence of obesity.
Evidence to Support: The same risk factors that
promote weight gain in individuals—increased caloric
intake and decreased physical activity—apply on a
larger scale to populations. Several measures have been
used to describe the risk factors for obesity, but the
evidence continues to point to the influence of the
built environment on diet and activity.17 For example,
physical activity is associated with community attributes
such as road connectivity, presence of sidewalks, avail-
ability of safe play areas, and residential density. Dietary
influences include the number and proximity of fast-
food restaurants, availability of healthy food choices,
and the cost of food. Specific risk factors may differ
between urban and suburban settings, but the relation-
ship between the built environment and obesity per-
sists in both.18 Disparity in obesity prevalence based on
race and socioeconomic status may in part be associ-
ated with the built environment.19

There are many resources available to communities
to address factors related to diet and the built environ-
ment. The recommendations include the following
interventions at the community level:

1. Improve availability of affordable healthier food and
beverage choices in public service venues

2. Improve geographical availability of supermarkets in
underserved areas

3. Improve availability of mechanisms for purchasing
foods from farms

4. Provide incentives for the production, distribution,
and procurement of foods from local farms

5. Discourage consumption of sugar-sweetened
beverages

To address factors related to physical activity and
the built environment, communities should:

1. Increase opportunities for extracurricular physical
activity

2. Improve access to outdoor recreational facilities
3. Enhance infrastructure that supports walking
4. Support locating schools within easy walking

distance of residential areas
5. Improve access to public transportation
6. Enhance traffic safety in areas where people

are/could be physically active20-22

7711_Ch06_128-156 21/08/19 11:03 AM Page 132

if chips of lead paint are ingested, then there is a definite
risk of lead poisoning. Many other substances, such as
solvents, can enter the body through skin contact. These
three pathways or routes of entry—ingestion, inhalation,
and dermal absorption—differ in their importance ac-
cording to the specific substance. Also, do not be fooled
into thinking a substance is not hazardous just because
its effects are not seen immediately. Cancer, for example,
often develops many years after an exposure occurs.
These time lags, known as latency periods, can interfere
with our ability to identify cause-and-effect links and
hamper our ability to anticipate and prevent negative
health effects.23

Exposure Risk Assessment
The process used by policy makers and other regulators
to evaluate the extent to which a population may suffer
health effects from an environmental exposure is called
exposure risk assessment. Exposure risk assessment
involves four steps: (1) hazard identification (described
in more detail later); (2) dose-response assessment (based
on experiments that look for a correlation between an
increase in harmful effects and an increase in quantity
of a substance); (3) exposure assessment (consideration
of the level, timing, and extent of the exposure); and
(4) risk characterization. This last step brings together
the information from the first three steps to guide a
judgment about the risk of health problems to those
who are exposed. That judgment is never without its
uncertainties.

Types of Exposures
Environmental exposures can be broadly categorized as
chemical agents, biological agents, physical hazards, and,
perhaps less commonly recognized, psychosocial factors.
To identify a hazard, we are interested not only in what
agents are present but also whether (and how) they can
affect human health.

Chemical Agents
Examples of chemicals are easily named, and many
are well known for their dangers to human health. For
example, carbon monoxide is produced by combustion
and is typically encountered in automobile exhaust and
home-heating emissions. Specific metals and pesticides
affect many body systems, sometimes accumulating
in the body and, because they release over time, per-
petuating their effects over a long period of duration.
Lead, for example, is stored in the bone, where it can
slowly release over time to cause deleterious health
effects long after the actual exposure has occurred. As

a final example, environmental cigarette smoke contains
thousands of chemicals, some of which are associated
with cancer.

Although we have knowledge of the actions of some
of the chemicals that are in current use, these represent
only a minor proportion of those that might be toxic.
There are more than 80,000 chemicals in use worldwide,
some natural and some made by humans. The Agency
for Toxic Substance and Disease Registry (ATSDR)
provides detailed information on chemicals. Using their
portal, you can search out information on chemicals and
how they may affect health.24

Biological Agents
The category of biological agents clearly includes infec-
tious agents that are well known to nurses, such as
bacteria, viruses, and other organisms such as rickettsia
(Chapter 8). However, there are many others. Some
molds are known to have effects on the respiratory sys-
tem and possibly other more systemic outcomes. Also,
there are many documented hazards associated with
plant and animal contact. Toxic plants and fungi such as
poisonous mushrooms and inedible plants are not always
thought of as environmental hazards. Likewise, allergens
such as dust mites, cockroaches, and pet dander are
serious but often unrecognized sources of biological
hazards.

Physical Agents
Even more varied are the hazards classified as physical
agents, defined as those responsible for the injurious
exchange of energy. Examples include heat and cold, all
forms of radiation, noise, and vibration. Other physical
forms of environmental risk for bodily injury include
events such as falls, vehicle crashes, and crush injuries,
as well as hazards associated with violence, such as knife
or gunshot wounds (see Chapter 12). These are environ-
mental hazards that nurses and the public health system
work to prevent and mitigate.

Psychosocial Factors
Finally, psychosocial factors form a category of environ-
mental risk to health that is less frequently included in
a formal environmental risk assessment. However, it is
important to recognize that communities and individuals
that live in fear or experience stress, panic, and anxiety
associated with real or perceived threats are subject to
psychosocial conditions that affect not only health and
safety but also overall well-being. These must be consid-
ered in a comprehensive assessment of environmental
determinants of health.

C H A P T E R 6 n Environmental Health 133

7711_Ch06_128-156 21/08/19 11:03 AM Page 133

Mixed Exposures
Rarely do environmental hazards exist independently.
Almost all scenarios that pose environmental risks to
health combine more than one threat, and these combi-
nations often act synergistically to raise the level of dan-
ger. Chemicals usually exist as mixtures, as is the case
with cigarette smoke, which contains at least 70 carcino-
gens.25 Interaction and a subsequent increase in hazard
may also occur when different agents are combined. For
example, noise (a physical hazard) in the presence of
some chemicals may result in what is called ototoxicity.
Ototoxicity is damage to the inner ear, that results
due to exposure to pharmaceuticals, chemicals, and/or
ionizing radiation.26 An additional example is the danger
related to combining household products. Mixing clean-
ing agents that contain ammonia with others containing
chlorine leads to the production of chloramines, which
are much more toxic than ammonia or chlorine alone.

The Environmental Health History
Understanding environmental exposures and the detri-
mental health effects they can cause is only one step
along the way to protecting the health of individuals,
families, and communities. That knowledge must then
be applied to strategies to effect change. The amount of
exposure to an environmental risk varies based on the
proximity to the exposure. Those that occur in the work-
place are often more concentrated than those in the
general environment. This reflects two key components
of environmental exposure to hazardous substances:
time and location.28 At the individual level, an environ-
mental exposure assessment begins with time and place.
An assessment should include three components: an
exposure survey, a work history, and an environmental
history.28 The exposure survey reviews any exposures
past and present as well as exposures for members of
the household. The work history asks about presence of
hazardous substances in the workplace, and the envi-
ronmental history includes potential exposure within
the community. 28

These questions are only guidelines and should prompt
further questions when appropriate. Actions required to
address environmental health hazards often raise the
ethical question of when to choose the public good over
individual rights. For example, in the case of lead poison-
ing, should homeowners and landlords be required to
pay for the cost of lead abatement? Another example is
the ban on smoking in public places. The ban reduces the
population’s exposure to the harmful effects of secondary
smoke yet limits the rights of individual smokers.

134 U N I T I n Basis for Public Health Nursing Knowledge and Skills

n CULTURAL CONTEXT OF OUR
ENVIRONMENT

Our culture influences how we live within our environ-
ment as well as how we view the importance of that
environment. Consider the practice of Fung Shui, based
on the concepts of Yin and Yang that influences how
objects are placed within a home to help positively
affect the energy flow. In a classic article Goodenough
addressed the problem of possible conflict between
how a professional might perceive a specific environ-
ment and how those living in that environment may
perceive it. He stated that “…the environment in which
people live is a part of their culture.”29 Thus those liv-
ing in a community may have specific perceptions about
their environment that is different from professionals
sent in to evaluate the environment from a health per-
spective. Therefore, as stressed by Goodenough, it is
important to account for the cultural perception of the
environment through the eyes of those living in the
community when conducting an environmental health
assessment and to be aware that your cultural percep-
tion may differ from that of the community. This opens
the opportunity for communication and partnership
with a community when working to improve the health
of an environment.

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Peeling Paint
Public Health Science Topics Covered:

• Screening
• Case finding
• Advocacy
• Policy

Jane, a nurse working at a county health department
based in a large, urban, midwestern city, was asked to
participate in the county lead-screening program to
identify families exposed to lead in their environment.
The usual method for determining if a child has been
exposed to lead is to screen for the amount of lead in
blood, which is referred to as the Blood Lead Level
(BLL). Measurement of BLLs is done in micrograms
of lead per deciliter of blood (μg/dL). Based on recent
surveillance data, i.e., the percent of children under
the age of 5, it appeared that not all of the children
in the high-risk neighborhoods had been tested. Due
to the higher percent of children with confirmed BLL
of ≥10 μg/dL in the county, the health department felt
it was important to once again initiate an outreach

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C H A P T E R 6 n Environmental Health 135

program to get children tested. The goal of this sec-
ondary prevention screening program was twofold:
(1) to identify current cases and initiate medical man-
agement if needed and (2) to identify what measures
should be taken to prevent further harm to children in
these families and other community members.

Jane began her review of the problem with Healthy
People (HP) 2020 objective EH-8-1: “To reduce BLL
in children aged 1–5 year”. She found that the method
for measuring BLL in children was revised in 2014.
The baseline measure was 5.8 μg/dL with a target of
5.2 μg/dL. The objective was that the concentration level
of lead in blood samples would be below the baseline
measure for 97.5% of the population aged 1-5 years.
This would reflect a 10% improvement.7

She then reviewed the HP 2020 midcourse review
to determine if the target had been met at the national
level. The report stated that: “The concentration level
of lead in blood samples at which 97.5% of children
aged 1–5 years were below the measured level (EH-8.1)
decreased from 5.8 µg/dL in 2005–2008 to 4.3 µg/dL in
2009–2012, exceeding the 2020 target (Table 12–2).” 8

Now that she had information at the national level,
she began examining the surveillance data at the county
level available on the CDC Web site.30 She found that,
of the 7,031 children tested in 2015, 6% were above
the desired level and 1.3% had confirmed BLL 10 μg/dL
or higher (see Table 6-1). In comparison to national
levels, the county was not meeting the HP 2020 target.
She then accessed the current county data and found
that the percent of children with a BLL above the
desired level had increased to 7.5%, a concerning
trend. In addition, 2% of children had confirmed BLLs
of 10 μg/dL or higher. She was also surprised to see
that, based on the most recent population estimates,
the total number of children aged 5 or younger in the
county was 56,967. Thus, only about 12% of all children
had been tested. If the target population was those
living below the poverty level, the county had still
come up short in the testing program because 16% of
households in the county were living below the poverty
level. In addition, she was aware that, with new gentrifi-
cation of older neighborhoods, the risk for exposure
might not be limited based on income. Based on these
data she began to develop a lead poisoning outreach
screening program for the county.

In the case of lead, a well-known hazard to children,
screening in this program consisted of measuring the
concentration of lead in the blood to estimate the
amount of lead that had been absorbed into the body,
and at the same time providing all the parents with

health education information about lead. Jane used the
current CDC recommendations on childhood lead
poisoning prevention guidelines in relation to BLL that
would require initiation of prevention measures. The
prior BLL that triggered interventions was 10 to
14.9 μg/dL but was changed in 2012 to a BLL value of
5 μg/dL based on evidence that even lower levels
of exposure increase the risk for adverse health
outcomes in children (Fig. 6-3).31

Jane then reviewed the 10 approaches to interven-
tion related to lead poisoning provided by National
Center for Healthy Housing (Box 6-2).32 Many of the
recommendations would need action at the county
level, but policy items seven and eight matched the use
of public health nurses (PHN) in an outreach home
visit program. These two items were: (7) Improve
blood lead testing among children at high risk of
exposure and find and remediate the sources of their
exposure; and (8) Ensure access to developmental and
neuropsychological assessments and appropriate high-
quality programs for children with elevated blood lead
levels. For item seven, for children with a BLL value
of 5 μg/dL or higher, a home visit would allow for an
assessment of the home environment and teaching
parents to remediate any sources of exposure as
well as connect parents with resources to assist with
remediation especially for renters. For item eight, a
home visit with children with a BLL value of 10 μg/dL
or higher would allow for further assessment of the
child and assist parents in obtaining high quality programs
for their children. Jane’s work to not only research the
problem, but also to seek funding for a program for
addressing the issue, is an excellent example of nurse
advocacy related to environmental health issues as
listed in the previously mentioned ANA report.11

In the home visiting program Jane designed, parents of
children screened with a BLL value at or above 5 μg/dL
received a home visit from a PHN and were provided
with an environmental assessment of their home,
education regarding dietary and environmental actions
to reduce the lead poisoning, and help with lead abate-
ment in their homes if needed. The home visit also
included providing the parents with information on
their legal rights as tenants/homeowners. They were
also provided with follow-up BLL monitoring for their
child. If a child in the home had a BLL value at or above
10 μg/dL, the PHN would provide the parent with in-
formation on how to access the resources they would
need for further developmental assessment. The PHN
would also provide information about on-going inter-
vention as needed based on the severity of the BLL.

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136 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Number of children tested
Percent of children with BLLs �5 µg/dL
Percent of children with confirmed BLLs �10 µg/dL

N
um

be
r

of
c

hi
ld

re
n

te
st

ed

B
LLs as %

children tested
U.S. Totals Blood Lead Surveillance, 1997–2014

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

4,500,000

4,000,000

3,500,000

3,000,000

2,500,000

2,000,000

1,500,000

1,000,000

500,000

0

8.00%

7.00%

6.00%

5.00%

4.00%

3.00%

2.00%

1.00%

0.00%

Figure 6-3 U.S. Totals Blood Lead Surveillance, 1997-2014. Comparison of the number tested with the percentage
confirmed. (From the Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/nceh/lead/data/Website_
StateConfirmedByYear_1997_2014_01112016.pdf.)

While the health department mounted a screening
campaign for lead poisoning, Jane and other PHNs at
the health department began conducting the home
environmental assessments for all children who had a
BLL ≥5 μg/dL. They were all experienced in conduct-
ing home visits. They understood that, to achieve the
goals of the program, that is, to reduce lead exposure
in the home and assist parents in accessing resources
for their children, it was important to conduct the
home visits using basic principles. First was to under-
stand that they were guests in the family’s home. Next,
it was important to identify the parent’s concerns as a
first step toward forming a partnership with the parents.
To meet the goals of the program they would explain
to the parents changes they could make to reduce
exposure and obtain assistance. The best approach is

to use motivational interviewing skills (Chapter 11).
The four principles that they routinely employed in
their home visits were: (1) expressing empathy for a
client or parent’s point of view; (2) supporting self-
efficacy by highlighting a client’s or parent’s success at
solving problems in the past; (3) remembering to roll
with any resistance they may encounter by helping the
client or parent define the problem and seek their own
solutions; and (4) developing discrepancy, which they
knew could be accomplished through helping a parent
or client examine the difference between current
behavior and future goals.33

Based on the findings of their assessments, the PHNs
assisted parents who were found to have lead-based
paint in their homes or apartments to engage the
county level coordinated abatement efforts. The PHNs

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C H A P T E R 6 n Environmental Health 137

1. Reduce lead in drinking water in homes built before
1986 and other places children frequent.

2. Remove lead paint hazards from low-income housing
built before 1960 and other places children spend
time.

3. Increase enforcement of the federal Renovation,
Repair, and Painting (RRP) rule.

4. Reduce lead in food and consumer products.
5. Reduce air lead emissions.
6. Clean up contaminated soil.
7. Improve blood lead testing among children at high

risk of exposure, and find and remediate the sources
of their exposure.

8. Ensure access to developmental and neuropsycho-
logical assessments and appropriate high-quality
programs for children with elevated blood lead levels.

9. Improve public access to local data.
10. Fill gaps in research to better target state and local

prevention and response efforts.

BOX 6–2 n Policies to Prevent and Respond
to Childhood Lead Poisoning

also educated parents and others in the home about
how to prevent further lead exposure. Together the
PHNs developed a community level education program
about lead poisoning and how the health department
and community could work together to eliminate lead
exposure. With extensive interventions the health
department hoped to meet the Healthy People targets
related to lead poisoning in children aged 5 and under.

Prior to making her first home visit, Jane reviewed
the pathophysiology of lead poisoning in children. She
found that young children are at greater risk because
they are more likely to ingest materials containing lead
and absorb more of the lead when it is ingested. A
child or fetus is especially vulnerable to the effects of
lead and many other toxic substances because their
developing organ systems are at high risk of damage.
Toddlers are more likely to put items contaminated
with lead, such as paint chips, in their mouths, making
screening most useful at 1 and 2 years of age. Ingestion
of lead, the most common route, can have an irreversible
negative effect on the child’s developing central nervous
and hematopoietic systems. Thus, children exposed
to lead can have lifelong health issues. Even with low
levels (<5 μg/dL) a child’s cognitive and behavioral
development can be slowed, resulting in learning
disabilities.33 Children with high levels of lead are at
increased risk for serious effects such as encephalopathy

marked by seizures and even coma. These effects can
lead to long-term, sometimes irreversible damage. In
contrast, the more mature central nervous system of
adults is better protected from the effects of lead
so that damage to peripheral nerves, rather than the
central nervous system, is more likely. Inhalation rather
than ingestion is the more common route for lead
poisoning in older children and adults.34

Jane was assigned to conduct a home visit with the
family of a 2-year-old child who had a BLL of 13 μg/dL.
Bobby and his family lived in an older building in one
of the poorest sections of the city. As Bobby’s mother,
Sharon, greeted her at the door, Jane noticed that
overall the apartment needed major maintenance with
older appliances and walls that had not been painted in
a while. Due to the initial purpose of the visit, she
began her visits with Sharon by letting her know that
she was doing the follow-up on Bobby’s positive lead
screening that Sharon had requested after getting the
results of Bobby’s BLL test. Remembering the value of
using a motivational interviewing approach, Jane began
the conversation by asking Sharon what her concerns
were and what goals she had. Sharon stated that she
was very upset not just about Bobby but her older
child. She said that she and her husband were struggling
to make ends meet and they took this apartment
because they could afford it, but now she found that
there were many problems and their landlord was not
responsive. Jane repeated back to Sharon what she had
heard, that Sharon was worried about her other child,
and she was concerned about the condition of the
apartment.

Jane encouraged Sharon to tell her a little more
about herself and her family so that she could help
her address her two concerns, the health of her
children and how to correct some of the issues with
the apartment. Sharon told Jane that she had rented the
apartment for a little more than a year and lived there
with her husband and their two children, 2-year-old
Bobby and another child in first grade. Sharon held
Bobby in her lap for the first half of the interview,
but Bobby got restless and slid off of her lap to play on
the carpet. Jane built on Sharon’s concerns about her
children and suggested that Sharon give her a tour of the
house to see where the lead might originate.

Jane used her knowledge of environmental risks
associated with lead poisoning in children to guide her
assessment. In the United States, leaded gasoline and
paint were both banned around the same time in the
early 1970s. Thanks to these policy interventions,
average BLLs in children have been steadily dropping.34

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138 U N I T I n Basis for Public Health Nursing Knowledge and Skills

However, the threat remains serious especially in
communities with a large number of older homes and
lead water pipes such as the serious problem in Flint,
Michigan.35, 36 Jane wondered how Bobby became
poisoned with lead despite the new regulations. Lead
poisoning is a good example of environmental risks in
the built environment. Although lead paint has been
banned, buildings built before 1978 often contain
lead paint. Many cities have initiated lead abatement
programs to remove this paint. This population-based
policy approach to the problem is one of the best
examples of how legislation can improve public and
environmental health.37 However, not all cities have
successfully removed all lead paint from city residential
buildings, and it is especially problematic in the poorer
neighborhoods where older buildings are not well
maintained.

Jane learned that Bobby played with his toys on
the floor of a room in which the paint was peeling
from the windowsills. Suspecting that lead-based paint
was largely responsible for the child’s elevated levels,
she noted the condition of all of the house’s painted
surfaces and found that many of them were chipping,
especially on the baseboards and windowsills, and
marred with tooth marks (Fig. 6-4). Paint in older
homes is known to be high in lead content, and its
availability to a child is a strong indication that the paint
is a major source of exposure. Even children who do
not directly ingest the peeling paint are at major risk of
exposure from lead dust that sloughs from the painted
surfaces and contaminates floors and toys that, through
the common hand-mouth behavior of children, are
ingested or inhaled.

Based on the results of her home environment
assessment, Jane explained to Sharon how Bobby
probably ingested the lead, primarily through the paint
chips. Sharon wondered how the lead paint could be
removed. Jane explained that there were steps that
could be taken with the landlord to remove the lead-
based paint; because precautions are needed when
doing any removal or work on painted surfaces in
homes built before 1978, it would need to be carefully
done. However, there were steps Sharon could take
now to reduce paint chips and airborne particulates
including keeping the apartment clear of paint chips
and dust, and keeping it well ventilated.

Jane asked Sharon if she would like to set up an
appointment with technicians from the health depart-
ment who would come to the home to verify and
measure the lead content of the paint and help Sharon

identify sources for assistance with the removal of lead
from her home. Sharon readily agreed and expressed
relief that someone would help her remove the threat
to her children. Jane commended Sharon on all the
steps she had previously taken to attempt to address
the peeling paint in the apartment. Jane further explained
that, depending on the state of the home, it might be
necessary to physically abate the exposure by entirely
removing the paint, which means moving the family
either temporarily or permanently to a more suitable,
lead-free living environment. Jane explained that there
were resources through the county public health
department and the housing authority to help the
family if this step was necessary.

Remembering Sharon’s other goal, Jane asked
Sharon about Bobby’s health. Sharon reported that he
complained occasionally of stomach pain, but she was
surprised by the elevated BLL because she had seen no
real symptoms of lead poisoning. Jane explained that
frequently there are no signs of poisoning and that the
results of the poisoning take time to manifest. That is

Figure 6-4 Removal of baseboards with lead paint. (From
CDC/Aaron L. Sussell, 1993.)

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C H A P T E R 6 n Environmental Health 139

why screening is so important. Jane suggested that
Sharon take Bobby for a full checkup at the county’s
child health clinic or with the child’s local provider,
and that Sharon and the older child should also be
screened for lead poisoning. Pregnant women with high
lead levels can transmit lead to their unborn children
because it crosses the placental barrier, and lead can
also be transmitted in breast milk, affecting both
mother and unborn child. Jane also explained that
stomach pain can be a sign of lead poisoning and urged
Sharon to tell the doctor about Bobby’s complaints.

To facilitate the process of setting up an appoint-
ment, Jane used what is called a warm handoff. This
is used in health care as a means for transferring care
between two members of the health-care team, in this
case the visiting PHN and the primary care provider
who would be able to further assess Bobby for lead
poisoning and begin treatment if needed. As in this case
the warm handoff is done in front of the patient and
family. Together Jane and Sharon set up these appoint-
ments. In addition, Jane helped Sharon identify the best
means for transportation to the appointment. Jane and
Sharon then put together a plan that set mutual goals
and a timeline for managing the lead poisoning.

At this point, Jane noticed that Sharon still seemed
worried. When prompted, Sharon said she had heard
about lead poisoning but did not understand what it
meant to her and her children. Jane went over the
relationship between lead in the home environment
and children’s health in more detail and explained to
Sharon that Bobby’s BLL was of concern, and that the
trip to the clinic would provide her with more informa-
tion on Bobby’s health status. Jane commended Sharon
for having Bobby screened and explained that early
intervention can help mitigate the effects of lead
poisoning.

Sharon said that she had talked with the landlord
about the apartment because of what she had seen on
the news about lead poisoning and was assured that
there were no problems. She also explained that her
sister lived in the same building. Jane knew that finding
an elevated BLL in one child had uncovered an environ-
mental hazard that could affect all of the tenants in the
building, especially the children. The affordability of the
apartments and proximity to the school resulted in the
building being home to many young families. Jane was
aware that the environmental hazard also extended to
mothers in the building who were pregnant or breast-
feeding their babies. When questioned, Sharon stated
that she had not received any information on the

potential of lead paint in the apartments as required
by law.

Jane was concerned about Sharon’s story that the
landlord had assured her that there were no environ-
mental problems in the apartment. It is against federal
law for landlords to withhold information on environ-
mental hazards in their buildings.38 Specifically, to meet
the federal requirements, landlords renting apartments
in buildings built prior to 1978 must inform tenants
about potential lead paint hazards prior to signing a
lease.

Jane was also concerned about the other children
living in the building, because this was the only child in
the building who had been screened. This resulted in
two different levels of action. First, from an advocacy
perspective, Jane reported the landlord for failure to
disclose the fact the apartment contained lead paint
and began to explore alternative housing for the young
families living in the building. Second, she implemented
her role of case finding. She asked Sharon whether she
would introduce Jane to her sister and her neighbor,
and help get all the children in the building screened.
Thanks to Sharon, a few more of the children in the
building were screened, and two of the children had
elevated BLLs. Jane recommended further outreach
to get all the children in the building screened and
helped to put together an on-site screening day at the
apartment building. Meanwhile, the health department
and the housing authority for the city worked to en-
sure that the landlord performed lead abatement in the
apartment complex and insured that he followed the
federal guidelines informing renters before signing a
lease of potential lead exposure.

Before ending her visit with Sharon, Jane explained
steps that Sharon could take now to protect her family
from further lead poisoning. She went over cleaning
methods that included mopping hardwood floors with
a weak bleach dilution to remove the dust, frequently
wiping windowsills with a damp cloth, vacuuming with
high-efficiency particulate air (HEPA) filters, and ensur-
ing that the children are kept away from areas with
active chipping and peeling paint.39

Jane also reviewed a secondary prevention strategy
with Sharon that she could use to reduce the amount
of lead a child absorbs and increase the amount
excreted by providing a calcium-rich, high-iron,
vitamin C–containing diet. Jane was aware that this
might be more difficult for some families than for
others. Impoverished areas, which represent low-
income residents and poor social conditions, can be

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140 U N I T I n Basis for Public Health Nursing Knowledge and Skills

thought of as “food deserts” where access to afford-
able healthy food is greatly limited. Jane confirmed that
Sharon was enrolled in the local Women, Infants, and
Children (WIC) supplemental nutrition program and
had access to the foods needed to implement this
strategy.

Due to her involvement in this lead poisoning
outreach program, Jane became very interested in
primary prevention for lead poisoning. It was clear
that, although screening was important, it would be
much better to prevent the problem in the first
place. She became interested in the wider issue of
the health of the built environment. Jane found that
the main primary prevention approach is lead abate-
ment, which is removal of lead-based paint in the
home or workplace. As of April 22, 2010, a federal
law went into effect that required that all contractors
doing renovations, repair, or painting that disturbed
more than 6 square feet in homes, schools, and child-
care centers be certified in lead abatement.38 Jane
found multiple state and municipal regulations that
focused on reducing exposure to lead paint, lead
paint dust, and soil contaminated from exterior lead-
based paint.

Despite all the regulations, Jane discovered that one
of the big stumbling blocks to starting a successful lead
abatement program in her county was cost. Because
of the seriousness of exposure to lead, the federal
government and states have strict lead abatement
regulations that result in labor-intensive measures and
require the use of specialized equipment. The high cost
of abatement raises the question of whether the cost
outweighs the benefit, and illustrates a common public
health ethical issue of determining whether the benefits
of a costly abatement program outweigh the rights of
the individual homeowner or landlord to choose not
to remove lead paint from a building.

n CELLULAR TO GLOBAL
Bobby’s lead exposure illustrates the fact the lead
poisoning and health occur from the cellular level up
to the global level. At the individual level, it enters the
body through either the oral or respiratory route
and ultimately causes permanent harm. However, lead
exposure occurs because of the presence of lead in the
ambient environment—primarily in paint and dust. In
Bobby’s case the lead was in a form that resulted in
ingestion as the most probable route of exposure,
especially given the hand-mouth behavior of a small

child. Yet the presence of lead and efforts to eliminate
it require interventions that start at the individual level
and expand to the global level. Lead poisoning is not
confined to the U.S. Globally, in 2015, there were
494,550 lead-exposure associated deaths. In addition,
there was a loss of 9.3 million DALYs due to the long-
term effects lead has on health. The burden is highest
in low- and middle-income countries.40 In Bobby’s case
the source of the exposure was the built environment.
Globally there are a number of other possible sources
of exposure including traditional cosmetics, medicines,
and lead-coated dishes and food containers. The WHO
is working to eliminate lead poisoning via the global
elimination of lead paint to meet Sustainable Develop-
ment Goal target 3.9: “By 2030 substantially reduce
the number of deaths and illnesses from hazardous
chemicals and air, water, and soil pollution and contam-
ination”; and target 12.4: “By 2030, achieve the envi-
ronmentally sound management of chemicals and
all wastes throughout their life cycle, in accordance
with agreed international frameworks, and significantly
reduce their release to air, water, and soil to mini-
mize their adverse impacts on human health and the
environment.”40

Environmental Justice and the
Environment
Economically disadvantaged populations and other
vulnerable populations (see Chapter 7)—whether as a
result of low income, social class, racial or cultural dif-
ferences, age, health status, or other social indices of
susceptibility—are frequently at greatest risk of exposure
to environmental hazards. Vulnerable populations face
challenges such as substandard housing, lack of access
to health care, diminished resources such as nutritious
food and safe places to play, poor working conditions,
and absence of clean air and water. Those who are employed
tend to work in riskier jobs. Disadvantaged communities
tend to be located near industrial areas, highways, and
rail transportation routes where certain types of cargo
and exhaust pose dangers and where hazardous waste
disposal sites exist.41,42 Environmental justice refers to
fair distribution of environmental burdens.41 According
to the EPA definition, it also refers to fair application of
environmental laws, policies, and regulations regardless
of race, color, national origin, or income.42

Social disadvantage can result in increased exposure to
environmental risks as well as an increased susceptibility

7711_Ch06_128-156 21/08/19 11:03 AM Page 140

to the risks.43 Recognizing the link between environmen-
tal health and social determinants of health, the WHO
has the Department of Public Health, Environmental
and Social Determinants of Health. The goal is to reduce
both environmental and social risk factors (Box 6-3). For
example, they have worked to promote safe household
water storage and to manage toxic substances in both
the home and the workplace. They work closely with the
United Nations’ sectors on energy, transport, and agri-
culture. They state that reduction in environmental and
social risk factors would prevent nearly a quarter of the
global burden of disease.43

C H A P T E R 6 n Environmental Health 141

This department advocates at the global and national
level for the improvement of environmental health
through its influence on policy. It accomplishes this by:

• Assessing and managing risks (such as from outdoor
and indoor air pollution, chemicals, unsafe water, lack
of sanitation, ionizing and nonionizing radiation) and
formulating evidence-based norms and guidance on
major environmental and social hazards to health.

• Creating guidance, tools, and initiatives to facilitate the
development and implementation of policies that
promote human health in priority sectors.

BOX 6–3 n World Health Organization:
The Department of Public Health,
Environmental and Social Determinants
of Health

w SOLVING THE MYSTERY
The Case of the Hazardous House
Public Health Science Topics Covered:
• Assessment
• Health planning
• Program evaluation

The work done by Jane and her team on the lead
screening outreach program resulted in the nurses
identifying other environmental risk factors in the
home, especially those associated with an increased
risk of asthma. Jane and the other PHNs who worked
on the lead poisoning outreach program initiated a
county health department safe home program focused
on asthma in collaboration with the school nurses
(Chapter 18), the local Parent-Teacher Association
(PTA), and the county pediatric hospital. The program
was initiated because of increased prevalence of

childhood asthma, lost school days for asthmatic
children, and increased emergency department (ED)
visits for acute asthma attacks. They were able to
provide evidence that a home assessment program is
a viable intervention that can help address the problem
of uncontrolled asthma in children.44

First, the PTA and the school nurses conducted a
campaign to promote the benefits of having a PHN from
the public health department visit the homes of children
with asthma to provide an environmental assessment,
additional health education, and links to resources. The
program contained three steps: (1) referral, (2) home
inspection, and (3) development of a home safety plan.
All students with asthma were referred to the health
department PHN asthma team, who then contacted
the parents of the children. The PHNs offered to
provide an environmental assessment for possible
pollutants in the home. When invited, the PHN con-
ducted a home visit that focused on residential health.

The team developed a protocol for conducting
these home visits based on the Healthy Homes Manual
developed by the CDC in 2006.45 Each visit began by
explaining to family members that the PHN was using
an assessment tool that had been adapted by the health
department that was specifically designed to identify
health hazards in the home in their area. Following the
motivational interviewing principle used in the lead
screening outreach program previously discussed, the
PHN invited them to participate in the review of their
home as full partners and began by asking them to
share their goals and concerns.

The team felt it was important to allow time at the
beginning of the visit for parents to list the concerns
they had as well as commend them for all they were
currently doing to address their child’s asthma. This
helped establish a partnership with the parents and
provided the PHN with an understanding of the
parents’ goals as well as their challenges. From there
they could mutually build an intervention specifically
targeted to maximize the use of available resources
to help improve the health of their home environment
and subsequently their child. The PHNs worked to
develop a relationship with parents that was nonjudg-
mental and that would help empower the parents with
the knowledge and access to resources they needed
to help reduce possible environmental risk factors
for childhood asthma and to improve access to
adequate care.

On one visit Jane met a family with a 7-year-old boy,
Joshua, who had repeated asthma attacks, multiple
absences from school, and an increasing number of

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142 U N I T I n Basis for Public Health Nursing Knowledge and Skills

ED visits. The family lived in a three-bedroom apartment
in a 300-unit building in an inner-city neighborhood in
New York State. There were other children in the
home not in school: a 4-year-old, a 2-year-old, and a
newborn. The mother, Betsy, reported that the 4-year-
old was also being treated for asthma and that the
other two children had frequent colds. When Jane
asked Betsy about her concerns, Betsy shared that she
was very concerned about all the missed school days.
She was also exhausted by all the trips to the ED.
Although she had been able to sign up for the Chil-
dren’s Health Insurance Program (CHIP) that helped
reduce the cost, getting to doctor’s appointments was
difficult with three other small children. She didn’t have
a car and her husband worked long shifts. She often
had to cancel appointments because she didn’t have
anyone to watch the other two children. Often when
Joshua had an attack it meant she had to rush him to
the ED with three other children in tow.

Recognizing that Betsy’s focus was on access to
care, Jane spent a little more time with Betsy to talk
about their environment and the role it played in exac-
erbating Joshua’s asthma. She explained that altering
the environment might help reduce the number of
attacks severe enough to require a visit to the ED.
She also assured Betsy that she would help her find
resources such as transportation and childcare to help
her keep clinic appointments.

Betsy seemed relieved that Jane understood her
main concerns and invited Jane to begin her inspection
of the home to help identify environmental risk factors
that could be addressed. Beginning with the kitchen,
under the sink they found cockroaches and evidence of
mice. Jane noted that pesticides and cleaning products
were stored in that location and a slow dripping faucet
had resulted in an accumulation of a small amount of
water in the space under the sink along with some
mold. Betsy also kept the kitchen wastebasket under
the sink where she disposed of food scraps. Betsy
stated that she was constantly trying to deal with the
cockroaches and the mice but had not been successful.
She had not realized that the black smudges were
actually mold.

When Jane asked Betsy about whether anyone
smoked in the home, she learned that both parents
smoked. Jane also noted that there was worn wall-to-
wall carpeting throughout the apartment. When they
went into Joshua’s room he shared with his 4-year-old
brother, Jane noted the large number of stuffed animals.
With Betsy, Jane examined Joshua’s bed. Betsy explained
that there was no money for mattress protectors or

pillow covers. She also stated that, with four children,
it was difficult to get to the laundromat to wash the
sheets, so she only did them once every 3 to 4 weeks.
Jane also asked Betsy about the medications she was
using to treat Joshua’s asthma. Betsy confirmed that
Joshua needed to administer his inhaler frequently
and stated that she was careful about giving him his
medications on time and regularly.

After completing the overview of the home environ-
ment, Jane discussed her findings with Betsy. Jane com-
plimented Betsy on her adherence to the medication
plan for Joshua. Jane explained that medications are less
effective if there continue to be triggers in the environ-
ment such as cigarette smoke, dust mites, and allergens
related to vermin.46 She provided the mother with fur-
ther information on risk factors for asthma, pulling up
the CDC Web site on her tablet so Betsy could see
a review of environmental risk factors. The main risk
factors mentioned by the CDC were tobacco smoke,
dust mites, outdoor air pollution, cockroaches, pets,
and mold. The only home environmental risk factor
that was not present in this home was pets.

Jane and Betsy discussed actions the family could
take to help reduce the risk. Jane began with the
problem of secondhand smoke. She explained that this
might also explain the frequent colds experienced by
the infant.47 Jane asked Betsy whether either she or her
husband would be interested in getting help to quit
smoking. Betsy stated that they would consider this if it
would improve the health of their children, especially
Joshua. Jane gave Betsy information on resources such
as local clinics that offer services for smoking cessation.
She also encouraged Betsy and her husband to smoke
only outside the apartment in a space that was not
near where the children played or by an open window.

Jane then discussed with Betsy the issue of cock-
roaches and mice as serious health risks to families.46

Aside from producing allergens that can exacerbate
asthma, they both carry a host of bacteria and viruses
that are dangerous to people, including staphylococcus,
streptococcus, Escherichia coli, and salmonella. Another
hazard associated with pest infestation has to do with
the types of chemicals and poisons used to fight them,
such as aerosol spray insecticides and poisoned pellets,
all of which put children at risk for poisoning. Serious
health outcomes associated with pesticides include skin
disorders, damage to the nervous system, poisoning,
endocrine disruption, respiratory illness, cancer, and
death. Jane described methods other than pesticides
that Betsy could use for controlling pests within the
apartment, beginning with removing food and standing

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C H A P T E R 6 n Environmental Health 143

water. Jane described how to use a separate container
for food scraps with a tight lid that would provide a
barrier to roaches and mice. She also explained how to
store food in the pantry in plastic containers with tight
lids rather than bags or cardboard containers.

Jane again used her tablet to refer Betsy to the New
York State Health Department’s Web site on the land-
lord and tenant’s guide to pest control. Together they
reviewed steps Betsy could take and what steps her
landlord could take to address the rodent and cock-
roach issue (Box 6-4). Jane also explained to Betsy

that she could contact her local cooperative extension
service for assistance with pest control.

The practice described on the New York State
Health Department’s Web site is known as integrated
pest management, a program that includes caulking
and sealing cracks and holes larger than a 16th of an
inch, eating in one place in the home to consolidate the
area that must be cleaned, getting rid of clutter where
pests hide, storing food in containers with locking lids,
preventing the accumulation of grease, and disposing of
the trash nightly.48,49 Jane also explained about better
chemical methods for fighting pests, such as the use of
bait stations and gels that do not contaminate surfaces
or the air, rather than poisons. She gave Betsy some
mice snap traps to be used in place of the poisoned
pellets, explaining that mice carry the poison from
seemingly safe locations and drop it in places easily
accessible to her young children. Jane also handed
Betsy a brochure from the local poison control center
with a magnet for the refrigerator and a child safety
lock for the cabinets under the sink. The lock was for
immediate short-term use until chemicals were moved
to a safer site. Poisons, solvents, cleaners, and other
types of household products should always remain in
their original containers, so information contained on
the labels will be available to inform emergency care
or calls to a poison control center.

Betsy stated that her sink has been leaking for some
time, but her landlord was unresponsive to her request
for its repair. The same was true of her furnace. Jane
pulled up the New York State Tenants’ Rights informa-
tion on the U.S. Department of Housing and Urban
Development Web site for Betsy to review.50 Jane
explained to Betsy that she would write up a housing
code violation report that should result in the landlord
making these repairs.

With Betsy’s permission, Jane’s assessment of the
home expanded to included risk factors beyond those
associated with childhood asthma. In the utility room,
Jane inspected the furnace and water heater and noted
that the water heater was set to 140°F. She told Betsy
that she should always make sure the heater is set
below 120°F to prevent scalding and demonstrated
how to lower the temperature. Jane also observed
that the vent connecting the water heater to the fur-
nace was not sealed, thereby allowing the release of
combustion products, such as carbon monoxide. Jane
explained to Betsy that, just like the gas stove upstairs,
water heaters, dryer vents, and furnaces should be
regularly maintained, and the level of carbon monoxide
should be monitored. She provided Betsy with a carbon

Proper Pest Management Practices for Landlords
and Tenants:
Integrated Pest Management is geared toward long-term
prevention or elimination of pests that does not solely
rely on pesticides. Integrated Pest Management follows
the principles of preventing entry, inspecting, monitoring,
and treating pests on an as-needed basis. These principles
help manage pests by using the most economical means,
and with the least possible hazard to people, property,
and the environment. Pests thrive in environments where
food, water, and shelter are available. If an undesirable
environment is created, pests can be prevented, reduced,
or eliminated.

Using Integrated Pest Management:
• Reduce pest problems by keeping the house, yard, and

garden free from clutter and garbage. Food should not
be left uncovered on counters. Food should be stored
in tightly sealed containers or in the refrigerator.

• Keep pests outdoors by blocking points of entry.
Quality sealant or knitted copper mesh can be used
along baseboards, pipes, drains, and other access points
to seal cracks and repair holes.

• If a pest problem arises, identify the pest and the
extent of the infestation. Your local branch of Cooper-
ative Extension office can offer assistance.

• Use methods with the least hazard to people and pets,
such as setting traps/bait, or using a flyswatter or fly
ribbon paper. Bait and traps should be kept out of the
reach of children and pets.

• Remove trash on a regular basis and always use trashcans
with tight-fitting lids. If pests can get in garbage, they will
return repeatedly to get food.

• If a certified pesticide applicator is needed, be sure that
(s)he understands and follow Integrated Pest Manage-
ment principles and practices.

BOX 6–4 n New York State Landlord and Tenant
Integrated Pest Control

Source: (48)

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144 U N I T I n Basis for Public Health Nursing Knowledge and Skills

monoxide detector with an alarm that emits a warning
sound when carbon monoxide levels are too high.
Assuring good ventilation, such as turning on the fan
when cooking or making sure that a window is open, are
other actions that families can take to make sure that
the air their families breathe is as healthy as possible.

While still on the topic of alarms, Jane asked whether
the family had working smoke alarms, windows that
could be opened on each floor, and a fire escape plan.
Betsy showed Jane the smoke detector in the living room
and then led Jane down the hall to see the other one,
which she thought needed new batteries. Jane noticed
that there was an extension cord running along the hall
floor. While Jane helped Betsy change the batteries in
the smoke detector she mentioned to Betsy the hazards
associated with extension cords, including fire, tripping,
and strangulation. Betsy explained that some of the
outlets in the back rooms were not working. Jane went
over how Betsy could address this with the landlord.

The final two areas that Jane and Betsy discussed
were the problems related to dust mites and mold.
Jane suggested that Betsy add repair of the kitchen
faucet to her request to the landlord. Meanwhile,
Betsy could clean under the sink using a solution of
1/10 bleach to 9/10 water, thus eliminating existing
mold. Betsy also explained that there were multiple
sources of dust mites in the apartment including the
carpets, the stuffed animals, and the bedding. Removal
of the carpets should be added to the landlord requests.
Removal of stuffed animals might be more difficult if
the children were attached to them, but Betsy felt the
boys were growing out of the stuffed animal phase and
that she would be able to remove most of them and
regularly wash the others. Betsy explained that she
had limited money to spend on pillow case covers and
mattress covers. Together they searched the depart-
ment store Web sites on Jane’s tablet and located
stores with reasonably priced mattress protectors
and pillow covers that Betsy felt she could afford.

When the visit was complete, Jane and Betsy had
developed an action plan that included actions Betsy
could take on her own, steps that she would need to
take with help from the landlord, and the identification
of available resources in the community. Betsy was
encouraged by the resources that were available and the
assistance that Jane had provided. Jane agreed to follow
up with Betsy in 2 weeks to determine whether she
needed further assistance.

Over the course of 6 months, word spread among
the parents of the school about how helpful the PHN
visits were. Prior to starting the home visits, the PHN

asthma team and the school nurse, Edward, had devel-
oped an evaluation plan for the program (Chapter 5).
They had collected baseline data on the key outcome
indicators for children with asthma in the school includ-
ing number of days absent, use of inhalers, number
of acute asthma attacks during school, and number of
pediatric ED visits related to asthma for children living
in the school district. They also kept track of the num-
ber of visits Jane made and the time each visit took.
Based on these data they found significant improvement
for the key outcome indicators and a significant drop in
ED use for severe asthma episodes. These data helped
them demonstrate that the cost of the PHN home visits
were offset by the savings in health-care costs, the
reduction in costs related to truancy, and overall
improved health outcomes for the children.

Environmental Health and Vulnerable
Populations
Vulnerability to health risks varies across populations
based on age, gender, geographical location, and socioe-
conomic status. This also holds true for environmental
health risks especially for children and older adults.

Children
Physiological and behavioral characteristics increase
vulnerability at each step of early development. Children
playing on the ground and floor may spend their time in
the most contaminated areas. For example, outdoor soil
is often contaminated with heavy metals and pesticides,
and hand-to-mouth behavior promotes ingestion of both
seen and unseen agents. Children near parents who are
washing work clothes may be playing amid toxins that
have been carried home as particles from the workplace.
Even toys may pose a risk for exposure to toxins including
lead and cadmium.50,51 Children have ingested substances
from unlabeled food containers that have been repur-
posed to hold chemicals or were stored in an easily acces-
sible place such as under the sink.

Compared with adults, children have faster rates of
absorption of most toxic substances and, once in the body,
the toxic action can be deadlier because children have a
higher metabolic rate, a faster rate of cell growth, and less
developed immune and neurological systems. There are
equally grave concerns for fetuses, which may be affected
when a pregnant woman is exposed to toxins. Fetal body
systems are selectively more vulnerable according to their
stage of development and the timing of exposure. Although
women are increasingly aware of the risks associated with

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alcohol and environmental tobacco smoke during preg-
nancy, they are often less informed about the dangers of
other environmental exposures. In addition, a pregnancy
may not be recognized in time to avoid or minimize expo-
sures. This is especially a concern during the first trimester,
when the earliest differentiation of organ systems begins.
For example, carbon monoxide, which is easily transported
across the placental barrier, is potentially devastating to the
developing fetus because of its sensitivity to hypoxia. Other
substances that cross the placenta may accumulate in fetal
tissue, leaving the newborn to begin life with a body burden
of a toxin. In addition, breast milk can constitute an ongo-
ing source of ingested toxins because some toxins will
transfer from the mother to her milk.

Environmental factors play a role in increasing the risk
that children are exposed to toxins and infectious agents
as well as risk of injury. In agricultural settings, children
and adolescents are at risk of injuries from farm equipment
and vehicles with an agriculture-related fatality of someone
under the age of 18 occurring every 3 days.53 In urban
settings, there are often limited spaces where children can
play, and available play spaces may have faulty playground
equipment, as well as exposure to chemical and biological
waste or threats of violence (Chapter 12). An example of
increased risk in urban playgrounds is the potential for
ingestion of canine roundworms, genus Toxocara, found
in the intestines of cats and dogs that are shed in the feces.54

If children get the microscopic eggs on their hands and
then swallow them, the eggs soon hatch and the larvae
migrate in the body and may reach the brain. The preva-
lence is higher in poorer urban neighborhoods. For exam-
ple, in New York City, three quarters of the parks in the
Bronx tested positive for Toxocara eggs, but none of the
parks in Manhattan did. This is partly due to a higher
number of strays in poorer neighborhoods versus pets with
regular veterinary care.55 Exposure to Toxocara may result
in long-term damage to the brain.54,55

There is clearly a need for community education and
assistance in identifying alternative, safer environmental
conditions for children. The safety of children is an emo-
tionally charged issue and one that can galvanize a com-
munity and spur it to action, whether it is by committing
or redistributing resources, enacting policy changes, or
seeking other solutions. Nurses who understand the vul-
nerabilities of children can be partners and change agents
in this process.

Older Adults
Older adults are at the other end of the life span, and
they face a different set of physical and behavioral char-
acteristics and challenges than children or midlife adults

(Chapter 19). Around the world, based on findings from
multiple studies, researchers (e.g., Ralston, 2018; Zhou,
2017) continue to demonstrate the association between
both the social and built environment and the psycho-
logical, cognitive, and physical health of older adults.56,57

Not only is access to built resources such as potable
water, sanitation, and adequate housing an important
factor but so is the social environment. In addition, the
movement to help seniors age in place (see Chapter 19)
requires not only assuring a safe home environment but
also access to community resources to support adequate
nutrition and activity.56-59

In addition to changes in physical and mental func-
tioning associated with age, older adults also experience
increased rates of chronic health conditions, accounting
for increased vulnerability to environmental health is-
sues. Some age-related changes that increase risk from
environmental hazards include hearing and vision loss,
respiratory disease, increased fragility of skin, decreased
rates of metabolism, and disorders such as osteoporosis
and heart disease. When combined with social stressors
in the environment, older adults’ vulnerability to envi-
ronmental hazards appears to increase.60

Older adults also have higher body burdens of chem-
icals that have been absorbed over their lifetimes. Some
substances accumulate over time in the body, a process
known as bioaccumulation. These toxic substances are
commonly retained in tissues such as bone or adipose
(fat) tissue and can become a long-term cause of poor
health outcomes including cancer, organ damage (in par-
ticular, to the kidneys, heart, and liver), cardiac disease,
increased chance of stroke, and neurological, immuno-
logical, and hematopoietic disorders. For example, lead
is stored in the bone with a half-life (time over which
only half of the amount is excreted) of more than 20 years.
Its slow release over time is reflected by high BLLs that
reach and damage target organs.61 Those whose organ
systems are already compromised are at higher risk.
For example, individuals with cardiac disease will be
more seriously affected more quickly in oxygen-deprived
atmospheres. In addition, many older adults tend to
spend a greater amount of their time indoors, where
indoor air pollutants and issues related to climate control
may be an issue.

In 2013, Gamble and colleagues, based on a review
of the literature, called for increased research on the
impact of extreme weather on older adults. They found
that older adults are more vulnerable and, with the an-
ticipated increase in extreme weather due to climate
change, the impact could be greater.62 To understand how
the environment plays a role, consider a hypothetical

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Chicagoan, Mr. Roberts, age 78, who lives on the ninth
floor of an 18-story high-rise apartment building for low-
income older adults and disabled community members
during an extreme heat wave. His wife died the year before,
and his children live three states away. There are two
elevators to serve the 180 occupants, but one of them
regularly breaks down. Mr. Roberts had worked most
of his life as a carpenter. When he was 62, he fell off
a roof, sustaining a hip injury that ended his working
career. Following the injury, he began to use a walker and
developed failing eyesight. Because of his exercise limi-
tations, he gained weight and developed type 2 diabetes.
He tried to be adherent to therapy by checking his blood
glucose, but his fixed income, travel distance to the
closest supermarket, and solitary cooking situation
stood in the way of eating healthy foods. Because of
these problems, as well as fear of robbery by strangers
who sometimes lurked in his building, he rarely went
outdoors. Mr. Roberts mainly kept to himself, did not
mix with his neighbors, and simply enjoyed his air-
conditioned apartment with its pretty view of the city.

During this hypothetical scenario, the temperatures
soar above 110°F. As had occurred in the 1995 heat wave
in Chicago,63 the city begins to experience brownouts,
then power outages, resulting in a 3-day loss of power in
Mr. Roberts’s building. The temperature inside begins to
climb, particularly in the afternoon. Two days later, one
of Mr. Roberts’s neighbors called the building’s manage-
ment concerned that she hadn’t seen Mr. Roberts in a
few days. When the maintenance person checks, he gets
no answer to his knock, and assumes that Mr. Roberts
had gone away with family. He leaves a note, the scope
of his authorization, because, as in many municipalities,
landlords are required to give 24-hour notice to a tenant
before they can enter without the owner’s permission.
Sadly, when the maintenance man enters the apartment
the next day, he discovers that Mr. Roberts died during
the heat wave.

This scenario is typical of stories that pepper the news
each summer in the United States. Mr. Roberts died of
heat stroke, a direct result of an environmental hazard
amplified by his age, health, and the built environment.
Another issue for Mr. Roberts was his social isolation, a
factor that may explain why more older men than women
died in the 1995 Chicago heat wave.63 A heat wave is an
example of a natural disaster (Chapter 22), but the built
environment often increases the risk of morbidity and
mortality, especially for the older adult.

One of the contributing environmental factors that
increases the vulnerability of older adults is a diminished
ability to regulate body temperature; thus, external

mechanical methods such as fans and air conditioners
are needed to reduce the surrounding temperature.
Unfortunately, this susceptibility often combines with
other risk factors for heat injuries, particularly in urban
settings. Seniors, who are more likely to stay indoors,
often live in relative isolation with few social contacts,
and those whose incomes cannot support telephones or
sophisticated air-conditioning systems are at greater risk
for heat-related illnesses. In several extraordinary heat
waves, death rates from heat stroke were highest among
the oldest age groups. For example, a severe heat wave
in France for 3 weeks during August 2003 resulted in
14,800 deaths, mainly among women older than age 75.
These deaths, especially when they occur in developed
nations, are preventable, and as a result France set up a
Heat Health Watch Warning system as well as prevention
plans.64 Thus the environment—adequate cooling, ade-
quate availability of water for hydration, and an effective
method of communication—are key components to inter-
ventions aimed at reducing environmental issues faced
by older adults who are caught in a heat wave.

Many issues also arise in cold climates concerning
home heating. In addition to cold injuries and death that
can result from lack of heat, many people use space heaters
that use fuel such as kerosene. This type of space heater
presents a serious fire hazard, as do other makeshift forms
of sustaining home heat. Deaths have been caused not only
by fire but also from carbon monoxide poisoning when
fuels such as charcoal or wood have been burned indoors.
There are programs in many locales to assist low-income
or older clients. Power companies can provide informa-
tion about these and, in most locations, cannot abruptly
discontinue service before taking certain required steps.

In addition, landlords must also abide by housing
codes.50 For example, when it comes to heating spaces,
most housing codes dictate a minimum temperature that
must be achievable if the space is to be legally rented.
There are many codes that apply to rental properties
as illustrated in Solving the Mystery: The Case of the
Hazardous House. You should know how to access the
code in the community where you work and live and, if
it is insufficient, advocate for adoption of the interna-
tional building codes that are being used increasingly
across the United States.65

Nurses are often key members of teams that intervene
to prevent deaths like that of Mr. Roberts, beginning with
those at the office of his primary care provider. Help with
contacting the city’s social services department can also
result in home visiting care. Many older people and oth-
ers with disabilities are unaware of their eligibility for
such services, and many others might be aware of these

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services but need assistance with applications. PHNs
are involved in developing emergency preparedness and
disaster management plans, and can help add to the
plans’ outreach to those most vulnerable such as older
adults or the homeless. Such plans include the establish-
ment of warning systems and emergency cooling centers,
monitoring of older adults and isolated persons during
an extreme heat or cold event, and improving commu-
nication and awareness among city officials and emergency
medical services. Outreach by PHNs to tenant organiza-
tions in buildings such as the one in which Mr. Roberts
lived is a means of informing community members
about available public health services, fostering better
networking and communication among residents, and
helping to strategize about safety concerns.

Gene-Environment Interaction
There is growing evidence that genetic factors are
responsible for some degree of individual variability in
susceptibility to toxic exposures. Gene-environment
interaction is defined as “an influence on the expression
of a trait that results from the interplay between genes
and the environment.”66,67 In other words, genes interact
with the environment either positively or negatively in
a way that influences disease development. Often it
involves a complex interaction between multiple genes
and the environment. There is a growing body of research
that identifies an increased risk for disorders such as
diabetes, pulmonary disease, breast cancer, and other
diseases when individuals with a specific genetic makeup
encounter environmental exposures. In addition, some
genes are thought to be protective and thus responsible
for a decreased risk of environment-related health out-
comes. This knowledge may someday be useful in iden-
tifying individuals who are at higher risk and intervening
by controlling their exposure. In 2006, the National In-
stitute on Environmental Health Sciences established
a 5-year genes and environment initiative in an effort
to increase understanding of the interaction between
environment and genes with a focus on asthma, diabetes,
and cancer. The efforts of this initiative resulted in an
increased understanding of the interaction between genes
and environment, and helped to develop better ways to
measure environmental exposures.68

Climate Change and Health
News related to climate change continues to emerge. For
example, there is new data that demonstrates that fresh-
water input from melting ice shelves in the Antarctic in

a warming climate is creating a feedback loop and will
trigger more melting, which would trigger a rapid sea
level rise.69 Changes in weather patterns, slowing of
the ocean currents, rising of sea levels, and melting of
glaciers are occurring across the globe.69-71 According
to the WHO, climate change is the result of human
activity especially in relation to the burning of fossil
fuels.72 The WHO list of the key facts (Box 6-5) demon-
strates that the impact on health is serious, that it
includes both social and environmental determinants
of health, and that it will have a greater impact on
LICs. A good example related to the disparity between
high-income and low-income communities is the
hurricane season of 2017 with two major hurricanes
impacting Houston, Texas, and Puerto Rico. Both areas
suffered severe damage from the hurricanes, yet Hous-
ton had more resources to restore power and aid per-
sons who suffered losses due to the hurricane. Puerto
Rico remained without power over the majority of the
island for months, and the devastation and consequent
lack of resources resulted in a large exodus of residents
from the island to other parts of the United States,
especially Florida.

Climate change is associated with numerous extreme
weather events including floods, droughts, hurricanes,
heat waves, heavy downpours, and blizzards.73 These
events result in increased risk of death, injury, and illness.

C H A P T E R 6 n Environmental Health 147

• Climate change affects the social and environmental
determinants of health: clean air, safe drinking water,
sufficient food, and secure shelter.

• Between 2030 and 2050, climate change is expected
to cause approximately 250,000 additional deaths per
year, from malnutrition, malaria, diarrhea, and heat
stress.

• The direct damage costs to health (i.e., excluding costs
in health-determining sectors such as agriculture and
water and sanitation), is estimated to be between USD
$2-4 billion/year by 2030.

• Areas with weak health infrastructure – mostly in
developing countries – will be the least able to cope
without assistance to prepare and respond.

• Reducing emissions of greenhouse gases through
better transport, food, and energy-use choices can
result in improved health, particularly through reduced
air pollution.

BOX 6–5 n World Health Organization Key Facts
Related to Climate Change

Source: (72)

7711_Ch06_128-156 21/08/19 11:03 AM Page 147

For example, heat waves cause direct injury, such as
heat exhaustion and heat stroke, which are particularly
devastating for older adults and young children. Changes
in atmospheric and weather conditions can also in-
crease or exacerbate cardiovascular and pulmonary
disease. There are also more indirect effects on health
and well-being. Climate-related redistribution of vec-
tors for diseases, such as mosquitoes, allows infections
to reach new and broader populations, who are often
the least immune. Decreased yield of crops brought
about by droughts, floods, or other impacts on the
natural environment will add to the current billion
people in the world who have inadequate nutrition. In
addition, populations are experiencing displacement
due to climate change with resulting adverse health
consequences.74

To help illustrate the complex interaction between
climate change and health, the CDC created a figure that
depicts the four aspects of climate change: rising temper-
atures, increased number of extreme weather events,
rising CO2 levels, and rising sea levels (Fig. 6-5). The next
level depicts the impact on the climate, and on the out-
side are the health effects.75

The WHO laid out specific actions needed to address
climate change. These include: to advocate and raise
awareness, to strengthen partnerships, and to enhance

scientific evidence.76 In alignment with the WHO action
plan, the Nursing Alliance for Healthy Environments
published a report on climate change and nursing. The
three areas for action on the part of nursing proposed in
this report were research, advocacy, and practice. Their
stance is that nurses are in a position “. . .to inform and
mobilize society to act on climate change.”77 The issue of
environmental sustainability reflects the concern of
long-term effects on the health of populations related
to climate change. Environmental sustainability reflects
the rates in which renewable resources are harvested,
the depletion of nonrenewable resources, and the cre-
ation of pollution that can continue for an indefinite
period of time. If the rates of population and diminish-
ing resources continue indefinitely, then the environ-
ment is not sustainable. Environmental sustainability
was one of the millennium developmental goals of the
WHO. The current Sustainable Development Goals
(Chapter 1), have integrated the concept of sustainabil-
ity across all goals related to improving the health of
individuals with the environment playing a key role. As
the next decades unfold, nursing will have a role in
mitigating the impact of our changing climate from the
local level to the global level. With the help of organi-
zations around the world, there is optimism that we can
make a difference.76,77

148 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Figure 6-5 Centers for Dis-
ease Control and Prevention:
Impact of Climate Change
on Health. (From CDC. [2014],
Retrieved from https://www.cdc.
gov/climateandhealth/effects/
default.htm.)

7711_Ch06_128-156 21/08/19 11:03 AM Page 148

Air
One of the issues related to climate change is the quality
of the air we breathe. In 2018, an artist in London,
England, Michael Pinsky, set up five geodesic domes
(pollution pods) in the city. Each dome replicates the
atmosphere of one of five places: Beijing, China; Sao
Paulo, Brazil; London, England; New Delhi, India; and
Norway’s Tautra Island. Many people visiting the pods
were unable to remain in them long due to immediate
respiratory problems.78 All animals depend on an ade-
quate supply of oxygen to maintain life. A healthy envi-
ronment requires not only air with an adequate supply
of oxygen but also air that is free from pollutants. Air pol-
lution has long been an issue, but with the arrival of the
Industrial Revolution the quality of the air we breathe
changed drastically. Industry and the need for energy
have resulted in the emission of toxic chemicals into the
air. The famous London fog was not a natural weather
phenomenon, but rather arrived on the heels of the
Industrial Revolution. Cities with high dependence on
motor vehicles for transport, such as Los Angeles and
London, have struggled with severe smog due to emis-
sions from automobiles. In Pinsky’s London geodesic
dome, the odor of diesel fuel dominated because it is one
of the main pollutants of London air. In the 21st century,
the continued emission of CO2 has resulted not only in
the warming of the climate but a reduction in the quality
of the air (Fig. 6-5).

Ambient Air
Ambient air is the air surrounding a place or structure
and is also referred to as outdoor air. Poor ambient air
quality is associated with increased mortality rates from
pulmonary and cardiovascular disease.75,79 Air contam-
ination may occur because of the emission of pollutants
into the atmosphere at consistent concentrations over
time, such as the emissions from factories. Scientists
devised a mechanism to evaluate the current air quality
called the ambient air standard. This refers to the high-
est level of a pollutant in a specific place over a specific
period of time that is not hazardous to humans. It is the
number of parts per million per hour that are considered
the safety limit. As evidenced by Pinsky’s geodesic domes,
the amount of air pollution presents a serious health
concern in many urban areas across all income levels.

Variability in air quality often reflects the surrounding
built environment. Populations located in the shadow of
chemical plants and next to large equipment, railroad
tracks, trailer trucks, and dusty access roads are often
made up of lower socioeconomic groups, because the

property values of homes located next to these sources
of pollution are lower. Thus, the population is dispropor-
tionately vulnerable to all types of hazardous exposures
that come with living in an industrial area. In addition
to the risks associated with chemicals emitted in indus-
trial areas, these residents face the social strain brought
on by these circumstances.

Many outdoor air contaminants originate from
major stationary sources, known as point sources, which
include chemical plants, power plants, refineries, and
incinerators. Alternatively, pollutants may be generated
by transportation sources such as buses, trucks, and cars
(on-road) and ships, planes, and construction equipment
(off-road), all referred to as mobile sources. A third type,
area sources, includes smaller sources of emission such
as gas stations, dry cleaners, commercial heating and
cooling systems, railways, and waste disposal facilities
such as landfills and wastewater treatment operations.80

In 1970, the United States promulgated the Clean Air
Act, which was reauthorized in 1990. The Clean Air Act,
enforced by the EPA, specifies allowable limits, known
as the National Ambient Air Quality Standards, for in-
dustrial emission of a set of major air pollutants called
the criteria air pollutants (Box 6-6).81 These are carbon
monoxide, nitrogen dioxide, ozone, particulate matter,
lead, and sulfur dioxide. Ground-level ozone and partic-
ulate matter are the greatest threats to human health.
Because particulate matter varies in size, separate stan-
dards are set for all particles less than 10 micrometers
(μm) in size (PM10) and for those less than 2.5 μm (PM2.5).
The size of a particle determines the site of its deposition
in the respiratory system. Particles less than 10 μm (less
than the width of a human hair) are respirable; they are
not removed in the upper airways, as are larger particles.
Increased levels of PM10 air pollution appear to affect
lung function and produce symptoms in asthma patients
of all ages.73 The subset of particles that are less than
2.5 μm enter the alveoli and are associated with lung
cancer and cardiovascular death.82 Vehicle traffic, in
particular diesel exhaust, is an important source of par-
ticulate matter.

One way to evaluate the degree of air pollution in a
specific area is the Air Quality Index (AQI) (Box 6-7).83

The AQI is computed by the EPA based on measures of
the five criteria for air pollutants. Although the calculation
of the AQI results in values on a scale of 0 to 500, these
are generally reported to the public as six category levels:
good, moderate, unhealthy for sensitive groups, unhealthy,
very unhealthy, and hazardous. They are also denoted
by colors that range from green to maroon. A value of 100
or less, corresponding to the levels of “good” and

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150 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Description of Common Ambient Air Pollutants
Carbon monoxide (CO): An odorless and colorless

gas produced by incomplete combustion of fuels in
vehicles, heating systems, lawn mowers, and other
motorized machinery.
Health effects: Reduces the oxygen carrying capacity

of blood, deprives tissues of oxygen to potentially
aggravate heart disease, harms fetuses, and dam-
ages oxygen-sensitive organs.

Nitrogen oxides (NOx): Levels are usually low in the
United States. Plays a role in the production of ozone.
Sources are vehicles, waste disposal systems, power
plants, and silage on farms.
Health effects: Lung irritant, aggravates asthma, and

lowers resistance to infection; pulmonary edema at
high concentrations; pulmonary fibrosis at long-
term lower concentrations.

Sulfur oxides (Sox): Sources are metal smelters and
processes that burn sulfur-containing coal and oil,
such as power plants and industrial boilers. Creates
“acid rain” and smog.
Health effects: Bronchoconstriction, aggravates and

triggers asthma, long-term exposure pulmonary
fibrosis, and possibly lung cancer.

PM 2.5 and PM10: Sources are vehicles, and wildland and
other types of fires.
Health effects: Dangerous to those with heart and lung

disease, causing shortness of breath, arrhythmias,
angina, and myocardial infarction. Long-term expo-
sures may be related to chronic obstructive lung
disease (COPD), lung cancer, and cardiovascular
disease.

Lead: A widely used metal present in smelting operations,
paint in old housing, water distribution systems, solder,
painted items such as some toys, and many others.
Organic lead compounds were once used in gasoline,
accounting for 81% of transportation emissions in
1985. This quantity has been reduced substantially
once lead was banned from this use. Lead often con-
taminates air, water, food, soil, and bioaccumulates.
Health effects: Damage to renal, gastrointestinal,

reproductive, hematopoietic, and nervous system.
Affects development and learning ability of children.

Ozone: In the stratosphere, 6 to 30 miles above the
earth, ozone is beneficial because it blocks the sun’s
harmful ultraviolet rays. At ground level, ozone is a
dangerous component of urban smog, produced by
sources such as power plants, refineries, and chemical
plants.
Health effects: Irritates the respiratory system, aggra-

vates and triggers asthma.

BOX 6–6 n Criteria Air Pollutants

Source: (82)

The features of the AQI include:

• A category that provides specific warnings for sensitive
groups, such as children with asthma and others with
special respiratory conditions

• Detailed warnings about how all people should protect
themselves and their families from harmful levels of air
pollution

• Warnings based on the most up-to-date scientific infor-
mation on the known health effects of air pollution levels

BOX 6–7 n Air Quality Index

Source: (83)

“moderate” (green and yellow), is the level set by EPA to
protect public health. As the index increases, the health
hazards associated with air pollution increase, first
affecting the most sensitive individuals at levels of 101
to 150, and at higher levels, everyone. As levels above
those classified as yellow (index of 100) are reached,
individuals should reduce their levels of exertion and
outdoor activities accordingly. The EPA provides a daily
updated forecast of the AQI and more information about
air pollutants on its Web site Air Now. This Web site
provides the current AQI for areas around the country
and includes information that can be used for teaching
clients.83 Significant advances have been made in re-
ducing ambient air pollution during the past 60 years.
Continued efforts to improve the health of ambient
air will require collaborative efforts within and across
nations.

Indoor Air Pollution
With the exception of laws that ban smoking in public
places and Occupational Safety and Health Administra-
tion standards for workplace exposures, there is little
regulation of indoor air contaminants. Several of these
have been mentioned previously in this chapter in the
discussion of the home evaluation, including environ-
mental tobacco smoke, animal dander, cockroaches, and
the spores of molds that grow in damp environments.
Each of these agents can cause allergic reactions, and all
are recognized triggers for asthma.

Many pollutants exist in the home in the form of
house dust, which may also be composed of heavy met-
als, pesticides, gram-negative bacteria, and chemicals
such as phthalates. The very young are especially at risk
because they ingest more dust and are more susceptible
to toxins. Home cleaning methods, which PHNs can teach
families and reinforce during home visits, significantly
reduce dust exposures over time periods as short as 1 week

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when practiced properly. Effective interventions combine
the use of allergy-control bed covers, quality doormats,
and vacuum cleaners with dirt finders and HEPA fil-
ters. Chemicals associated with the materials used to
build homes, such as formaldehyde, are another concern.
Buildings that are well insulated, tightly sealed for efficient
climate control, and lack windows that can be opened by
occupants are more likely to retain indoor air pollutants,
especially if the ventilation systems provide infrequent
air exchanges per hour.

Potable Water
Just as all animals need oxygen to survive, all living things
need water. The availability of potable water has, since
ancient times, dictated where humans settle. Humans
need water to sustain their own bodies and to sustain
their crops and livestock. Water has also played a key role
in commerce and the generation of hydroelectrical
power. Water has become an important issue in the
United States in areas that have limited access to water,
especially in the Southwest and in Southern California.
The lack of water contributed to the depth of the Depres-
sion of the 1930s, creating the dust bowl on the Great
Plains and one of the worse environmental disasters in
the 20th century. The drought that hit the Midwest eco-
nomically wiped out farmers and reduced the availability
of food, resulting in 3 million leaving their farms and half
a million migrating to other states.84

The quality of water is a major determinant of the
health of a population. Both organic and inorganic
contaminates are associated with adverse outcomes.
According to the WHO:

Water is essential for life. The amount of fresh water on
Earth is limited, and its quality is under constant pres-
sure. Preserving the quality of fresh water is important for
the drinking-water supply, food production, and recre-
ational water use. Water quality can be compromised
by the presence of infectious agents, toxic chemicals, and
radiological hazards.85

Inorganic Water Contaminants

C H A P T E R 6 n Environmental Health 151

w SOLVING THE MYSTERY
The Case of the Tainted Water
Public Health Science Topics Covered:
• Assessment
• Epidemiology
• Rates
• Surveillance

Flint, Michigan, became front-page news when
evidence of lead-contaminated water surfaced. The
process of how it happened and how it was discovered
provides a special case study not only in the importance
of safe drinking water but also the complexity of cultural,
political, and monetary influences on decisions related
to provision of potable water. In 2014, the city had an
estimated population of 100,569 with 58% of the popu-
lation identifying themselves as African American and
7.6% of the population under the age of 5.86 In that
same year, the city decided to switch the water source
for the city from Lake Huron through Detroit Sewer
and Water Department to the Flint River. They were
in the process of completing a new pipeline to Lake
Huron, which would then allow them to join the
Karengnondi Water Authority (KWA).87,88 Part of the
reason for taking this course of action was the possible
savings to the city of an estimated $200 million over
25 years. The problem was they did not add corrosion
control chemicals to the water. Flint River water is
more acidic than the water from Lake Huron, and
lead as well as other metals in the aging pipes leached
into the water.87

Within weeks of the switch, problems began to
emerge including health problems, the smell and
appearance of the water, and water main breaks.89

The city issued water boil alerts due to the evidence of
E. coli and other contaminants in the water. The extent
of the lead contamination was not understood at this
point, but families began to purchase bottled water due
to the boil alert. Due to work by Marc Edwards, a pro-
fessor at Virginia Polytechnic Institute and State Univer-
sity, and a local pediatrician, Mona Hanna-Attisha, the
significant increase of BLLs in children after the switch
to the Flint River water source was identified and pub-
lished. The City of Flint ultimately switched back to
using treated Lake Huron water supplied by DWSD,
due in part to the study and the subsequent public
outcry.90, 91 Edwards, in his report, issued information
to residents on how to reduce their exposure to
lead-contaminated water (Box 6-8).90

However, understanding the extent of the harm
required further evaluation of the data. Zahran and
colleagues examined four phases related to the expo-
sure: prior to the switch, after the switch to the Flint
River, after the boil advisory, and after the switch back
to the original water source. They found that a total
of 561 additional children in Flint exceeded a BLL
of ≥5 μg/dL following the switch to the Flint River.
They found that, after the switch back to the DWSD
water system, elevated BLLs returned to the pre-Flint

7711_Ch06_128-156 21/08/19 11:03 AM Page 151

Safe Water from a Global Perspective
The case of Flint, Michigan, demonstrates the impor-
tance of a number of standard public health practices
such as surveillance, case finding, timely public health
alerts, and the need for maintaining adequate infra-
structure. Globally, a major issue related to potable
water is organic contaminates that increase the risk for
communicable diseases (Chapter 8).93 Improvements
have occurred over the last few decades. Currently 71% of
the global population has access to safely managed
drinking water and 89% have access to at least a basic
service. Challenges remain with 50% of the global
population projected to live in water-stressed areas by
2025.93

The main barriers to the provision of safe drinking
water include setting it as a priority, financial capacity,
sustainability of the water supply, sanitation, and hygiene
behaviors. The main actions recommended by the WHO
include increasing the supply of safe water, increasing

the number of facilities for the sanitary disposal of excre-
ment, and implementing safe hygiene practices.93

Community Environmental Health
Assessment
In addition to the environmental assessments discussed
thus far that focused on individuals and families, a
community environmental health assessment can be
done as well. It is a means by which public health and
environmental health professionals and agencies partner
with community members, organizations, and each
other to identify, prioritize, and address environmental
health issues.94 One of the most widely used community
assessment methodologies is the Protocol for Assessing
Community Excellence in Environmental Health (PACE
EH), developed in partnership between the National
Association of County and City Health Officials (NAC-
CHO) and the CDC.94 Communities that have imple-
mented PACE EH consider it to be a successful tool for
expanding the capacity of health agencies in essential
environmental health services; engaging the community
in problem-solving; and implementing action plans that
use community resources to reduce health risks.95

According to the PACE EH guidebook (pp. ix, x),
PACE EH is intended for use domestically and interna-
tionally, and is being used in numerous locales to take a
“collaborative community-based approach to generating
an action plan that is based on a set of priorities that re-
flect both an accurate assessment of local environmental
health status and an understanding of public values
and priorities.”94 It outlines a series of tasks, shown in
Box 6-9, to accomplish this goal. Implementation of
the PACE EH process is supported by several resources,
including guidebooks in English and Spanish, other

152 U N I T I n Basis for Public Health Nursing Knowledge and Skills

Until further notice, we recommend that Flint tap water
only be used for cooking or drinking if one of the follow-
ing steps are implemented:

• Treat Flint tap water with a filter certified to remove
lead (look for certification by the National Sanitation
Foundation [NSF] that it removes lead on the label).

• Flush your lines continuously at the kitchen tap, for
5 minutes at a high flow rate (i.e., open your faucet all
the way), to clean most of the lead out of your pipes
and the lead service line, before collecting a volume
of water for cooking or drinking. Please note that
the water needs to be flushed 5 minutes every time
before you collect water for cooking or drinking. For
convenience, you can store water in the refrigerator
in containers to reduce the need to wait for potable
water each time you need it.

BOX 6–8 n Recommendations to Flint Residents

Source: (90)

River water period. Zahran concluded that if the city
had issued warnings as soon as they had received com-
plaints, much of the increase in BLLs might have been
prevented.89 In 2018, the New York Times reported
that the state of Michigan would no longer provide free
bottled water because the water had met federal safety
guidelines for 2 years. In addition, the City of Flint was
on target to replace all of the affected pipelines by 2020
with just over 6,200 replaced so far and 12,000 still
to go.92

This methodology guides communities and local health
officials in conducting community-based environmental
health assessments. PACE EH draws on community
collaboration and environmental justice principles to
involve the public and other stakeholders in:

• Identifying local environmental health issues
• Setting priorities for action
• Targeting populations most at risk
• Addressing identified issues

BOX 6–9 n Steps in PACE EH Methodology*

*PACE EH = Protocol for Assessing Community Excellence in Environmental
Health

Source: (94)

7711_Ch06_128-156 21/08/19 11:04 AM Page 152

publications, a toolbox with a number of materials and
resources, and online and regional training. In addition to
PACE EH methodologies, there are additional approaches
to community assessment in current use, one of which
is to conduct a health impact assessment (HIA). These
assessments allow communities to examine the impact
of city planning related to land use and policy on the
health of the community. HIAs are being implemented
at a growing rate throughout Europe to effectively gauge
the health impacts of land use planning and policy
decisions.96

n Summary Points
• The environment plays a role in health from the

cellular level to the global level.
• Nurses play a crucial role in the promotion of

optimal environmental health and mitigation of
the effects of climate change.

• The built environment contributes to the health of
individuals, families, and populations.

• Assessment and management of environmental
issues are conducted at the individual, family, and
community level.

• There is an interaction between genetics and the
environment.

• Characteristics of populations, such as age, genetics,
health status, and culture play a role in the interac-
tions between health and the environment.

• Climate change is affecting the environment with
specific concerns related to air and water quality, an
increase in extreme weather events, rising sea levels,
and increased risk of communicable diseases.

C H A P T E R 6 n Environmental Health 153

t CASE STUDY
A Contaminated Town

Learning Outcomes
At the end of this case study, the student will be able to:

• Describe the effects of an environmental toxin on
the health of a population

• Discuss polices related to environmental hazards
• Apply primary, secondary, and tertiary prevention

approaches to an environmental health issue

Since the early 1900s, the major industry in the town
of Libby, Montana, was the mining of vermiculite, a mate-
rial used to insulate buildings. A contaminant of vermicu-
lite is asbestos, which is well known for causing serious
lung diseases, including cancer. Concerns about health

problems among the town residents, not only the miners,
began to surface when a reporter revealed the popula-
tion’s high rate of asbestosis and related diseases. Con-
taminated soil was the major source of asbestosis around
town—near homes, schools, and many public places
that included athletic fields—and the dust made its
way indoors on vehicles such shoes, pets, and workers’
clothes. The mine was closed in 1990, but by then a large
proportion of the townspeople had been exposed, with
ongoing exposure because the asbestosis remained in
the soil. In 2002, the EPA placed Libby on its National
Priority List, thereby identifying the town as a site that
appeared to warrant remedial action, leading to the test-
ing and inspection of almost 5,000 residential and com-
mercial properties. Cleanup operations began throughout
the town. In 2009, the EPA declared the town of Libby a
public health emergency. This status mobilizes funds to
conduct further home-to-home cleanup and install
health-care resources for those with asbestos exposure.

1. What type of hazardous agent is asbestos, what is
the typical route of exposure, and what are its major
health effects? Are there government standards that
regulate the permissible amount of asbestos?

2. List the agencies that would partner to address this
extensive environmental disaster.

3. What primary, secondary, and tertiary preventive
actions can be applied to protect the public’s health?

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gov/criteria-air-pollutants/naaqs-table.

82. Environmental Protection Agency. (2015). Consolidated
lists under EPCRA/CERCLA/CAA §112(r). Retrieved from
https://www.epa.gov/epcra/consolidated-list-lists-under-
epcracerclacaa-ss112r-march-2015-version.

83. Environmental Protection Agency. (2016). Air now: Air
quality index. Retrieved from https://airnow.gov/index.
cfm?action=aqibasics.aqi.

84. Egan, T. (2006). The worst hard time. Boston, MA: Houghton
Mifflin.

85. World Health Organization. (2018). Water. Retrieved from
http://www.who.int/topics/water/en/.

86. U.S. Census Bureau. (2018). Quick facts: Flint Michigan.
Retrieved from https://www.census.gov/quickfacts/fact/
table/flintcitymichigan/PST045216.

87. Abuelaish, I., & Russell, K.K. (2017). The Flint water contam-
ination crisis: the corrosion of positive peace and human
decency. Medicine, Conflict and Survival, 33(4), 242-249.
doi:10.1080/13623699.2017.1402902.

88. Lin, J., Rutter, J., & Park, H. (2016, January 21). Events that
led to Flint’s water crisis. The New York Times. Retrieved
from https://nyti.ms/2k406rO.

89. Zahrana, S., McElmurryb, S.P., & Sadler, R.C. (2017). Four
phases of the Flint Water Crisis: Evidence from blood lead
levels in children. Environmental Research, 157, 160-172.
https://doi.org/10.1016/j.envres.2017.05.028.

90. Edwards, M., (2015). Our sampling of 252 homes demonstrates
a high lead in water risk: Flint should be failing to meet the
EPA lead and copper rule. Flint water study: Blacksburg, VA,
September 8. Retrieved from http://flintwaterstudy.org/
2015/09/our-sampling-of-252-homes-demonstrates-a-high-
lead-in-water-risk-flint-should-be-failing-to-meet-the-epa-
lead-and-copper-rule/.

91. Hanna-Attisha, M., et al. (2016). Elevated blood lead levels
in children associated with the Flint drinking water crisis: a
spatial analysis of risk and public health response. American
Journal of Public Health, 106, 283-290.

92. Fortin, J. (2018, April 18). Michigan will no longer provide
free bottled water to Flint. The New York Times. Retrieved
from https://nyti.ms/2uW6ubP.

93. World Health Organization. (2018). Fact sheets: Water.
Retrieved from http://www.who.int/en/news-room/fact-
sheets/detail/drinking-water.

94. Centers for Disease Control and Prevention. (2016). PACE
EH—Protocol for assessing community excellence in environ-
mental health. Retrieved from https://www.cdc.gov/nceh/
ehs/ceha/pace_eh.htm.

95. Florida Department of Health. (n.d.). PACE EH Project: The
power of PACE EH. Retrieved from http://redevelopment.
net/wp-content/uploads/2010/11/Thurs11-Role-of-Public-
Health-The-Power-of-PACE-EH-Julianne-Price.pdf.

96. World Health Organization. (2018). Health impact assessment.
Retrieved from http://www.who.int/hia/en/.

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157

Community Health Across Populations:
Public Health Issues

Chapter 7

Health Disparities and Vulnerable Populations
Christine Savage, Beverly Baccelli and Sara Groves

LEARNING OUTCOMES

After reading the chapter, the student will be able to:

KEY TERMS

1. Compare and contrast the concepts of health
disparity, equity, and inequality from a local to
global perspective.

2. Discuss the magnitude of health disparities both in
the United States and internationally.

3. Define and explain the role of the social determinants
of health and social justice in the health of populations.

4. Describe the concept of vulnerability from a population
perspective.

5. Examine vulnerability of specific populations.
6. Compare and contrast population level strategies for

improving health among different vulnerable groups.
7. Understand the role of culture when caring for

vulnerable populations.

Asylee
Correctional population
Discrimination
Disparity
Equity
Food security
Gene-environment

interaction
Health disparity
Health gradient

Health inequity
Homelessness
Illegal alien
Immigrant
Incarcerated population
Marginalization
Migrant agricultural

worker
Migrant worker
Permanent Resident Alien

Point in time estimate
Poverty
Poverty guidelines
Poverty threshold
Primary homelessness
Refugee
Secondary

homelessness
Social capital
Social gradient

Social determinants of
health

Social justice
Socioeconomic status

(SES)
Stigma
Sustainability
Tertiary homelessness
Vulnerability
Vulnerable populations

n Introduction
In 2016, the infant mortality rate (IMR) for the World
Health Organization (WHO) African Region was 52 per
1,000 live births compared to 8 per 1,000 live births for the
WHO European Region with a range of 2 per 1,000 in Ice-
land and 120 per 1,000 in Mozembique.1,2 Why is there
such a disparity, or great difference, between these coun-
tries? Is there anything that can be done to reduce this and
other gaps in health outcomes between populations? Why

are some populations at greater risk for adverse health out-
comes compared to other populations? Answering these
questions involves understanding the underlying social
determinants of health-realated gaps in health outcomes
between populations.

Equity is the underlying concept behind optimum
health as a basic human right. To explore this in more
detail, consider three people: one tall, one medium
height, and one short wanting to watch a ball game over
a fence (Fig. 7-1). If all three are provided with a box that

U N I T II

7711_Ch07_157-190 23/08/19 10:23 AM Page 157

is the same height, this represents the concept of “equal-
ity.” Although they were all given the same resource to
view the game, the shortest person is still not able to see
the game. If instead they are provided with boxes at
varying heights based on their stature, all of them get to
see the game. Then there is “equity” among the three
persons.

When health equity does not exist, there are often dif-
ferences in health outcomes. The terms used to describe
gaps in health outcomes include health disparity and
health inequity. Health disparity exists when “… a
health outcome is seen to a greater or lesser extent be-
tween populations.”3 The IMR (see Chapter 17) provides
a prime example of disparity with higher rates between
countries or between ethnic groups within a country.
Identifying a disparity is the first step in understanding
the underlying risk factors and the development of pos-
sible interventions to reduce or eliminate the disparity.
Health inequity describes avoidable gaps in health
outcomes.3 For example, persons with type 2 diabetes
who cannot afford the cost of medication and therefore
are unable to take it as ordered will experience higher
A1C levels and experience more adverse outcomes. The
inequity in access to diabetic medications may be a
major driver in the disparity in outcomes between
lower- and middle-class persons. Drivers of health
inequities are linked to the vulnerability experienced by
some populations based on the social determinants of
health including where they stand in the social hierarchy
related to income, education, occupation, gender,
race/ethnicity, and other factors.2

Addressing health inequity requires providing persons
the opportunity for optimal health. This may require
more services for those who have noncommunicable
chronic diseases and are on a fixed income compared to
persons in general good health and who are in higher in-
come brackets. Nurses address health inequity in a variety
of ways beginning with advocacy. For example, nurses on
the front lines with patients who have difficulty affording
their prescriptions advocate for those patients by identi-
fying pharmacies that provide assistance as well as other
sources of help to pay for medications. Nurses also advo-
cate for health-care policies aimed at addressing health
inequalities at the local, state, and national level. They also
actively provide improved care for those in need through
nurse-managed clinics or by working as outreach nurses
for the public health department.

Vulnerability is the degree to which an individual,
population, or organization is unable to anticipate, cope
with, resist, and recover from the impact of disease and
disasters.4 An individual or group’s vulnerability can be
affected by a number of factors, some of which can be
changed, and some of which cannot. Vulnerability is es-
pecially evident during a natural disaster (see Chapter 22).
For example, those with fewer resources have a greater
difficulty evacuating during hurricanes due to a lack of
transportation and inability to pay for or find alternative
shelter. After the hurricane, income level plays a large
role in the ability to repair damaged dwellings and ob-
tain needed supplies, as evidenced in Puerto Rico after
Hurricane Maria. To understand the increased risk for
experiencing health inequities, specific vulnerable pop-
ulations have been identified based on race, ethnicity,
age, gender, sexual orientation, history of incarceration,
socioeconomic status (SES), exposure to violence and
war (Chapter 12), and lack of a permanent residence.5
Vulnerability is not exclusively tied to social status. For
example, frail elderly experience vulnerability related
to impaired mobility and difficulty completing activities
of daily living. However, when age-related frailty is
combined with poverty, the vulnerability of that person
increases. Nurses are often confronted with the dilemma
of how best to care for a vulnerable person. For example,
when discharging a hospitalized patient who has no
permanent address or a family member to assist that
patient, the nurse must seek resources to help the patient.
This requires knowledge of the resources within the
hospital, such as the social work department as well as
resources within the community.

Comparing life expectancy between countries helps to
further demonstrate the health disparity between coun-
tries. For example, Monaco’s estimated life expectancy in

158 U N I T I I n Community Health Across Populations: Public Health Issues

Figure 7-1 Equality versus Equity. (“Interaction Institute
for Social Change | Artist: Angus Maguire.” Retrieved from inter-
actioninstitute.org and madewithangus.com.)

7711_Ch07_157-190 23/08/19 10:23 AM Page 158

2017 was 89.4 years whereas the estimated life expectancy
in Chad was 50.6 years.6 For the U.S., in 2016, the esti-
mated life expectancy was 78.6 years, a decline since
2015.7 There is also health disparity among populations
within a country. These disparities are frequently seen as a
health gradient wherein there is a series of progressively
increasing or decreasing differences. The health gradient
reflects the relationship between health and income at the
population level with health gradually improving as income
improves. The WHO uses the term social gradient, which
refers to “… a gradient in health that runs from top to
bottom of the socioeconomic spectrum. This is a global
phenomenon, seen in low-, middle-, and high-income
countries. The social gradient in health means that health
inequities affect everyone.”8 The WHO utilizes the example
of maternal mortality to describe social gradient (see Chap-
ter 17). A comparison of the lifetime risk of maternal death
during or shortly after pregnancy shows at the top of the
gradient, a 1 in 17,400 risk versus 1 in 8 in Afghanistan.8

Caution must be taken when interpreting the under-
lying risk factors contributing to the disparity. On the
surface, it might appear that the disparity is due to
genetic differences, when in fact, much of the health
disparity between groups is driven by socioeconomic
factors. Poverty and access to resources such as food,
shelter, sanitation, and health care all play a role in im-
proving life expectancy. Other risk factors must also be
considered. Since 2015, life expectancy has been declin-
ing in high income countries partially due to the rise in
opioid overdoses in younger persons (see Chapter 11).9
Thus, where a person lives, level of vulnerability, and
individual health behaviors play a role in increasing or
decreasing an individual’s risk for premature death.

Disparity and Inequity at the National
and Global Level
The WHO stated that “A characteristic common to
groups that experience health inequities—such as poor or
marginalized persons, racial and ethnic minorities, and
women—is lack of political, social, or economic power.
Thus, to be effective and sustainable, interventions that
aim to redress inequities must typically go beyond reme-
dying a particular health inequality and also help
empower the group in question through systemic
changes, such as law reform or changes in economic or
social relationships.”10 Vulnerable groups with a higher
level of risk of experiencing adverse health outcomes are
also less apt to have a voice in creating opportunities to
reduce health inequity.

Health Disparity in the U.S.
Comparing groups based on racial category provides a
starting point for illustrating health disparities in the
U.S. with the strong caveat that this does not mean that
these differences are attributable to genetic differences
but rather differences in availability of resources. Again,
the IMR illustrates significant differences in birth out-
comes. Although the overall IMR for the U.S. in 2016 was
5.9 per 1,000 live births, it was almost double for African
Americans (11.4 per 1,000 live births) and much lower
for Asians (3.6 per 1,000 live births) (Fig. 7-2).15 Yet when
the data are examined based on geography, differences in
IMR by state ranges from less than 1 per 1,000 live births
(Vermont) to 9.1 per 1,000 live births (Alabama).15 Access

C H A P T E R 7 n Health Disparities and Vulnerable Populations 159

Figure 7-2 Comparison of IMR within the United
States. (From Centers for Disease Control and Prevention.
[2018]. Infant Mortality. Retrieved from https://www.cdc.gov/
reproductivehealth/maternalinfanthealth/infantmortality.htm.)

n CELLULAR TO GLOBAL
A 2018 article in the New York Times utilized videos
and photos to highlight the plight of mothers and
newborn infants in South Sudan.13 The images of moth-
ers and infants accompany the stark facts of limited
physicians, electricity, equipment, and medication.
Breastfeeding mothers must sleep out in the open.
The reality in 2018: 1 in 10 babies brought to the clinic
died, most from conditions that were treatable, such
as respiratory infections. Because the mothers were
unsure if their babies would survive, most were not
even named. The lack of resources to treat respiratory
infections in newborn infants contributes to the IMR in
South Sudan (48.8 per 1,000 births in 2017),14 which
then drives life expectancy (60.6 in 2017)6.

U.S. Infant Mortality Rate 2016 by Race

Non-Hispanic
Black

American
Indian/
Alaskan
native

Native
Hawaiian/

Pacific
Islander

Hispanic Non-Hispanic
White

Asian

11.4

9.4

7.4

5 4.9
3.6

12

10

8

6

4

2

0

7711_Ch07_157-190 23/08/19 10:23 AM Page 159

to resources and poverty are important risk factors for
infant death and help explain the differences seen between
racial groups that have a higher percentage living
in poverty. Although IMR is just one example of health
disparity among groups in the U.S., it underscores the ra-
tionale for continuing to keep elimination of health
disparities as a priority. HP 2030 continues to include
elimination of health disparity as a priority as it has since
Healthy People was first initiated.

exposures and incorporates the full context of the com-
munities in which an individual resides and their
effect on health.

Social Determinants of Health and Social
Capital
The social determinants of health are the social and en-
vironmental conditions in which people live and work.19

These social determinants include neighborhood and the
built environment (see Chapter 6), economic stability,
education, social and community context, and health and
health care (Fig. 7-3).19 These determinants are not only
associated with risk for communicable and noncommu-
nicable disease but are also associated with risk for men-
tal health disorders, substance use disorders, injury, and
violence. According to the WHO, social determinants
of health account for “… the unfair and avoidable differ-
ences in health status seen within and between coun-
tries”.20 Social capital, defined by Lin in 1999 in terms of
resources available to individuals and communities based
on membership in social networks21, is another factor to
consider when examining underlying factors contribut-
ing to disparity in health outcomes.

160 U N I T I I n Community Health Across Populations: Public Health Issues

n HEALTHY PEOPLE
Disparities: Although the term disparities is often
interpreted to mean racial or ethnic disparities, many
dimensions of disparity exist in the United States,
particularly in health. If a health outcome is seen to a
greater or lesser extent among populations, there is
disparity. Race or ethnicity, sex, sexual identity, age,
disability, SES, and geographic location all contribute
to an individual’s ability to achieve good health. It is
important to recognize the impact that social deter-
minants have on health outcomes of specific popula-
tions. Healthy People strives to improve the health
of all groups.16

Healthy People 2030 Framework
and Health Disparities
Addressing health disparities in the U.S. continues to
be a priority in HP 2030. There are seven foundation
principles for HP 2030 that guide the development of
HP 2030 topics and objectives including: “Achieving
health and well-being requires eliminating health
disparities, achieving health equity, and attaining health
literacy.”17 There are five overarching goals including:
“Eliminate health disparities, achieve health equity,
and attain health literacy to improve the health and
well-being of all”.17

Social Determinants of Health, Social
Capital, and Social Justice
Health is a complex state that truly reflects a cellular to
global model. It reflects a gene-environment interaction
from the individual to the global level. For example,
according to the National Institute of Environmental
Sciences, “Nearly all diseases result from a complex inter-
action between an individual’s genetic make-up and the
environmental agents that he or she is exposed to.”18 The
terms social determinants of health, social capital, and
social justice help to further understand how this gene-
environment interaction goes beyond environmental

Social
Determinants

of Health

Social
Community
and Context

Economic
Stability

Neighborhood
and the Built
Environment

Social
Community
and Context

Health and
Health Care

Education

Figure 7-3 Social determinants of health. (Data from
National Institute of Environmental Sciences. [2018]. Gene-
environment interaction. Retrieved from https://www.niehs.
nih.gov/health/topics/science/gene-env/index.cfm.)

7711_Ch07_157-190 23/08/19 10:23 AM Page 160

24%

Informational
Little or no change
Improving
Met or exceeded

31%

27%

18%

Healthy People 2020 Midcourse Review:
Social Determinants of Health

For all health-care providers, including nurses, under-
standing social determinants of health and integrating
that knowledge into plans of care results in improved
outcomes. When patients come to the hospital for care,
it is not always easy to understand the context of their
daily lives because nurses are not interacting with them
in their home environment. Yet with increasingly short
hospital stays, nursing care that incorporates this context
in the nursing plan of care and discharge instructions
becomes even more important. Often patients go home
with complex instructions and a need for medical supplies,
yet lack the health literacy (see Chapter 2) and/or the
resources to implement those instructions. This can re-
sult in poor outcomes and a return to the hospital. At the
tertiary prevention level, addressing this health inequity
may include requesting an order for a home health nurse
or home health aide on discharge, thus helping vulnera-
ble patients improve their ability to self-manage the dis-
ease. On the secondary prevention level, nurses in public
health departments are on the front line with screening
programs for vulnerable populations at high risk for
disease such as lead poisoning or sexually transmitted
infections. On the primary level, nurses provide educa-
tion to at-risk populations. As explained in Chapter 2,
understanding the social determinants of health is essen-
tial to help identify persons at risk as well as patterning
an intervention at the individual or community level that
considers how the social and environmental conditions
in which people live affects their ability to achieve opti-
mal health.

Social Justice
Addressing health disparities comes under the umbrella
of social justice, defined by the Merriam-Webster
dictionary as “a state or doctrine of egalitarianism.”23

In other words, because health disparities represent a
lack of equality in health outcomes among groups, it is
important to adopt a doctrine of social justice related to

C H A P T E R 7 n Health Disparities and Vulnerable Populations 161

Figure 7-4 Social determinants of health midcourse
review. (Data from National Institute of Environmental Sciences.
[2018]. Gene-environment interaction. Retrieved from https://
www.niehs.nih.gov/health/topics/science/gene-env/index.cfm.)

Healthy People 2020 highlighted the importance of
addressing the social determinants of health by includ-
ing “Create social and physical environments that
promote good health for all” as one of the four overar-
ching goals for the decade. This emphasis is shared by
the WHO, whose Commission on Social Determinants
of Health (CSDH) in 2008 published the report, Closing
the Gap in a Generation: Health Equity through Action on
the Social Determinants of Health.2 The emphasis is also
shared by other U.S. health initiatives such as the Na-
tional Partnership for Action to End Health Disparities
3 and the National Prevention and Health Promotion
Strategy.19

Midcourse Review: For Healthy People 2020, there
were eight primary objectives. The midcourse review
included 25 related objectives from other topic areas
for a total of 33 objectives that were all measurable.
Eight were informational. For the other objectives,
10 showed little or no improvement, 9 were improving,
and 6 met or exceeded the 2020 targets (Fig. 7-4).22

n HEALTHY PEOPLE
Social Determinants of Health HP 2020

Goal: Create social and physical environments that
promote good health for all.
Overview: Health starts in our homes, schools,
workplaces, neighborhoods, and communities. We
know that taking care of ourselves by eating well and
staying active, not smoking, getting the recommended
immunizations and screening tests, and seeing a doctor
when we are sick all influence our health. Our health is
also determined in part by access to social and economic
opportunities; the resources and support available in
our homes, neighborhoods, and communities; the quality
of our schooling; the safety of our workplaces; the
cleanliness of our water, food, and air; and the nature of
our social interactions and relationships. The conditions
in which we live explain in part why some Americans are
healthier than others and why Americans more generally
are not as healthy as they could be.

7711_Ch07_157-190 23/08/19 10:23 AM Page 161

health and to strive to promote equal opportunities to
maximize the health of individuals and communities.
The CSDH convened by the WHO in 2005 concluded
that “… social justice is a matter of life and death”.24

Although this report was completed more than a decade
ago, the gaps in life expectancy among countries remain.
Social justice continues to be a major issue at the policy
level, with the U.S. continuing to debate whether health
is a right or a privilege. At the global level, distribution
of needed health services, as depicted in the case of
newborn care in Southern Sudan earlier, continues to be
hampered by poverty, war, and fragile infrastructure in
low-income countries.

The Intersection of Race, Poverty, and Place
Although African Americans account for only 13% of the
U.S. population, they account for almost 50% of persons
infected with HIV when there is no biological or genetic
basis for the difference.26 The driving factors are a “nexus
of race, poverty, and place” as demonstrated in 2014 by
Gaskin et al.27 Race is a social construct with no biological
foundation and is not a useful clinical marker for disease.
Instead, understanding the role of poverty and place
should help drive the development of policies aimed at ad-
dressing health disparity. Communities with a higher level
of poverty are less apt to be able to provide community-
level resources, which include grocery stores, parks and
recreation facilities, quality schools, and public transporta-
tion. There are also fewer employment opportunities and
limited access to health care.27

Based on the WHO list of 10 facts on health inequities
and their causes,26 addressing health disparity requires
more than improving treatments for specific diseases. It
requires a more complex approach in which health-care
services link with social services.28 According to the
WHO, “The lower an individual’s socioeconomic posi-
tion, the higher their risk of poor health.”26

162 U N I T I I n Community Health Across Populations: Public Health Issues

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Doctorless Children
Public Health Science Topics Covered:

• Community assessment
• Health planning

Emily, a school nurse in a large community-based
public elementary school, grew concerned due to the
increasing diversity among the students. Many first-
generation immigrants have moved into the lower-
income, working-class community served by the

school. Emily found that, among the students, 15 differ-
ent languages were spoken at home as the primary
language, particularly among the 40% of the students
whose families came from Asia, Africa, South America,
and Central America. The make-up of the rest of the
students is: African Americans, 40%; second generation
Hispanics, 10%; and whites, 10%.

Emily reviewed the health statistics for the popula-
tion at her school at the beginning of the school year.
In this school, she found disparities in disease/illness
rates compared with those in other schools in the
district:

• 32% were not completely immunized compared with
3% at other schools.

• 51% had not received the required physical exam.
• There was a higher than average rate of failure for

the vision and hearing screening tests.
• There was a higher absenteeism rate.
• 67% had not seen a dentist compared with 31% at

the other schools.
• 24% of the children were overweight but not much

more than the children in the other community
schools.

• Children between 5 and 8 years old had a higher rate
of asthma than in other schools in the same district.

Emily wondered if one of the issues facing these
families was access to care. To help determine what
barriers to health care the families might be experienc-
ing, she examined the children’s school records in
more detail as well as resources available within the
neighborhood. She found that:

• Few children had a primary care physician listed in
their school record.

• The nearest pediatric and family practice clinics
required that families using the bus system make a
minimum of two transfers.

Emily wished to gather more data from the parents
but was challenged by the language barriers and by
the fact that most of the parents worked. She sought
interpreters in the community for the different lan-
guages spoken at home and then set up focus groups
(see Chapter 4) with parents to help find out more
about why the children had received less health
care than children in the other schools in the district,
especially preventive care.

Although she was unable to conduct a focus group
with all of the different groups within the community,
she was able to include immigrant groups, Hispanics,

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C H A P T E R 7 n Health Disparities and Vulnerable Populations 163

African Americans, and whites. For all of the parents,
a central issue was the difficulty of getting to the
primary care clinics located outside the neighborhood
because it required taking two to three buses with
time-consuming transfers, and the offices were only
open during working hours. They said the clinics were
very crowded and, when they finally got to see some-
one, they often had less than 10 minutes with the
care provider. For the non-English-speaking parents,
translators were rarely available. The parents, even
those with English as their primary language, reported
that going to the clinic had little value because often
they did not understand what the health-care provider
was telling them, the suggested steps for prevention
weren’t always possible to carry out (“I can’t afford all
that fancy fruit!”), and often minimal explanation was
provided related to any prescriptions, including where
to get them filled. When their children were really sick,
most of the parents used the urgent care clinic in the
community, but this required up-front payment, so
they often delayed going until their child was really
sick, which often meant a trip to the emergency room.

The parents mentioned that the department of
public health provides free immunization clinics and
school physicals for a nominal charge, but they pointed
out they cannot afford to miss a day of work without
pay to bring the children. They wished the clinics were
open on Saturday or in the evenings. Based on the
data from these focus groups, Emily identified several
factors in the health-care system that contributed to
the health-care disparity at her school:

• Limited access to care
• Lack of primary care practitioners in the overbur-

dened clinics
• No primary health care in the immediate neighborhood
• Health department clinics that meet at hours inacces-

sible to the working population in the community
• Limited public transportation
• Lack of translators at the clinics

She invited parents, teachers, and staff to attend a
series of early evening meetings to strategize about how
some of these factors could be mitigated to reduce the
disparity. Several of the teachers and the school coun-
selor saw this as an important component of school
health and also agreed to attend. Emily suggested that
the parents who do not speak English find someone
who can translate for them and that the translators can
also participate. She encouraged the families to bring
others from the community. She pointed out that it is

really a community issue and not just a school issue.
Emily valued the time of all these stakeholders and
tried to be organized to help them arrive at some clear
outcomes by the end of the meeting.

The group had three meetings. Participants offered
suggestions and concrete plans to be implemented,
some to be done at the school and others in the
community. These suggested collaborative actions
included the following:

• Improve access to care.
• With the partnership of the local public health de-

partment, provide an immunization clinic and school
physicals one evening a month (or on Saturday) at
the school.

• Negotiate with one of the primary care clinics
outside the community and the board of education
to provide a satellite comprehensive clinic at the
school, developing underutilized school space.

• Provide information at the school about the insur-
ance and other health program eligibilities for
children of low-income working parents.

• Bridge cultural/literacy gaps.
• Develop evening English as a Second Language (ESL)

classes for the parents, coordinated by one teacher
at the school, a local social service agency, and
volunteers from the local university.

• Start monthly cultural programs organized by the
school Parent-Teacher Association to showcase
all of the cultures at the school and facilitate more
communication among the parents.

• Create information tools that can be used by people
with low health literacy to gain information on com-
mon childhood illnesses; health promotion and dis-
ease prevention actions; and new skills the families
can use, even with limited resources, to navigate the
U.S. health-care system. Offer to share these infor-
mation tools with the local primary care clinics.

• Communicate with the clinics about the need to
provide required translation services either with
trained, certified volunteers including university
students, or with a telephone translation service.

With the assistance and support of the community,
Emily and the planning group were ready to design
actions to implement some of these changes. Emily
received two neighborhood development grants to
help cover program implementation. The next steps
in the process included looking for sustainable funding
for an ongoing school health program aimed at reduc-
ing the gap in access to care.

7711_Ch07_157-190 23/08/19 10:23 AM Page 163

Public Health Organizations: Global
to Local
Universal Declaration of Human Rights
The Universal Declaration of Human Rights, adopted by
the General Assembly of the United Nations in 1948, con-
tinues to provide the underlying framework for equity in
health at the WHO and down through national- and
state-level approaches to improving health equity. The
Declaration consists of 30 articles that serve as a standard
of achievement for all nations to measure compliance
with human rights and fundamental freedoms. Article
25 states, “Everyone has the right to a standard of living
adequate for the health and well-being of himself and of
his family, including food, clothing, housing, medical care

and necessary social services, and the right to security in
the event of unemployment, sickness, disability, widow-
hood, old age, or other lack of livelihood in circumstances
beyond his control.”29 Articles 22 to 27 are most specific
to equity in health care, examining economic, social, and
cultural rights (Box 7-1).

In 1978, at the International Conference on Primary
Care, the Alma-Ata Declaration affirmed these human
rights (see Chapter 15). The goal was to see the provision
of primary health care to every individual by the year
2000, thus achieving the goal of health care for all. The
second section of the Alma-Ata Declaration stated, “The
existing gross inequality in the health status of the people
particularly between developed and developing countries
as well as within countries is politically, socially, and eco-
nomically unacceptable and is, therefore, of common

164 U N I T I I n Community Health Across Populations: Public Health Issues

Article 22
Everyone, as a member of society, has the right to social
security and is entitled to realization, through national
effort and international co-operation and in accordance
with the organization and resources of each State, of the
economic, social, and cultural rights indispensable for his
dignity and the free development of his personality.

Article 23
1. Everyone has the right to work, to free choice of

employment, to just and favorable conditions of
work, and to protection against unemployment.

2. Everyone, without any discrimination, has the right
to equal pay for equal work.

3. Everyone who works has the right to just and favorable
remuneration ensuring for himself and his family an
existence worthy of human dignity, and supplemented,
if necessary, by other means of social
protection.

4. Everyone has the right to form and to join trade unions
for the protection of his interests.

Article 24
Everyone has the right to rest and leisure, including reason-
able limitation of working hours and periodic holidays
with pay.

Article 25
1. Everyone has the right to a standard of living adequate

for the health and well-being of himself and of his fam-
ily, including food, clothing, housing, and medical care
and necessary social services, and the right to security

in the event of unemployment, sickness, disability,
widowhood, old age, or other lack of livelihood in
circumstances beyond his control.

2. Motherhood and childhood are entitled to special care
and assistance. All children, whether born in or out of
wedlock, shall enjoy the same social protection.

Article 26
1. Everyone has the right to education. Education shall

be free, at least in the elementary and fundamental
stages. Elementary education shall be compulsory.
Technical and professional education shall be made
generally available and higher education shall be equally
accessible to all on the basis of merit.

2. Education shall be directed to the full development
of the human personality and to the strengthening of
respect for human rights and fundamental freedoms. It
shall promote understanding, tolerance and friendship
among all nations, racial or religious groups, and shall
further the activities of the United Nations for the
maintenance of peace.

3. Parents have a prior right to choose the kind of educa-
tion that shall be given to their children.

Article 27
1. Everyone has the right freely to participate in the

cultural life of the community, to enjoy the arts, and
to share in scientific advancement and its benefits.

2. Everyone has the right to the protection of the moral
and material interests resulting from any scientific,
literary, or artistic production of which he is the
author.

BOX 7–1 n The Universal Declaration of Human Rights, WHO 1948

Source: (29)

7711_Ch07_157-190 23/08/19 10:23 AM Page 164

concern to all countries.”30 In the 21st century, the WHO
continues to advocate for reducing health inequity based
on the concept that health is a fundamental human
right.10

United States
Healthy People 2020 stated that the impact of social and
physical determinants of health “… determinants affect a
wide range of health, functioning, and quality of life out-
comes.” They provided a number of examples (Box 7-2).19

As noted earlier, Healthy People 2030’s foundational
principles include “Achieving health and well-being
requires eliminating health disparities, achieving health
equity, and attaining health literacy”.17

Along with Healthy People, a number of U.S.
national-level organizations have placed health equity as
a priority. The Centers for Disease Control and Preven-
tion (CDC) not only tracks disparity in health outcomes
but also provides detailed information on evidenced-
based resources to states and local governments. Every
few years, they release a report on programs aimed at
reducing health disparity.31 The U.S. Office of Minority
Health (OMH) was created to address disparity and
inequity in health among racial and ethnic minorities
including Native Americans on reservations. The OMH
provides funding for assessment, research, education,
and intervention with public and private collaborative
partners as suggested by the summit.32 In 2008, the OMH

generated a logic model specific to improving ethnic and
minority health that continues to describe what the
OMH does (Fig. 7-5) (see Chapter 5).32,33 The model
provides guidance to health-care providers, policy mak-
ers, community stakeholders, and researchers to move
the process along in a unified way.32 The goal is to create
interventions that change outcomes and decrease racial
and ethnic disparities. The five purposes of the model
are to:

1. Provide policy makers and others concerned with
health disparities a better appreciation of the issues

2. Better understand the interrelationship of all the
variables

3. Provide a research format and direction for data
input

4. Give building blocks to the community stakeholders
so they can contribute input and improve structure

5. Improve the systematic planning of data collection,
interventions, and evaluation33,34

State and Local Public Health Organizations
At the state and local level, public health departments
include minority and ethnic health as part of their mis-
sion, and they are often the organizations that implement
evidenced-based programs aimed at reducing disparity
and promoting health equity as evidenced by the CDC’s
Racial and Ethnic Approaches to Community Health
(REACH) program.35 The REACH program also funds
tribes, universities, and community-based organizations
to develop and implement health programs aimed at
reducing health disparities. Funded programs have in-
cluded a wide range of health issues including improving
physical activity, increasing access to healthy foods, and
increasing breastfeeding.

Vulnerability at the Population Level
Social determinants of health, including economic deter-
minants, environmental determinants, social capital, and
health system determinants, are associated with the de-
gree of vulnerability experienced by different populations.
Thus, individual risk factors combine with community
and population factors to influence the vulnerability
of at-risk groups. These at-risk groups who experience
vulnerability due to challenges related to the social deter-
minants of health include those experiencing homeless-
ness, migrants, immigrants, asylees, those with a history
of incarceration, and members of Lesbian, Gay, Bisexual,
Transgender, Queer (LGBTQ+) community. Develop-
mental stages also contribute to vulnerability for older
adults (Chapter 19) and children (Chapters 17 and 18)

C H A P T E R 7 n Health Disparities and Vulnerable Populations 165

• Access to parks and safe sidewalks for walking is
associated with physical activity in adults.

• Education is associated with longer life expectancy
and improved health and quality of life.

• Health-promoting behaviors like getting regular physical
activity, not smoking, and going for routine checkups
and recommended screenings can have a positive
impact on health.

• Discrimination, stigma, or unfair treatment in the
workplace can have a profound impact on health;
discrimination can increase blood pressure, heart rate,
and stress, as well as undermine self-esteem and
self-efficacy.

• Family and community rejection, including bullying,
of lesbian, gay, bisexual, and transgender youth can
have serious and long-term health impacts including
depression, use of illegal drugs, and suicidal behavior.

BOX 7–2 n Healthy People: Examples of the
Impact of Social and Physical
Determinants of Health

Source (19)

7711_Ch07_157-190 23/08/19 10:23 AM Page 165

166 U N I T I I n Community Health Across Populations: Public Health Issues

1. Racial/Ethnic Minority Health Status Issues (i.e., preventable morbidity &
premature mortality)
2. Racial/Ethnic Health Disparities
3. Need for a Systems Approach

Long-Term
Problems

1. Individual Level:
• Knowledge
• Attitudes
• Skills
• Behaviors
• Biological/Genetic Risks
2. Environmental/Community Level:
• Physical Environment
• Social Environment
• Community Values
• Community Assets
• Community Involvement
• Economic Barriers
3. Systems Level:
• Components and Resources
• Coordination and Collaboration
• Leadership and Commitment
• User-Centered Design
• Science and Knowledge

1. Individual Level:
• Efforts to Increase Knowledge
• Efforts to Promote Attitudes Conductive to Good Health
• Efforts to Build Skills
• Efforts to Promote Healthy Behaviors
• Efforts to Address Biological or Genetic Risks
2. Environmental/Community Level:
• Efforts to Increase Knowledge
• Efforts Aimed at the Social Environment
• Efforts to Address Economic Barriers
3. Systems Level:
• Efforts to Strengthen Components and Resources
• Efforts to Promote Coordination and Collaboration
• Efforts to Foster Leadership and Commitment
• Efforts to Promote User-Centered Design to Address R/E Minority Needs
Through
• R/E Minority Participation
• Health Care Access/Coverage
• Culturally and Linguistically Appropriate Service
• Workforce Diversity
• Racial/Ethnic Data Collection
• Efforts to Improve Science and Knowledge

1. Individual Level: E.g.,
• Increased awareness/knowledge about disease prevention or risk reduction
• Increased health care provider skills in providing culturally & linguistically
appropriate services
• Increased patient adherence to prescribed treatment regimens
• Reduced morbidity & mortality
2. Environmental/Community Level: E.g.,
• Decreased exposure to risks in the physical environment
• Increased public awareness about racial/ethnic health disparities
• Increased health care access & appropriate utilization
• Increased plans & policies that promote health & well-being at the local, state, &
national levels
• Reduced morbidity & mortality
3. Systems Level: E.g.,
• Increased inputs & other resources for racial/ethnic minority health-/health
disparities-related priorities
• Increased partnerships & collaborations for greater effectiveness & efficiency
• Increased strategic planning, with goals & objectives, evaluation, & performance
monitoring
• Increased system design characteristics to minimize barriers for minority users
• Increased knowledge development/science base about “what works”

1. Increased quality and years of healthy life for racial/ethnic minorities
2. Reduced and, ultimately, eliminated racial/ethnic health disparities
3. Systems approach to racial/ethnic minority health improvement and health
disparities reduction

A Strategic Framework For Improving Racial/Ethnic (R/E) Minority
Health & Eliminating R/E Health Disparities

Contributing
Factors

Strategies and
Practices

Outcomes and
Impacts

Long-Term
Objectives and

Goals

Office of Minority Health

Figure 7-5 Logic Model of a strategic framework for improving health disparities.

7711_Ch07_157-190 23/08/19 10:23 AM Page 166

especially vulnerable to adverse health consequences such
as increased mortality and morbidity due to communi-
cable diseases, injury, environmental exposure to toxins,
and during disasters. Experiencing marginalization,
stigma, racism, and discrimination increases vulnerability
when coupled with the social determinants of health of
poverty, education, and place.

Poverty
Economic factors are, perhaps, the most important factor
influencing the health status of an individual or group.
Lower socioeconomic status is associated with increased
vulnerability. Socioeconomic status (SES) is a composite
measure of the interrelated concepts of income, educa-
tion, and occupation. With higher levels of education, a
person is more likely to secure a better job, which in turn
provides a higher rate of pay. By contrast, a person who
does not earn a high school diploma has more difficulty
finding a job that pays a living wage (a wage that provides
access to the means of a healthy living, e.g., housing,
food, and health care). Therefore, individuals at a lower
SES level have increased vulnerability to poor health
because of lack of economic resources.

When household income falls below the economic
threshold considered to be adequate to support the
number of persons in the household, the members of
that household are considered to be living in poverty.
There are multiple aspects to defining this poverty
threshold and the applications of this threshold to de-
termine poverty rates. In the United States, the poverty
threshold is the measurement used by the U.S. Bureau
of the Census to calculate all official poverty population
statistics. The poverty threshold is a yearly determina-
tion of a standard of living below which a family has the
lack of goods and services commonly taken for granted
by mainstream society.36 The census bureau adjusts the
threshold based on family size and other demographic
variables. For example, in 2017, the threshold for a
single person under the age of 65 was $12,752, and for a
household of five with three children under the age of
18, the threshold was $29,253.36 With very few adapta-
tions, the U.S. government’s measurement of poverty
has remained unchanged for 40 years, although the basis
on which the initial calculations were made has shifted.
For example, the percentage of income spent on food
has decreased, and the percentage spent on such cate-
gories as transportation, health care, and childcare have
increased.

There are also considerable variances among costs in
different parts of the United States and between urban
and rural areas (see Chapter 16). These variances are not

considered in the current poverty threshold. The poverty
threshold is primarily used for statistical purposes, so
a consistent method of measurement is used at the
national level.

The poverty guidelines are another federal measure
(see Table 7-1). These guidelines simplify the poverty
thresholds and are used for administrative purposes such
as determining who is eligible for federal programs
aimed at aiding those living in poverty.37 Both poverty
guidelines and poverty thresholds are established on a
yearly basis and are issued by the U.S. Department of
Health and Human Services.36,37

In 2016, the median household income was $59,039,
up slightly from 2015. The 2016 U.S. poverty rate
remained higher than in 2000 (12.7% versus 11.1%)
but had improved from 2012 when it was 15.0%. This
translated to 40.6 million people living in poverty in
2016.38 This is not the highest percentage, as more than
20% lived in poverty in the early 1960s. The War on
Poverty, under the Johnson administration, decreased
the poverty rate to 11.1% in 1973. Unfortunately, the
number rose again in the 1980s and has since fluctuated
based on economic growth and recession, even with mul-
tiple programs directed at decreasing poverty in the
United States. When considering the influence of SES on
health, it becomes clear that health-care providers must
focus their efforts on improving not just health outcomes
but also social determinants of health such as educational
and employment opportunities.

C H A P T E R 7 n Health Disparities and Vulnerable Populations 167

TABLE 7–1 n The 2018 Poverty Guidelines for
the 48 Contiguous States and the
District of Columbia

Persons in Family/Household Poverty Guideline

For families/households with more than 8 persons, add
$4,320 for each additional person.

1 $12,140

2 $16,460

3 $20,780

4 $25,100

5 $29,420

6 $33,740

7 $38,060

8 $42,380

Source: (38)

7711_Ch07_157-190 23/08/19 10:23 AM Page 167

Social Capital and Vulnerability
Social capital is a term that has numerous definitions
in the literature. The central point of social capital is
the benefits that occur through social networks. One
example is that persons often secure a job based on
whom they know rather than what they know. Social
capital usually refers to a person’s or a community’s
capacity to obtain support from the social connections
available to the person or community. Social capital
resides in the quantity and quality of interpersonal ties
among people and communities.39 These relationships
represent a resource (capital) that can be drawn upon
during challenging times. Social capital is reflected in
the institutions, organizations, and informal practices
of giving that people create to share resources and build
attachments with others. The values and norms of
a community influence the health, well-being, and vul-
nerability of individuals and populations. Community-
level attributes such as social stability, recognition
and valuing of diversity, safety, good working relation-
ships, and a cohesive community provide a supportive
environment in which to live, thereby reducing a per-
son’s potential risk for poor health. These ties may
be with family, friends, or colleagues, as well as with
various community institutions and agencies. When a
person or group has reduced social capital, he or she is
at greater risk for vulnerability at all times but especially
when faced with a challenge.

A good example of community-level social capital is
the case of the community referred to as Little Italy in
Baltimore, Maryland. The neighborhood located east of
downtown Baltimore experienced a number of assaults
and robberies. The community already had a long-
standing community committee. The committee called
a meeting and invited the Baltimore police and their
state representative to attend. Because of the relation-
ships this community had built over time with the city
of Baltimore and their state representative, they were
able to obtain heightened police presence in the com-
munity. The members of the community also banded
together and began to pool their resources so that they
could obtain further security for the community. As a
result, the number of assaults and robberies fell. The
community had developed strong social capital over
time by building a sense of pride in the community
among residents, the support among community busi-
nesses, and the ability to gain the attention of lawmakers
and the city police department. In addition, the commu-
nity came together for one assault victim who had sus-
tained serious injuries and raised funds to help cover his
hospital expenses.

An individual may have social attachments with
other individuals within their community yet remain
vulnerable because of a lack of social capital. For exam-
ple, during Hurricane Maria in Puerto Rico, many of the
individuals who were most vulnerable lacked connec-
tions with individuals or agencies that could assist them
with evacuation during the disaster. Although these
individuals and families no doubt had social connec-
tions with supportive family and friends, many of those
same individuals lacked the capacity to provide needed
support for evacuation in the form of money, trans-
portation, and shelter.

Multiple Determinants of Vulnerability
To reduce vulnerability, it is necessary to examine the
root causes in a comprehensive manner. Approaches to
understanding vulnerability from the lens of individual-
level determinants of health can result in a failure to
assess the effect that larger social influences have on the
individual or population. Conversely, approaches to vul-
nerability that focus entirely on the social determinants
of health at the population level could result in a failure
to recognize the manifestation of these influences on in-
dividuals and families. Using a multiple determinants of

168 U N I T I I n Community Health Across Populations: Public Health Issues

n CULTURAL CONTEXT
A person’s cultural identity provides a sense of con-
nection to a community of individuals who share a
culture. This can lead to an increase in social capital
and often improved health. By contrast, those sepa-
rated from their cultural group may experience
increased isolation and thus increased vulnerability.
For example, one set of researchers found that the
isolation of men who sought same-sex relationships
in Indonesia was associated with an increased vulnera-
bility to HIV infections among participants in the study
due to prohibitive cultural perspectives and norms
with respect to homosexuality.40 In a 2004 editorial
in the American Journal of Public Health, Thomas, Fine,
and Ibrahim stated: “Efforts to eliminate health dispari-
ties must be informed by the influence of culture on
the attitudes, beliefs, and practices of not only minor-
ity populations but also public health policymakers
and the health professionals responsible for the
delivery of medical services and public health interven-
tions designed to close the health gap.”41 Addressing
disparity in vulnerable populations requires not only
understanding the cultural context of the community
and the population needing care but also the cultural
perspectives of those providing the care.

7711_Ch07_157-190 23/08/19 10:23 AM Page 168

vulnerability approach acknowledges the overlap of
risk across many of the determinants of health at the
population and individual level that results in increased
vulnerability. That is, the more risk factors for poor
health that a person or group has distributed across the
individual and societal levels, the more likely it is that the
person or group will be vulnerable. In particular, mar-
ginalization, racism, discrimination, and stigma of a pop-
ulation can result in increased vulnerability.

Marginalization
Marginalization is a social process through which a
person or group is on the periphery of society based
on identity, associations, experiences, or environment.42

To marginalize someone is to treat the person as though
she is of little or no consequence or is unimportant. The
marginalization of certain groups conveys the idea that
individuals in those groups do not matter or are of little
concern to the rest of society. Often, group differences,
such as gender, ethnicity or race, education or income,
geographical location, or sexual preference contribute to
marginalization. Women, racial and ethnic minorities,
and persons living in poverty are examples of groups that
have a long history of marginalization within our society.
Marginalization limits an individual’s or a group’s op-
portunities for establishing beneficial relationships nec-
essary for accessing health-care services. In addition,
those who are marginalized can experience heightened
levels of stress and despair related to their sense of
powerlessness.43

Racism and Discrimination
According to the Merriam-Webster online dictionary,
racism is defined as “A belief that race is the primary
determinant of human traits and capacities and that racial
differences produce an inherent superiority of a particular
race.”44 Discrimination occurs when one group gives un-
just or prejudicial treatment to another group based on
his or her race, ethnicity, gender, SES, or other group
membership. Discrimination can occur at the individual,
institutional, or structural level (see Box 7-3).45 Over time,
a causal link between racial discrimination and increased
risk for morbidity and mortality has emerged demon-
strating a negative impact on both mental and physical
health.46,47

Stigma
Stigma is defined by the online Merriam-Webster dic-
tionary as “a mark of shame or discredit”.48 Stigmatized
individuals either possess, or are believed to possess,
some attribute that is not valued in a particular social

context. For example, being diagnosed with a mental
health disorder (see Chapter 10) or a substance use
disorder (see Chapter 11) can result in being stigmatized
in a demeaning way and seen as less than. Members of
vulnerable populations who are stigmatized experience
loss of status within society, which can then result in
discrimination. This discriminatory treatment leads
to further stigma and further loss of status, thus perpet-
uating a cycle that enhances vulnerability and marginal-
ization that is, once again, beyond the control of the
individual.

Ethical Issues
The majority of the literature on ethics and health care
with vulnerable populations revolves around the inclu-
sion of vulnerable populations in research. Health-care
research focused on vulnerable populations includes par-
ticipants who are at greatest risk for coercion and may
not be able to give informed consent. These groups in-
clude prisoners, pregnant women, children, those who
are mentally incapacitated, refugees, the poor, older
adults, sexual minorities, and persons with a substance
use disorder.49 From a public health perspective, the issue
of ethics and vulnerability extends beyond the ethical
concerns of including participants in health-care re-
search. Identifying a group as vulnerable must be done
in a way that avoids paternalism and stereotyping. Vul-
nerability does not mean that an individual or group is
“less than” but rather acknowledges the increased risk

C H A P T E R 7 n Health Disparities and Vulnerable Populations 169

• Individual discrimination refers to the behavior of
individual members of one race/ethnic/gender group
intended to have a differential and/or harmful effect on
the members of another race/ethnic/gender group.

• Institutional discrimination, on the other hand, is
quite different because it refers to the policies of the
dominant race/ethnic/gender institutions and the
behavior of individuals who control these institutions
and implement policies intended to have a differential
and/or harmful effect on minority race/ethnic/gender
groups.

• Finally, structural discrimination refers to the policies
of dominant race/ethnic/gender institutions and the
behavior of the individuals who implement these
policies and control these institutions, which are race/
ethnic/gender neutral in intent but which have a
differential and/or harmful effect on minority race/
ethnic/gender groups.

BOX 7–3 n Levels of Discrimination

Source: (45)

7711_Ch07_157-190 23/08/19 10:23 AM Page 169

for adverse health outcomes and provides a means to ad-
dress health inequity.

Nursing care of vulnerable populations uses a frame-
work of cultural competence, social justice, and human
rights. The ethical code of nursing states that all indi-
viduals, families, groups, and communities will receive
equal nursing care.50 Nurses who demonstrate compe-
tence with advocacy for social justice and protection
of human rights are better able to address the social
inequities of vulnerable populations. There is always a
tension between availability of scarce resources and the
perceived worthiness of the individual receiving these
resources.

Experiencing Homelessness
Although not a disease, homelessness kills. Globally, per-
sons experiencing homelessness often lack the resources
needed for basic needs such as shelter, clothing, and
food. If they experience a health issue, they may have
limited access to health-care insurance, leaving the hos-
pital emergency department (ED) as the primary acces-
sible source of health care for homeless adults.51 Often
health needs are complex and include both mental and
physical health issues, and there is limited evidence on
the effectiveness of interventions aimed at improving
their health.52,53,54 Persons experiencing homelessness
have a shorter life span.54 Viewed through the lens of
social determinants of health, the relationship between
homelessness and poorer health in this population is a
consequence of adverse social and economic conditions.
This situation leads to later diagnosis of disease and fewer
resources for treating physical and mental health issues,
which in turn leads to higher morbidity and mortality.54

Thus addressing social issues such as housing and access
to primary care could counter the enormous economic
costs of hospital care for people who are experiencing
homelessness.54

Who exactly experiences homelessness? Is it someone
who lives on the street or someone who lives in a shelter?
What about someone sleeping on the couch of a friend
or family member? To answer these questions, the U.S.
government has a two-part definition of homelessness.
According to The McKinney-Vento Homeless Assistance
Act of 2009 that was reauthorized in 2015, someone who
is homeless meets one or both of the following criteria:55

• One who lacks a fixed, regular, and adequate night-
time residence

• One who lives in a supervised shelter or institution
designed for temporary residence, or one who lives

in a place that is not normally used as accommoda-
tion for people

Using this definition of homelessness, a person who
lives on the street, in a shelter, or is couch-surfing is ex-
periencing homelessness. If a person moves from home
to home constantly, then that person is lacking a fixed
and/or regular nighttime residence and therefore is
homeless.

There are then clearly different types or levels of
homelessness. Just as we separate prevention into three
levels—primary, secondary, and tertiary—the standard
for defining the degree of homelessness is to place those
experiencing homelessness into three groups:56

• Primary homelessness includes everyone who is
living without adequate shelter—those living in
vehicles, surviving on the streets, staying in parks,
or squatting in abandoned buildings.

• Secondary homelessness includes those who are
staying in a temporary form of housing because
they have nowhere else to go—those living with
friends or family, or in shelters.

• Tertiary homelessness includes those who rent
single rooms on a long-term basis without security
of a fixed or permanent residence.56

Time periods provide another way of understanding
homelessness. According to the National Coalition on the
Homeless, there are three types of homelessness – chronic,
transitional, and episodic. Those experiencing chronic
homelessness are more likely to require shelter on a long-
term basis, are chronically unemployed, older, and more
apt to have physical and/or mental health issues. Persons
experiencing transitional homelessness require shelter for
a shorter period, are younger, and are more likely to ex-
perience homelessness due to a catastrophic event. Those
experiencing episodic homelessness are also younger, are
in and out of the shelter system, are more likely to be
chronically unemployed, and have medical and/or mental
health issues.57

Persons Experiencing Homelessness
Obtaining estimates of the number of persons who expe-
rience homelessness is a challenge because of the difficulty
in collecting the data. One way to get an estimate of how
many people experience homelessness is to determine the
number of persons experiencing homelessness on a given
night. This is called a point in time estimate of homeless-
ness, because a single night, or one point in time, was used
to determine prevalence. In 2017, HUD found 553,742
individuals to be homeless on a single night. Less than a

170 U N I T I I n Community Health Across Populations: Public Health Issues

7711_Ch07_157-190 23/08/19 10:23 AM Page 170

fifth were chronically homeless (95,419). According to the
report, a little under 112,000 had severe mental illness and
little less than 90,000 had chronic substance use issues.
About 7% were veterans. Based on racial categories,
almost half of those tracked in this report (47%) were
African American though only 13.4% of the U.S. popula-
tion is African American.58

Estimating the prevalence is also done by the type
of homelessness (primary, secondary, or tertiary) or
the different populations experiencing homelessness.
Certain segments of the population are at greater risk for
experiencing homelessness. For example, families, single
youths, and single adults do not experience the same
rates of homelessness. There are also differences based
on geography, with 50% of persons experiencing home-
lessness residing in one of five states: California,
New York, Florida, Texas, and Washington.57 Warmer
climates make it easier to deal with issues related to
weather. In the general population, using data from the
2017 Housing and Urban Development (HUD) report,
less than 2% are experiencing homelessness.58 However,
the HUD data does not necessarily include persons dou-
bling up with friends and neighbors.

Single or solitary adults, mostly males, are more likely
to experience primary homelessness than those who are
either solitary youths or in families. Homeless families are
more likely to experience secondary homelessness than
primary homelessness, as are solitary youths. Most cities
responded that this was likely the result of the policies in
place to protect families with children from experiencing
homelessness, including policies that made it more diffi-
cult to evict families who had fallen behind on their rent.

Homelessness is not just a big city problem; rural
homelessness does exist. Estimating how many people ex-
perience homelessness in a rural setting is difficult because

estimates such as that reported by HUD (Table 7-2) rely
on counts of persons using services. Persons experiencing
homelessness in rural areas have access to fewer rural serv-
ice sites. In addition, there are a limited number of re-
searchers working in rural communities.57 In comparison
with urban homeless populations, the rural homeless are
more likely to be white, female, married, homeless for the
first time, to have jobs, and to be homeless for a shorter
period of time.57

Impact on Health
Adults experiencing homelessness are faced with an
excess disease burden, a shorter life expectancy, limited
access to care, and consumption of significantly more
health-care resources when she or he does finally receive
care.59-61 Establishing current prevalence of communi-
cable and noncommunicable disease presents a challenge
due to the lack of regular surveillance and the transient
nature of the population. Available data underlines
the fact that those experiencing homelessness have a
higher rate of disease compared with the general U.S.
population.60-62 According to the National Alliance to
End Homelessness, those experiencing homelessness are
three to six times more likely to have diabetes, HIV/
AIDs, cardiovascular disease, and/or a substance use dis-
order.61 Between 25% to 33% of homeless persons have
mental health issues, including schizophrenia, depres-
sion, and bipolar disorder compared with 6% of the gen-
eral population that experience the same severe mental
health issues.62 A person experiencing homelessness is
much more likely to arrive at the hospital in an ambu-
lance, be uninsured, be admitted, and is also more likely
to have a longer stay.60

The living conditions of those experiencing primary
homelessness are not optimal. If a patient who is currently

C H A P T E R 7 n Health Disparities and Vulnerable Populations 171

TABLE 7–2 n Prevalence of Homelessness by Race in 2017

Emergency Shelter Transitional Housing Unsheltered Total

African American

White

Asian

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Other Race

TOTAL

128,721

106,543

2,571

6,228

2,807

15,560

262,430

38,768

47,946

1,132

2,496

1,678

6,417

98,437

57,448

106,490

3,057

8072

4,040

13,768

192,875

224,937

260,979

6,760

16,796

8,525

35,745

553,742

Source: (58)

7711_Ch07_157-190 23/08/19 10:23 AM Page 171

homeless is admitted to the hospital for surgery, it will be
much more difficult for that patient to keep an incision
infection-free postdischarge than it will be for someone
who is living in a place suitable for human shelter. Second,
transportation costs make it difficult for a patient experi-
encing homelessness to receive follow-up care and testing.
Third, the nutritional intake of a homeless patient is
irregular and less healthy than that of the general popu-
lation, making diet instructions hard to follow, which may
be further impacted by poor dental care. There are other
complicating factors that are easily overlooked. For
example, where can a diabetic homeless patient store
insulin? How does such a patient keep a medication from
being stolen?

172 U N I T I I n Community Health Across Populations: Public Health Issues

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Rubbermaid Storage
Box
Public Health Science Topics Covered:

• Community assessment
• Community diagnosis
• Organization and management
• Community partnerships

While in graduate school pursuing a degree as an
advanced public health nurse (APHN), Adele was asked
to supervise a group of undergraduate nursing students
assigned to take weekly blood pressure readings at a
local homeless shelter, the City Gospel Mission. This
faith-based nondenominational mission was located in
downtown Cincinnati and provided multiple services
including meals and shelter beds but did not offer
health care. From her first trip to the City Gospel
Mission, Adele felt compelled to reach out to this
vulnerable population.

Adele recognized that these men had very few
options for health care, and she wanted to offer
more than blood pressure screenings. As part of her
practicum experience, she went to the mission on a
weekly basis to provide nursing assessments, health
education, and nursing care. She began to interact
more with the men when they came to the clinic and
worked with them to help identify their health needs
and, in some cases, offer referrals. All of her supplies,
including her blood pressure cuff and a glucometer, fit
into a Rubbermaid storage box, which she left at the
shelter. Although she was providing some assistance,
she knew these men needed more. When she ap-
proached her faculty preceptor, she was encouraged
to apply the health planning process, do a focused

assessment that would help her to understand whether
there was a need for expanding the care, and consider
developing the model of a nurse-managed clinic if there
was a need. The faculty member explained that the
assessment could provide the data she needed to
develop a plan to address the health needs of the men
she was seeing.

In conducting part of their assessment, Adele and a
fellow APHN student asked key informants, homeless
men at the mission, where they sought health care.
They all mentioned the ED at a nearby major urban
medical center. The students’ assessment at the med-
ical center focused on identifying the costs associated
with nonurgent ED care for patients experiencing
homelessness. The students presented the findings
to the hospital performance improvement committee.
The committee agreed that an intervention aimed at
providing nonurgent care to homeless men outside
the ED would result in a cost benefit to the hospital,
and that a nurse-managed clinic model had the poten-
tial to meet that need.

After Adele graduated, she no longer had time to
continue to provide even the small amount of nursing
care she had offered at the mission. Having established
a need, Adele together with her faculty preceptor
sought sources of possible funding for expanding
Adele’s practicum experience to establish a permanent
nurse-managed clinic at the City Gospel Mission. The
success of this project depended on the application of
public health science and the public health competencies
that Adele had acquired. First, a team was formed that
included Adele, two faculty members from the Univer-
sity of Cincinnati College of Nursing, the chief nursing
officer from the hospital, and the director of the City
Gospel Mission. The next step was to flesh out the
initial assessment conducted by Adele and her fellow
student. Adele’s assessment of ED use by the homeless
was crucial information for the potential cost/benefit of
the clinic. However, to help understand the breadth of
the problem, further assessment was done using aggre-
gate data from the City Gospel Mission on the number
of potential clients for the clinic as well as secondary
analysis of available data on the prevalence of primary
homelessness in the city of Cincinnati. These data pro-
vided a clear picture of the need for the clinic. The final
step was to develop the program expanding on Adele’s
Rubbermaid container of supplies to include a more
comprehensive nurse-managed clinic model.

The team chose a nurse-managed clinic model
that would link with other resources in the city. Thus,

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C H A P T E R 7 n Health Disparities and Vulnerable Populations 173

patients of the clinic would receive nursing assess-
ments, health education, and nursing care under the
direction of Adele and be referred to other clinics
for more complex medical problems. To do this, the
project needed start-up funds to provide supplies,
equipment, a method to keep clinic medical records,
and to conduct an evaluation.

The first grant application was not funded. The team
took the grant reviews, refined the application, and
submitted it to another funding agency. They were
successful this time in obtaining a 2-year start-up grant.
The grant application succeeded based on three key
elements: (1) a clear delineation of the need for the
clinic; (2) evidence of sustainability of the clinic once
the funding was exhausted; and (3) a clear plan to
evaluate the effectiveness of the clinic. Sustainability
refers to the ability of a program to be maintained
once the funding period has been completed. In this
case, the three organizations that supported the
grant—the college, the hospital, and the shelter—all
committed to maintaining the clinic if the evaluation
demonstrated that it was effective. The college com-
mitted to sending students to the clinic for clinical
experiences, and the hospital agreed to be the “owner”
of the clinic, that is, staff would maintain the medical
records and provide salary support for Adele to
continue her work at the clinic. City Gospel Mission
agreed to continue to provide the space and utilities
for the clinic. The homeless men also became partners,
offering suggestions about time, location, and some of
the health needs they would like to see met. They also
saw a role in helping with the running of the clinic.

After 2 years of clinic implementation, the evalua-
tion team demonstrated that the clinic had indeed
improved health outcomes. One of the faculty mem-
bers from the college conducted the evaluation. Atten-
dees at the clinic were asked to complete a survey the
first day they used the clinic and at least 2 months after
they had begun to use the clinic. Forty-five homeless
adults completed both a baseline survey and a survey
after starting care at the clinic. There was a significant
increase in the percentage of participants who were
very satisfied in relation to perceived quality and avail-
ability of health care. In addition, there was a significant
improvement in health-related quality of life in relation
to mental health, physical problems, and vitality.63

Adele’s story is true. Although the grant ended in
2006, the nurse-managed clinic was still operating in
2018. The City Gospel Mission had built a new facility
and included a clinic for the nurses. They continue to

see 30 or more persons a night. The clinic is staffed
by volunteer nurses, nursing students, and, of course,
Adele, who provides nursing care, as well as extra
emotional support to her patients. The important
issue here is that Adele alone with her Rubbermaid
container was not enough. Adele took her enthusiasm
and concern for a vulnerable population and built a
team. The use of solid public health approaches re-
sulted in organizational commitment. Addressing the
health-care challenges for those who are vulnerable
requires this approach and can be successfully initiated,
implemented, and sustained by nurses.

Interventions and Services for Persons
Experiencing Homelessness
Even in the best of circumstances, health-care providers
experience problems in an acute care setting in helping
any patient manage personal health for the long term.
For example, sometimes it is difficult to ensure that, after
discharge, patients will follow up on time with their
health-care providers. Other times, patients may not take
their medicines as prescribed, which makes it even more
difficult to ensure that conditions are treated in the best
way possible. In primary care, patients might not get rec-
ommended testing because of embarrassment (e.g.,
colonoscopy) or because of costs associated with that
testing. Each of these problems is magnified for patients
who are also experiencing homelessness.

Shelter
Housing is the biggest need of the homeless. Simply pro-
viding housing can improve the health of the homeless
and reduce the number of hospital visits and hospital ad-
missions.59, 60 Homeless shelters provide an immediate
and temporary solution, usually for a stipulated and
limited amount of time (e.g., 3 months) for an individual
or a family. It is a safe and warm place to sleep and, in
areas of the United States when the winter weather is
more severe, an essential service. Shelters are frequently
sponsored by nonprofit organizations that have religious
and/or government sponsorship. Most shelters limit
their service to certain groups of people, frequently not
allowing any alcohol or illegal drugs, and have in place
strict rules about there being no violence in the shelter.
Many provide separate space or facilities for adolescents
and families with children. Most shelters open late in
the afternoon and close early in the morning, leaving the
person staying at the shelter on the street for the daylight
hours. Usually, shelters offer their service free of charge,

7711_Ch07_157-190 23/08/19 10:23 AM Page 173

and some will provide an evening meal for those staying
at the shelter. Some communities supplement their night
shelters with day shelters where people can go during the
time the night shelters are closed. These facilities usually
have an array of social services to help with permanent
housing, job placements, mental health care and services
for those with addictions, and job training. There may
also be showers, laundry facilities, used clothing avail-
able, as well as other amenities to help individuals and
families secure more permanent housing.

A step above the shelters is the more permanent tran-
sitional housing, which is affordable due to significant sub-
sidies, but again, there is usually a time limit (6 months to
2 years). People who agree to live in transitional housing
usually must participate in programs that provide coun-
seling, job searches, and job and educational training. Peo-
ple are taught skills on how to maintain more permanent
housing and manage their money.

Permanent affordable housing is the long-term solu-
tion. If the rent is subsidized based on the resident’s
income, the person is usually allowed to stay as long as he
or she remains in the low-income bracket. Permanent
supportive housing combines this housing assistance with
services for homeless persons with disabilities. Usually,
they serve individuals and members of that household
who have serious mental illnesses, chronic substance
abuse problems, physical disabilities, or AIDS and related
diseases. People may receive these services either at the
housing site or through partnering agencies.

Preventing homelessness is a cost-effective interven-
tion. Funds can be used to pay expenses and resolve sit-
uations in certain circumstances so that individuals and
households can avoid homelessness, receive support
services to help them pay for the cost of their housing,
and develop skills and employment to avoid a recurrence
of the problem. Moving people rapidly into permanent
housing has also been shown to be cost effective and is
the goal now of several nongovernmental organizations.

Food
When families and individuals live in poverty, they fre-
quently have to make impossible choices between paying
the rent, buying food, or buying essential medications.
This can lead to homelessness and decreased ability to
provide adequate food. Homelessness and hunger are in-
separably linked. Those experiencing homelessness often
experience food insecurity. The United Nations World
Food Summit in 1996 defined food security as existing
“when all people at all times have access to sufficient, safe,
nutritious food to maintain a healthy and active life.”64

This definition of food security usually includes both

physical and economic access to food that meets people’s
dietary needs as well as their food preferences. In 2017,
in the United States, 15.1% of households experienced
food insecurity at some time during the year.65 The rate
was higher (18.1%) in households with children.65 Non-
profit organizations frequently help to provide food se-
curity through private donations to food pantries, food
banks, and soup kitchens.

Health Care
Steps are being taken to help address some of the barriers
the homeless face in trying to attain health care, espe-
cially access to health care. In many cities, health-care
services are provided at places frequented by those expe-
riencing homelessness, for example, soup kitchens and
shelters. Outreach workers often go to the locations
where the homeless are and tell them about the availabil-
ity of different health-care resources. Some communities
have mobile medical units that can travel to the patients’
locations. Some of these mobile medical units are very
specialized (such as only providing dental care), and
others provide primary care and referral services.

Policy
The housing-first model promotes providing immediate
housing with supportive services and is gaining traction
nationally. The underlying premise of housing-first is that
obtaining health, security, and wellness is best achieved by
first providing housing without other prerequisites.66 Sup-
portive housing is effective for those who have had a long
history of homelessness, for homeless veterans, and for
those who are homeless with mental health and addiction
problems.66 Preventing families from becoming homeless,
along with very rapid rehousing if the family does become
homeless, is also effective policy. Preventing individuals
with disabilities from becoming homeless is also effective
and requires the collaboration of health-care providers,
social workers, and individuals who monitor subsidized
supportive housing. Providing more and better mental
health services, effective services to individuals who have
suffered domestic violence, and creating additional addic-
tion treatment centers also will have an impact on prevent-
ing homelessness and will provide the additional support
services necessary for individuals to keep their housing.

Immigrants, Migrants, Refugees,
and Asylees
In the United States, migrants, immigrants, refugees, and
asylees are often grouped together as one population,
even though they are distinctly different populations.

174 U N I T I I n Community Health Across Populations: Public Health Issues

7711_Ch07_157-190 23/08/19 10:23 AM Page 174

They are distinct, though sometimes overlapping, popu-
lations with different risk factors for adverse health
outcomes and different barriers to achieving optimal
health. The recent political debate over whether to admit
immigrants or grant asylum highlights the importance
of understanding the differences among these popula-
tions as well as understanding how membership in one
of these groups increases vulnerability in different ways.

Immigrants
Immigrant as defined by the Merriam-Webster diction-
ary is a person who comes to a country to take up
permanent residence.67 In the glossary of terms on the
U.S. Department of Homeland Security (DHS) Web
site, a reader looking up the term immigrant is referred
to “Permanent Resident Alien.” A permanent resident
alien is “An alien admitted to the United States as a law-
ful permanent resident”68 such as a person who is not a
citizen but who entered the country with a valid visa, or
obtained a work permit, as well as permission to stay
indefinitely. Illegal alien is a term sometimes used to
describe those who enter a country without proper
permission and with the intent of becoming permanent
residents. For example, under the definition of perma-
nent resident alien in the DHS glossary of terms is this
qualifier: “… however, the Immigration and Nationality
Act (INA) broadly defines an immigrant as any alien in
the United States, except one legally admitted under spe-
cific nonimmigrant categories (INA section 101(a)(15)).
An illegal alien who entered the United States without
inspection, for example, would be strictly defined as an
immigrant under the INA but is not a permanent resi-
dent alien.”68 Other terms in use include undocumented
workers and undocumented immigrants based on a con-
cern over possible stigma associated with the use of the
term illegal alien. These two terms are not listed in the
DHS glossary. (See the DHS Web site for more detail on
the different categories of immigrants and different types
of visas.)

Migrant Workers
The term migrant worker is used to describe those who
move from place to place to get work and who often work
in another country that is not their own.69,70 Globally,
there are approximately 32 million migrants (3.1% of the
global population).70 Across the globe, migrant workers
are at increased risk for exploitation because of limited
social protection, inequalities in the labor market, and
increased risk for human trafficking.71

Migrant workers are at greater risk for experiencing
modern slavery. Modern slavery includes the selling of

people in public markets; women forced into marriage
to provide labor; and forced work inside factories or fish-
ing boats where salaries are withheld, or under threats of
violence, that is, labor extracted through force, coercion,
or threats.71 The Walk Free foundation and the Interna-
tional Labour Organization developed the Global Slavery
Index to help address the gap in knowledge related to the
extent of modern slavery. They reported that, in 2016,
there were 40.3 million persons living in modern slavery,
24.9 million were in forced labor, and 15.4 million were
living in a forced marriage. Regions with a high level
of modern slavery include Africa and Asia. However,
data from Arab states in the Middle East were not avail-
able, countries that host 17.6 million migrant workers.72

Modern slavery is also a concern in the U.S., with a par-
ticular focus on sex trafficking, forced labor, bonded
labor, child labor, and domestic servitude (see Box 7-4).73

Migrant Agricultural Workers in the U.S.
In the U.S., migrant agricultural workers provide much
of the labor in the agricultural industry, with an esti-
mated 2.5 to 3 million migratory and seasonal agricul-
tural workers in the United States.73, 74 Not all migrant

C H A P T E R 7 n Health Disparities and Vulnerable Populations 175

“Trafficking in persons,” “human trafficking,” and
“modern slavery” are used as umbrella terms to refer to
both sex trafficking and compelled labor. The Trafficking
Victims Protection Act of 2000 (Pub. L. 106-386), as
amended (TVPA), and the Protocol to Prevent, Suppress,
and Punish Trafficking in Persons, Especially Women and
Children, supplementing the United Nations Convention
against Transnational Organized Crime (the Palermo
Protocol) describe this as compelled service using a num-
ber of different terms, including involuntary servitude,
slavery or practices similar to slavery, debt bondage, and
forced labor.

Human trafficking can include, but does not require,
movement. People may be considered trafficking victims
regardless of whether they were born into a state of
servitude, were exploited in their home town, were
transported to the exploitative situation, previously
consented to work for a trafficker, or participated in a
crime as a direct result of being trafficked. At the heart
of this phenomenon is the traffickers’ aim to exploit and
enslave their victims and the myriad coercive and decep-
tive practices they use to do so.

BOX 7–4 n U.S. Department of State’s Answer
to the Question “What is Modern
Slavery?”

Source: (73)

7711_Ch07_157-190 23/08/19 10:23 AM Page 175

agricultural workers are immigrants. In the 2018 report
by the National Center for Farm Worker Health,
47% of crop workers were unauthorized, 31% were citi-
zens, 22% had work visas, and 73% were foreign born.74

Under Title 29 of the U.S. Code, “A migrant agricultural
worker is a person employed in agricultural work of a
seasonal or other temporary nature who is required to
be absent overnight from his or her permanent place of
residence. Exceptions are immediate family members of
an agricultural employer or a farm labor contractor, and
temporary H-2A foreign workers. (H-2A temporary
foreign workers are nonimmigrant aliens authorized
to work in agricultural employment in the United States
for a specified time period, normally less than 1 year.)”75

In 2018, farmers and agricultural businesses that relied
heavily on migrant workers blamed severe shortages
of labor on the tightening of immigration laws in the
U.S.76,77

Because migrant workers move around or are fre-
quently away from their permanent place of residence,
establishing residency for benefits (e.g., federal assis-
tance through food stamps) is often difficult for this
group. Most of these workers have no access to workers’
compensation or disability compensation. Many mi-
grant farm workers employed in planting and harvesting
follow the crops for jobs. For example, major agricul-
tural work starts in California, Texas, and Florida. These
starting points result in three streams of workers: the
western stream from California to Washington State,
the midwestern stream from Texas to all the midwestern
states, and the eastern stream from Florida through
Ohio to Maine (Fig. 7-6). These streams represent how
migrant workers follow the jobs, especially in agricul-
ture, where the time to harvest crops changes with the
seasons. In the past few years, these streams have been
less distinct.74

176 U N I T I I n Community Health Across Populations: Public Health Issues

WA

OR

CA
NV

MT
ID

WY

UT

AZ

CO

NM
TX

ND

SD

NE

KS

OK

MO

AR

MN

WI

IL

IA

TN

LA

AL

MA

MS

FL

KY

ID

MI

OH

GA
SC

NC

WV VA

MD
DE

CT

NJ

NY

PA

NH

ME

VT

RI

PR

Major Migratory Streams for Farmworkers in the United States

West Coast Stream

Midwestern Stream

East Coast Stream

Figure 7-6 Migratory patterns of migrant farm workers. (Copyright (c) 1985–2002 National Center for Farm Worker Health, Inc.
Used with permission. Retrieved from http://www.ncfh.org/)

7711_Ch07_157-190 23/08/19 10:23 AM Page 176

This group is particularly vulnerable for multiple
reasons. In 2017, only 31% of migrant agricultural work-
ers reported that they could speak English well and
27% could not speak English at all.74 In relation to health
care, more than a third were uninsured (36.3%) and
63.5% lived below the poverty level.78

Impact on Health
Poor, substandard housing is frequently a part of the life
of a migrant or seasonal farm worker. If a person has to
continually move to find work, it is more likely that the
person moving will not have long-term or stable housing,
putting him or her into one of the groups of tertiary, sec-
ondary, or possibly even primary homelessness. The health
of migrant workers reflects their poverty and poor living
situations, making them vulnerable to conditions no
longer thought of as being prevalent in the United States.
Most foreign workers are from Mexico78 and have a higher
incidence of tuberculosis, other communicable diseases,
and poor nutrition in addition to having daily exposure to
the dangerous occupation of farming and to pesticides.
The workers live in crowded housing and working condi-
tions, making them six times more likely to develop
tuberculosis when compared with other workers.78

Intervention and Services for Migrant
Workers
Despite efforts at the federal level to help with building
housing, substandard housing continues to be an issue
for migrant workers.79,80 There is the option of housing

C H A P T E R 7 n Health Disparities and Vulnerable Populations 177

l APPLYING PUBLIC HEALTH SCIENCE
The Case of the Wandering Diabetic
Public Health Science Topics Covered:

• Focused community assessment
• Partnership building
• Advocacy

Sara, a nurse at the local nurse-managed clinic run
by the hospital, met Manuel and listened to his story.
He told Sara he had lived in 12 states, following the
jobs. He had dropped out of high school to help raise
his siblings, and with the tough economy and his lack of
education he couldn’t find anything except seasonal and
other temporary work. This meant he held many differ-
ent jobs as he traveled from place to place to find work.
He worked as a ranch hand, did construction work, and
followed the promise of riches to the oil fields of North
Dakota. When the oil fields started letting workers go,
there were few other jobs available. He returned to
his home base in New Mexico and slept on friends’
couches for the first few months he was in town. After
4 months, he had worn out his welcome.

Finally, Manuel found a job as an agricultural worker
that had a workers’ tent city where he could live.
Manuel came to the clinic because he was a type 1

diabetic, and with the lack of reliable refrigeration, he
was no longer able to store his insulin and hoped that
Sara had some ideas about where he could store it. He
also had sores on his feet that worried him. He told
Sara that many people in the tent city had limited re-
sources, minimal electricity, and only a central water
spigot that served as the main source of water for the
workers and their children.

After assessing her patient, Sara wondered if the
lack of refrigeration and sanitation concerns were part
of the underlying health problems being experienced by
Manuel and some of her other patients. She started by
gathering data about the tent city and its residents. She
investigated the unmet health needs of this group of
people and examined the impact of the squalid living
conditions using a qualitative survey of the residents
(see Chapter 4). Many of the respondents to the sur-
vey stated that they had recently experienced infec-
tions. Others had noncommunicable diseases that they
were unable to manage properly.

Based on this preliminary assessment, Sara collabo-
rated with other health partners to come up with
solutions. She contacted her colleagues at the hospital,
including the diabetes management experts and com-
municable disease experts. She also contacted the local
health department to request assistance in examining
options for this group. Next, she formed a coalition
with her colleagues and other agencies, and used this
coalition to inform policy makers about the situation at
the tent city. By doing so, she advocated for the health
of her patients. Sara applied for a grant to extend the
clinic services to include a weekly outreach clinic at the
tent city. She also found a local company to donate a
generator so that Steven and other residents would
have electricity for refrigeration to safely store their
medications.

Sara used a public health approach to the problem.
She gathered data to examine the problem and applied
her problem-solving skills in helping a population. She
worked with the public health department and the
hospital to evaluate the outreach program so that they
would have evidence to share that would help other
free clinics and public health departments that were
trying to solve the same problem.

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located on the farm, but that generally means lower
wages because housing rent is removed from the base
salary, and there’s no guarantee that the housing will be
adequate. The off-the-farm option usually consists of
very makeshift shelters, not close to any basic infra-
structure, and with limited or absent water access and
sanitation.

Farm workers, as a vulnerable population (low liter-
acy levels, different culture and language, poverty), have
difficulty accessing health care, paying for health care,
and participating in prevention activities. Migrant
farmers usually work for an hourly wage or per item
harvested or planted, and do not have the luxury of sick
time or paid time to visit a health-care provider. Ac-
cording to the National Center for Farm Worker
Health, migrant workers are faced with numerous bar-
riers related to accessing adequate health care. These
include the cost of coverage, lack of health-care
providers in the area, and lack of transportation to
health-care services.78 Another issue is the cultural and
language barrier that prevents workers from knowing
about accessible services.74, 78

Children of migrant workers are especially susceptible
to unmet health needs. More than half (57%) of migrant
workers are parents. In addition, an estimated 300,000
to 500,000 children under the age of 18 are engaged in
agricultural work. Not only do children of migrant work-
ers have less access to care, their mothers are often ex-
posed to toxic pesticides during pregnancy. More than
one half have unmet medical needs.81

Policy
At the global level, goal 10 of the United Nations’ Sus-
tainable Development Goals includes as one of the tar-
gets: “Facilitate orderly, safe, regular, and responsible
migration and mobility of people, including through the
implementation of planned and well-managed migration
policies”.82 In the U.S., the Immigration and Nationality
Act (INA), protects immigrant and workers’ against dis-
crimination. The law specifically prohibits “1) citizenship
status discrimination in hiring, firing, or recruitment or
referral for a fee; 2) national origin discrimination in hir-
ing, firing, or recruitment or referral for a fee; 3) unfair
documentary practices during the employment eligibility
verification, Form I-9 and E-Verify; and 4) retaliation or
intimidation.”83

The Affordable Care Act (ACA) does not directly ben-
efit migrant workers, especially those who are undocu-
mented. Employers with 50 or more employees are
mandated to provide health-care insurance. Because
farms use seasonal workers, the ACA uses a different

formula. If the farm employs on average more than
50 full-time seasonal workers for fewer than 121 days,
then the farm is not required to provide health-care cov-
erage. In addition, workers who are undocumented are
not required to purchase individual health-care insur-
ance. This may leave a segment of the workforce unin-
sured. In some cases, large farms are establishing clinics.
Many migrant workers currently pay for health care out
of pocket. Thus, further policy may be needed to cover
the cost of health care to this population.

Refugees and Asylees
The 1980 Refugee Act in the United States, which is still
in effect, defines a refugee as “a person outside of his or
her country of nationality who is unable or unwilling to
return because of persecution or a well-founded fear of
persecution.”84 This definition is based on a United
Nations 1951 Convention that states, “any person who,
owing to a well-founded fear of being persecuted for rea-
sons of race, religion, nationality, membership in a par-
ticular social group, or political opinion, is outside the
country of his nationality and is unable or, owing to such
fear, is unwilling to avail himself of the protection of that
country; or who not having a nationality and being out-
side the country of his former habitual residence as a re-
sult of such events, is unable or, owing such fear, is
unwilling to return to it.”85

Refugees and asylees seeking resettlement in the
United States constitute a special type of immigrant. An
asylee is also a person “who is unable or unwilling to re-
turn to his or her country of nationality because of per-
secution or a well-founded fear of persecution on
account of race, religion nationality, membership in a
particular social group, of political opinion.”86 The dis-
tinction between the two is that a person asking to re-
ceive refugee status is outside the United States and
seeking to enter, whereas an asylee is a person already re-
siding in the United States when applying for asylum.86

Other terms used to describe forcibly displaced persons
include internally displaced persons, stateless persons,
and returnees (Box 7-5).87 The challenges facing refugees
are the subsequent political issues around who should
and who should not be allowed to seek asylum, with po-
litical parties taking sides.

Refugees Seeking Asylum
In 2017, 68.5 million persons worldwide were forced
from their homes by disasters, conflict, and persecution,
up from 43.3 million in 2010. According to the UN HCR,
every 20 minutes “… people leave everything behind to
escape war, persecution, or terror.”88 Of these, 25.4 million

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7711_Ch07_157-190 23/08/19 10:23 AM Page 178

were refugees and 3.1 million were seeking asylum. More
than half (57%) were from three countries, South Sudan,
Afghanistan, and Syria. Turkey accepted the highest
number of refugees (Table 7-3).88

In the U.S., the Trump administration announced in
September of 2018 that the maximum number of
refugees the U.S. would accept in 2019 would be dropped
from 45,000 (the cap in 2018) to 30,000, the lowest num-
ber in decades. Given the total number of refugees world-
wide (25.4 million), this represents only 0.12% of
refugees worldwide. Despite the existing cap of 45,000,
only 19,899 refugees were admitted into the U.S. between
October 2017 and the end of August 2018.89

Refugees seeking asylum are often in a position of in-
security and unknown outcomes, many remaining in
refugee camps for several years as the problems resolve
in their own country. There currently are three sugges-
tions for a permanent solution to the temporary refugee
settlements. The preferred solution is for the refugees and
asylees to be repatriated, returning to their home country
when it is once again safe. However, this must be volun-
tary and currently is occurring less frequently. If they
can’t go home, there are two other options—they can
stay in the host country, which most host countries do
not want, or request resettlement to a third country.88

Impact on Health
Refugees victimized by war and/or political repression,
famine, or natural disasters frequently experience food
insecurity, poor sanitation, exposure to multiple com-
municable diseases, violence, and mental health issues
with limited medical care both while fleeing their country
of origin and while in refugee settlement camps in the
host country. Many live in refugee camps, some for sev-
eral years, with a major impact on their health. Those liv-
ing in refugee camps are at greater risk for a number of
health issues including chronic disease90, intimate part-
ner violence,91 and poor sanitary conditions.92 Children
in refugee camps are at increased risk for stunted growth
due to chronic malnutrition.93

Mental health poses a significant health risk for
refugees. Post-traumatic stress disorder (PTSD) and de-
pression are common diagnoses among those in the re-
settlement programs who have had severe exposure to
violence.94-96 Silove, Ventevogel, and Rees presented an
ecological model related to the mental health risk factors
associated with migration including events prior to mi-
gration, the stresses that occur during migration, and

C H A P T E R 7 n Health Disparities and Vulnerable Populations 179

Refugees
A refugee is someone who fled his or her home and
country owing to “a well-founded fear of persecution be-
cause of his/her race, religion, nationality, membership in
a particular social group, or political opinion”, according
to the United Nations 1951 Refugee Convention. Many
refugees are in exile to escape the effects of natural or
human-made disasters.

Asylum Seekers
Asylum seekers say they are refugees and have fled their
homes as refugees do, but their claim to refugee status is
not yet definitively evaluated in the country to which
they fled.

Internally Displaced Persons
Internally Displaced Persons (IDPs) are people who have
not crossed an international border but have moved to a
different region than the one they call home within their
own country.

Stateless Persons
Stateless persons do not have a recognized nationality
and do not belong to any country. Statelessness situations
are usually caused by discrimination against certain groups.
Their lack of identification—a citizenship certificate—can
exclude them from access to important government
services, including health care, education, or employment.

Returnees
Returnees are former refugees who return to their
own countries or regions of origin after time in exile.
Returnees need continuous support and reintegration
assistance to ensure that they can rebuild their lives
at home.

BOX 7–5 n Types of Forcibly Displaced Persons

Source: (87)

TABLE 7–3 n Refugees Accepted by Country

Country

Turkey

Pakistan

Lebanon

Islamic Republic of Iran

Germany

Bangladesh

Sudan

Source: (88)

Approximate Number
of Refugees Hosted

3.5 million

1.4 million

998,900

979,000

970,400

932,200

906,600

7711_Ch07_157-190 23/08/19 10:23 AM Page 179

events that occur during the resettlement phase.
They state that these events represent a “… dynamic
inter-relationship of past traumatic experiences, ongoing
daily stressors, and the background disruptions of core
psychosocial systems, the scope extending beyond the
individual to the conjugal couple and the family.”96

Intervention and Services
The U.S. Public Health Service requires a health screen-
ing for all immigrants and refugees prior to departure
from their country of origin or their host countries.
Refugees can be kept from immigrating if they have un-
treated communicable disease, an untreated substance
abuse disorder, or a mental illness that causes them to
respond violently. If the refugee agrees to treatment,
then he or she can be reconsidered for immigration.97

Upon arrival, refugees are eligible for 8 months of Med-
icaid or Refugee Medical Assistance (RMA).98 During
this 8-month period, refugees need to complete re-
quired health screenings, begin to understand the
health-care system, begin to learn English, and seek out
and secure paid employment. After the 8-month period
is over, many are then eligible for expanded health in-
surance options under the ACA.98 They are also en-
couraged to apply if eligible for other subsidy programs,
such as Supplemental Security Income, for which they
are entitled in their status as a refugee.

Based on current global trends, the refugee issue con-
stitutes a complex crisis. Politically, countries struggle
with whether to accept refugees while millions continue
to flee conflict and violence. Unaccompanied children
and orphans further complicate the crisis. Central to the
crisis is the ongoing short- and long-term consequences
on the physical and mental health of the refugees. Health-
care professionals continue to provide a central role in
addressing the adverse effect of migration on populations
seeking work, asylum, and resettlement because it is the
nurses, physicians, and other health-care providers who
provide health screening and treatment, and contribute
to overall planning for the care of these extremely vulner-
able populations.

Incarcerated and Correctional
Populations
According to the U.S. Department of Justice, the incar-
cerated population includes persons living under the
jurisdiction of state or federal prisons, and in the custody
of local jails. The correctional population includes the
incarcerated population as well as persons living in the
community while supervised on probation or parole.99

According to global data the U.S. has the highest
incarceration rate in the world. In 2017, the U.S. incar-
ceration rate was 655 inmates per 100,000 people
compared to 77 per 100,000 in Germany.100 This is
an alarming statistic for the sheer numbers, but equally
important because once individuals have a history
of incarceration, they have limited opportunities
for employment, education, housing, and a stable
family life. This in turn has significant impact on
health.101

Persons Experiencing Incarceration
Based on the U.S. Department of Justice data in 2016, a
total of 2,162,400 persons were incarcerated in the U.S.,
out of an estimated 6,613,500 persons supervised by U.S.
adult correctional systems or approximately 1 in
38 adults age 18 or older in the United States.102 Overall
the jail incarceration rate in the U.S. was 860 prison or
jail inmates for every 100,000 adults ages 18 and older,
down from 1,000 per 100,000 in 2006 to 2008.103

African Americans were disproportionately repre-
sented in this population with an incarceration rate
among Non-Hispanic black adults 3.5 times higher
than non-Hispanic white adults (599 per 100,000 versus
171 per 100,000, respecively).103, 104 However, looking
at trends over the past decade, there has been a drop in
the incarceration rate for African American men (9.8%)
and women (30.7%) while at the same time there has
been an increase in incarceration rate for white men
(8.5%) and women (47.1%). The incarceration rate for
Latino men declined 2.2% and rose 23.3% for Latina
women.104

The U.S., even in states with more progressive
approaches to incarceration, has a higher rate of incar-
ceration than almost all other countries.105 However,
many of the issues related to incarceration remain the
same across countries. Issues include the debate related
to punishment versus rehabilitation and what constitutes
progressive reform related to imprisonment.

Impact on Health
Under the 1976 U.S. Supreme Court ruling Estelle v.
Gamble, states are compelled to provide a constitution-
ally adequate level of medical care for those who are
incarcerated or care that generally meets a “community
standard.”106 As the cost of health care increases, the cost
to the state prison system increases as well. Not only does
incarceration itself increase a person’s vulnerability, vul-
nerable subpopulations are over-represented in prisons
and jails. This translates into a greater need for health
care. For example, the prevalence of hepatitis C is higher

180 U N I T I I n Community Health Across Populations: Public Health Issues

7711_Ch07_157-190 23/08/19 10:23 AM Page 180

in prisons.107 In addition there is an increasing preva-
lence of noncommunicable diseases, and a high preva-
lence of mental health and substance use disorders.101

The increase in the number of incarcerated older adults
presents an emerging challenge for the correctional sys-
tem due to a higher prevalence of noncommunicable dis-
eases as well as cognitive disorders such as Alzheimer’s
disease.108

The health needs of the incarcerated and correc-
tional population reflect the health needs of the other
populations they represent—in general, a vulnerable
population of poverty with limited access to health care,
low education levels, at-risk drug and alcohol use, men-
tal health issues, and communicable disease such as
hepatitis and HIV. All of these problems are amplified
in prison. The stresses of prison life, poor diet, and
frequently less than adequate medical care often exac-
erbate noncommunicable conditions such as diabetes
and hypertension.

Men and women who are incarcerated or in the cor-
rectional system experience higher rates of comorbidities
of substance use and psychiatric disorders. These psychi-
atric diagnoses include major depressive disorder, anti-
social personality disorder, anxiety, PTSD, borderline
personality disorders, and eating disorders. In one study,
incarcerated women with a history of at-risk drug and
alcohol use were nearly twice as likely to have affective
disorder, a major depressive disorder, PTSD, or border-
line personality disorder as women in the community.101

With 2.4 million schoolchildren having an incarcerated
parent, there is also a collateral impact on families, in-
cluding both significant economic effects and major
mental health effects on the children.109

Policy
Approaching the issue of incarceration requires imple-
menting policy across the continuum of upstream, mid-
stream, and downstream. An example of upstream policy
is working with high-risk youth at the community level
to promote education, provide opportunity for advance-
ment, and prevent incarceration. Examples of midstream
policies include providing alternatives to jail and prison
for minor offenses, promoting education through these
alternative sentencing options, providing treatment for
mental health and substance use disorders, and providing
opportunities for employment. This requires a cultural
shift from zero tolerance to a broader concept of early re-
habilitation and remediation efforts outside of the jail or
prison to help prevent later, more serious crimes. Down-
stream interventions provided within the context of re-
habilitation rather than punishment have the potential to

help vulnerable populations obtain access to education
and behavioral health services with the intention of
improving their opportunities of gainful employment on
release.

C H A P T E R 7 n Health Disparities and Vulnerable Populations 181

n EVIDENCE-BASED PRACTICE
Use of Agonist Treatment for Persons
Experiencing Incarceration

In the U.S., more than half of persons incarcerated in
state prisons and more than 60% of those incarcerated
in jails meet the criteria for a substance abuse
disorder.1 Yet few prisons or jails provide treatment
for Opioid Use Disorder (OUD) to their inmates.2

Practice Statement: During incarceration persons
with an OUD should be offered medication-assisted
treatment (MAT), the gold standard for treatment
of an OUD (Chapter 11).

Targeted Outcome: All persons incarcerated in jails
or prisons diagnosed with an OUD will be provided
with MAT as well as direct links to providers of
MAT in their community on release.

Supporting Evidence: The effectiveness of MAT
to treat OUDs in the general population is well
documented.3 There is emerging evidence that
MAT delivered to persons while incarcerated can
result in better outcomes. In one study conducted
in Britain, “… prison-based opioid substitution ther-
apy was associated with a 75% reduction in all-cause
mortality and an 85% reduction in fatal drug-related
poisoning in the first month after release.”4

Recommended Approaches: MAT can be delivered
using three different medications. Methadone
and buprenorphine work as opioid agonists and
thus suppress and reduce cravings for the abused
drug. Naltrexone is an opioid antagonist that
works in the brain to prevent opiate effects (e.g.,
feelings of well-being, pain relief) as well as the
desire to take opiates. Choosing which medication
to administer is done on a case-by-case basis (see
Chapter 11). In addition to the administration of
MAT, during the period of time a person is incar-
cerated additional psychosocial treatment should be
provided, as well as a warm handoff at the time of
release. That is, the person should not only be told
where to obtain a continuation of MAT but have a
firm appointment and evidence that they have any
needed transportation assistance to make their
first appointment at the clinic, primary care office,
or treatment facility.

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Lesbian, Gay, Bisexual, Transgender,
Queer+
According to the WHO, persons who do not conform to
established gender norms often face stigma, discrimina-
tory practices, and/or social exclusion. This can adversely
affect health through increased susceptibility to diseases
as well as their mental and physical health. It can also re-
sult in decreased access to health services, all of which
can result in poorer health outcomes.110 In the U.S. and
in other high-income countries, LGBTQ+ persons have
experienced growing inclusion into the mainstream of
society as evidenced by the increasing recognition of
LGBTQ+ marriages. Despite this growing acceptance,
those who identify as LGBTQ+ continue to experience
discrimination from friends, family, and others, with in-
creased risk for adverse health outcomes and becoming
victims of violence. From a public health perspective,
LGBTQ+ persons’ risk for poorer health outcomes re-
quires action at the population level. However, before
health-care professionals can address the health-care
needs of this population, they must first understand the
underlying social constructs associated with the
LGBTQ+ community.

The traditional social construct focuses on the char-
acteristics of women and men including the “… norms,

roles, and relationships of and between groups of women
and men.”110 Moving away from this traditional con-
struct is the presentation of gender identification and
sexual orientation occurring across a continuum rather
than in the more traditional binary model of female or
male. This continuum includes persons who identify as
straight (cisgender), gay, lesbian, bisexual, transgender,
agender, or other gender-based terms (LGBTQ+) (see
Box 7-6).111 Understanding these terms requires shifting
from only a biological approach to a broader under-
standing of how we view ourselves. As depicted in the
graphic, Gender Bread Person, this involves an intricate
interplay of our gender identity, our gender expression,
and who we wish to be with sexually and romantically
(see Fig. 7-7). This not only includes gender identity but
also gender expression, our biological sex, as well as who
we are sexually attracted to and who we are romantically
attached to. For example, a cisgender person identifies

182 U N I T I I n Community Health Across Populations: Public Health Issues

References
1. Bronson, J., & Stroop, J. (2017, June). Drug use, de-

pendence, and abuse among state prisoners and jail
inmates, 2007-2009. U.S. Department of Justice
Special Report. Retrieved from https://www.bjs.gov/
content/pub/pdf/dudaspji0709.pdf

2. Lopez, G. (2018, Mar 26). How America’s prisons
are fueling the opioid epidemic. Vox. Retrieved from
https://www.vox.com/policy-and-politics/2018/3/13/
17020002/prison-opioid-epidemic-medications-
addiction

3. Substance Abuse and Mental Health Services Admin-
istration. (2015). Medication and counseling treatment.
Retrieved from https://www.samhsa.gov/medication-
assisted-treatment/treatment#medications-used-
in-mat

4. Hedrich, D., Alves, P., Farrell, M., Stöver, H.,
Møller, L., & Mayet, S. (2012). The effectiveness of
opioid maintenance treatment in prison settings:
A systematic review. Addiction, 107(3), 501–517.
https://doi-org.ezp.welch.jhmi.edu/10.1111/
j.1360-0443.2011.03676.x

Asexual: The lack of a sexual attraction or desire for
other people.

Androgynous: Identifying and/or presenting as neither
distinguishably masculine nor feminine.

Bisexual: A person emotionally, romantically, or sexually
attracted to more than one sex, gender, or gender
identity although not necessarily simultaneously, in the
same way, or to the same degree.

Cisgender: A term used to describe someone whose
gender identity aligns with the sex assigned to them at
birth.

Gay: A person who is emotionally, romantically, or
sexually attracted to members of the same gender.

Gender fluid: A person who does not identify with a
single fixed gender and expresses a fluid or unfixed
gender identity.

Genderqueer: A term for people who reject notions of
static categories of gender and embrace a fluidity of
gender identity and often, although not always, sexual
orientation.

Lesbian: A woman who is emotionally, romantically, or
sexually attracted to other women.

Queer: A term people often use to express fluid identi-
ties and orientations. Often used interchangeably with
“LGBTQ.”

Transgender: An umbrella term for people whose
gender identity and/or expression is different from
cultural and social expectations based on the sex
they were assigned at birth.

BOX 7–6 n Gender Identity Terms

Source: (111)

7711_Ch07_157-190 23/08/19 10:23 AM Page 182

with the gender they were assigned to at birth, they
express themselves in that gender, and they are sexually
and romantically attracted to cisgender persons assigned
to a different gender at birth.

The challenge for health-care providers is to provide
an opportunity for patients to share their identity in
relation to gender and sexual orientation in a way that is
accepting. In 2011, the Joint Commission, the primary
accreditation body for health-care facilities, stated that
“Admitting, registration, and all other patient forms
should provide options that are inclusive of LGBTQ+ pa-
tients and families, and should allow LGBTQ+ patients
to self-identify if they choose to do so.”112 Yet most
health admission and assessment documents continue to
use the binary approach of male or female. In addition,
few medical schools or nursing schools include essential
content related to caring for LGBTQ+ persons in their
curriculum.113

Another problem is the lack of data on LGBTQ+ per-
sons due to how health surveys ask the gender question.

To address this, HP 2020 included two measurable
objectives under the new topic of Lesbian, Gay, Bisexual,
and Transgender Health with targets for increasing the
number of population-based data systems that include
questions related to sexual orientation and gender iden-
tity at the state and national level.114

C H A P T E R 7 n Health Disparities and Vulnerable Populations 183

Figure 7-7 Gender Bread Person. (Artist Sam Killerman, uncopyrighted. Retrieved from http://itspronouncedmetrosexual.com/
genderbread-person/)

n HEALTHY PEOPLE
Lesbian, Gay, Bisexual, and
Transgender Health

Goal: Improve the health, safety, and well-being of
lesbian, gay, bisexual, and transgender (LGBT)
individuals.
Overview: LGBT individuals encompass all races and
ethnicities, religions, and social classes. Sexual
orientation and gender identity questions are not asked
on most national or state surveys, making it difficult to
estimate the number of LGBT individuals and their
health needs.114

7711_Ch07_157-190 23/08/19 10:23 AM Page 183

LGBTQ+ and Health
According to a Gallup poll, in 2017, 4.5% of Americans
identified as LGBTQ+ with 5.1% of women identifying
as LGBTQ+ and 3.9% of men. This reflects an increase
mostly in millennials.116 Persons who identify as
LGBTQ+ reflect a diverse population across all racial and
ethnic groups.117 They are also at increased risk for
poorer health compared to their heterosexual peers.
Some of these differences are attributable to differences
in sexual behavior, but the underlying issues for those
who identify as LGBTQ+ “… are associated with social
and structural inequities, such as the stigma and discrim-
ination that LGBTQ+ populations experience”.117 They
are at increased risk for communicable diseases, suicide,
mental health issues, and substance use disorders often
linked to discrimination and social isolation.117

Another health issue for the LGBTQ+ community is
the increased risk of being a victim of violence, specifi-
cally hate crimes. Persons who identify as LGBTQ+ are
more apt to be victims of hate crimes than any other
minority group.118 The Orlando, Florida, mass shooting
in 2016 highlighted the violence attached to these hate
crimes. Adolescents and adults also experience partner
violence.119,120 Park and Mykhyalyshyn explained that,
as LGBTQ+ persons become more an accepted part
of American society, those opposed to this community
become more radicalized and less tolerant.118

Providing appropriate care to persons based on how
they identify themselves in relation to gender is an im-
portant first step. Health-care delivery to all persons
must occur within the context of the person. For nurses,
this begins with a clear understanding of the complexity
of gender identity, gender expression, and sexual orien-
tation. From a public health perspective, it requires ad-
vocating for policies that support a more inclusive
approach to health care across the continuum of gender.
It also requires policies aimed at reducing hate crimes,

stigma, and social isolation, the main drivers of disparity
in health for those who identify as LGBTQ+.

At-Risk LGBTQ+ Groups
Civil rights expansions, most notably the U.S. Supreme
Court decision in Obergefell vs. Hodges (5/15/15), which
established the right to gay marriage in all 50 states, has
encouraged more openness and societal acceptance of
LGBTQ+ individuals and families. However, despite
much research, landmark legal rulings, and the increasing
willingness of individuals to publicly identify themselves
as LGBTQ+, homophobia and its resulting behaviors of
discrimination, violence, and shunning remain promi-
nent in all areas of our society. Three subgroups of the
LGBTQ+ community are especially vulnerable and face
daunting barriers to leading a physically and emotionally
healthy life: transgender youth, LGBTQ+ elders, and
gay/bisexual men and women with HIV/AIDS.

Transgender youth include an increasing number of
very young children (ages 3 years and older) who are
expressing gender nonconforming identities (gender
dysphoria). Parents of these young children find them-
selves searching for medical assistance and support as
they navigate uncharted territory. These children are also
vulnerable to bullying and societal/familial denial of their
expressed gender, circumstances that can lead to depres-
sion, anxiety, and other problems that can inhibit a
healthy social and physical development. Medical sup-
port may not be readily available outside of large metro-
politan areas, and local community and educational
support are often scarce. Older transgender youth are
among our most vulnerable population groups. They are
at high risk for family rejection, homelessness, substance
use, risky sexual behavior, depression and suicide, as well
as targets of sexual violence.121

LBGTQ+ elders face a variety of challenges as they
grow older. Like their non-gay counterparts, they often
feel socially isolated and less able to provide for them-
selves or live independently. However, having experi-
enced the depths of homophobia in their earlier years,
the rejection of family and being “in the closet” at work
and in their community, LGBTQ+ elders tend to be mis-
trustful of mainstream medical and social services. Fear-
ing discrimination and rejection, they are often wary of
sharing their sexual orientation with their medical and
social service providers, or even seeking out such services
when needed. Many have already experienced insensi-
tivity and discrimination by health care and social service
providers in their younger years.122

Gay/bisexual men and women with HIV/AIDS con-
tinue to be marginalized in our society for several reasons.

184 U N I T I I n Community Health Across Populations: Public Health Issues

Midcourse Review: Of the two measurable
objectives, objective one (Increase the number of
population-based data systems used to monitor
Healthy People 2020 objectives that include in their
core a standardized set of questions that identify
lesbian, gay, bisexual, and transgender populations)
showed improvement. Objective two (Increase the
number of states, territories, and the District of
Columbia that include questions that identify sexual
orientation and gender identity on state level surveys
or data systems) had little or no improvement.115

7711_Ch07_157-190 23/08/19 10:23 AM Page 184

The stigmas of HIV/AIDS and homophobia have not
diminished in many rural areas and among some ethnic,
cultural, and religious groups. This reality leads many
LGBT+ people with HIV/AIDS to avoid accessing med-
ical and social services for fear that their health status will
be discovered and result in family rejection and discrim-
ination in employment and housing.123,124

Interventions and Policy
In October 2009, the Matthew Shepard and James Byrd,
Jr., Hate Crimes Prevention Act was signed into law and
makes hate crimes based on sexual orientation, among
other offenses, federal crimes in the United States.125 For
the parents of children who express a nonconforming
gender identity, there is often confusion and a sense of
being an inadequate parent. Unless the family lives near
a large urban area, it is unlikely that parents will have
access to the medical care, psychosocial services, and
educational resources that they and their child will need.
This lack of resources is currently being filled by online
groups and Web sites, sites where parents and children
can search for information and connect with other fam-
ilies. One potential resource for parents is the school
nurse (see Chapter 18).

Fortunately, there is a growing awareness in the
medical/academic community to provide accurate infor-
mation to families and their local health providers, as
well as a growing number of clinics and clinicians trained
to provide services to transgendered youth and their
families. The American Psychological Association has
published “Guidelines for Psychological Practice with
Transgender and Gender Nonconforming People”,126

a comprehensive guide for those professionals working
with transgendered people of all ages. In addition, many
urban university medical centers and hospitals are estab-
lishing clinics and programs for transgendered and gender
nonconforming children and young adults.

Medical issues aligned with transgendered youth and
children who express a nonconforming gender identity
include pharmacologic therapies to address body image
issues, depression, anxiety, and suicidal ideations. Social
and psychological therapies can address social function-
ing, peer issues, school adjustment, and family issues as
they arise. The availability of these resources is vital to
the healthy development of these children in all areas of
functioning.

For LGBTQ+ older adults, their invisibility to main-
stream elder service providers and medical personnel in
many settings significantly diminishes their quality of
life.127 Additionally, the lack of training for staff and res-
idents in most long-term care settings such as assisted

living complexes and nursing homes leave LGBTQ+
older adults open to psychological and physical abuse,
which can lead to depression and self-isolation. For
LGBTQ+ older adults living at home but in need of
assistance in a variety of areas, the same problem arises
with home care services. Staff may not be trained to
respect the individual’s LGBTQ+ identity and her/his
relationships with others.127,128

Understanding the needs of LGBTQ+ older adults is
an essential skill for nurses who provide care and begins
with not assuming a patient’s sexual orientation is het-
erosexual, and/or dismissing the relationship between
two partners. Nurses in all settings need to be under-
standing of the discrimination and abuse LGBTQ+
older adults may have encountered in their lives and
provide a supportive, affirming environment for the
patients.128

Gay/bisexual men and women with HIV/AIDS pres-
ent a variety of serious medical problems and psycholog-
ical issues. Despite the many advances in medical care
for people with HIV, there are significant disparities in
how these new therapies are utilized in geographic and
racial areas. In 2016, the CDC predicted that, if current
rates continue, one in two African American gay and bi-
sexual men will be infected with HIV.129 These statistics
clearly demonstrate the need for more comprehensive
measures to address the issues of poverty, race, and class
inherent in the health care of gay/bisexual men and
women with HIV/AIDS.

Community-based organizations can be supportive of
LGBTQ+ people and can influence the general commu-
nity to provide a more inclusive environment. Public
campaigns are a way to reach a large number of people
with messages challenging homophobia. Schools also can
educate young people, confronting widely accepted prej-
udices. This might include specific curriculum and action
against bullying, creating a school environment wherein
all students feel comfortable. Political leaders, police de-
partments, health services, broadcasters, and employers
can all positively influence the way that the LGBTQ+
population is treated.

n Summary Points
• Health disparity and vulnerability reflect a complex

intersection of risk factors at the individual, commu-
nity, national, and global levels.

• Social forces such as discrimination and stigma lead
to the marginalization of certain segments of our so-
ciety, resulting in increased levels of marginalization
overall.

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• Health disparities disproportionately affect
members of racial, ethnic, minority, underserved,
and vulnerable groups and affect the overall health
of the United States.

• Social determinants of health including poverty,
access to care, cultural barriers, and education play
a role in increasing the vulnerability of certain
populations.

• Nurses are uniquely positioned to provide care for
vulnerable populations, functioning in a variety of
roles through which they enhance health and reduce
vulnerability.

• Certain populations like the homeless, migrant
workers, immigrants, refugees, the incarcerated, and
LGBTQ+ people are more likely to be vulnerable
and benefit from specific interventions and changes
in policy.

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186 U N I T I I n Community Health Across Populations: Public Health Issues

t CASE STUDY
Vulnerability extends from the cellular to the global
level and increases the risk of adverse health conse-
quences. Financial factors often drive access to the re-
sources necessary to ensure optimal health. The most
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2. Map out the natural history of disease in relation to
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3. The issue of rheumatic heart disease in Rwanda ex-
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dressing this issue in Rwanda?

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